done: Practice Question Banks 61-75 (Not Required)

An 82-year-old male client is admitted with benign prostatic hyperplasia (BPH). Which finding by the nurse will require immediate action? A blood pressure of 180/105 Severe abdominal pain A heart rate of 110 bpm A bladder ultrasound value of 900 mL

A bladder ultrasound value of 900 mL Complications of BPH include acute urinary retention. Urinary retention is the accumulation of urine in the bladder due to bladder outlet obstruction caused by the enlarged prostate gland. Acute urinary retention is a medical emergency that requires prompt bladder drainage.The elevated heart rate and blood pressure and the severe abdominal pain are signs and symptoms of the acute retention. They will most likely resolve when the retention is resolved. The high bladder scan/ultrasound value confirms the retention of a large volume of urine that will require catheterization. Incorrect LESSON Basic Care and Comfort Elimination COURSE RN & PN Review BODY SYSTEM urinary KEYWORDS urinaryretentionBPHcatheterization

The nurse is teaching a pregnant woman who follows a vegetarian diet about prevention of iron-deficiency anemia. Which food selection indicates that the woman understood the teaching? Whitefish with potatoes Whole grain bread with butter Scrambled eggs with cheese Cereal with dried fruits

Cereal with dried fruits Iron is found in both plant and animal sources. Heme iron, found in animal sources of meat, fish, and poultry, is more easily absorbed than nonheme iron found in plant foods. Animal sources of iron also contain nonheme iron in addition to heme iron. Although egg yolks contain iron, the iron in them is not absorbed as well as other heme from other sources. Nonheme iron plant sources include vegetables, legumes, dried fruits, whole-grain cereals, and enriched grain products, especially iron-fortified dry cereals. For this client (vegetarian), cereals with dried fruits represent a food selection as a good source of iron. LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS iron-deficiencypregnancyvegetarian

The nurse is beginning nutritional counseling with a pregnant client. Which step should the nurse take first? Question her understanding and use of the food pyramid Conduct a diet history to determine her normal eating routines Teach her the risks of Pica during pregnancy Explain diet changes that are necessary for pregnant women

Conduct a diet history to determine her normal eating routines; Assessment is always the first step in planning teaching for any client. A thorough and accurate history is essential for gathering the needed information. The results of this information provides the basis of the planned educational needs. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS nutritionalcounselteach

The nurse is caring for a client who is actively dying and has been receiving high doses of opioid analgesics. The client has become unresponsive to verbal stimuli. What action should the nurse take? Stop giving the analgesic Continue the analgesic at the current dose Decrease the analgesic dosage by half Give an extra dose of the analgesic

Continue the analgesic at the current dose Clients who are actively dying and have been experiencing chronic pain, will probably continue to experience pain even though they cannot communicate this. Pain medication should be continued at the same dose as long as it is effective at that dose; some adjustment may be needed based on the client's physical manifestations of pain, such as grimacing or moaning. Incorrect LESSON Pharmacological (and Parenteral Therapies) Pharmacological Pain Management COURSE RN Review KEYWORDS opioidanalgesicterminal

The nurse is calculating the end-of-shift intake and output balance for a male client with continuous bladder irrigation. During the shift, the client's intake consisted of 2 liters of irrigation fluid, 1,400 mL of oral fluids, 400 mL of maintenance IV fluids and a 250 mL antibiotic piggyback. The client's output for the shift consisted of a small emesis of 100 mL and urine output of 3,800 mL total. What is the end-of-shift intake/output (I/O) balance? Record your answer as a whole number. mL

Correct answer = 150 mLStep 1: Add all intake: 2 liters or Step 2: Add all output: Step 3: Subtract output total from input total: [positive] I/O balance Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN & PN Review KEYWORDS dosage calculation

Following craniotomy surgery, the client develops a cardiac dysrhythmia. The provider prescribes a continuous intravenous infusion of lidocaine at 3 mg/minute. The supplied bag contains 2 grams of lidocaine in 500 mL of 5% dextrose in water. At how many mL per hour should the nurse program the infusion pump? Record your answer as a whole number. mL/hour

Correct answer: 45 mL/hour Steps to calculate the infusion rate in mL per hour: Convert the 3 mg/minute: 3 x 60 minutes = 180 mg/hour Convert 2 grams to mg: 2 x 1,000 = 2,000 mg (in 500 mL) Set-up the equation to calculate how many mL contain 180 mg. 180 mg x 500 mL, divided by 2,000 mg = 45 mL Incorrect LESSON Pharmacological (and Parenteral Therapies) Dosage Calculation COURSE RN Review KEYWORDS dosage calculation

The nurse is preparing to administer mannitol to a client with increased intracranial pressure. The prescribed dose is 20 gram intravenous bolus. The supplied vials contain 12.5 gram of 25% mannitol in 50 mL solution per vial. How many total mL shall the nurse draw up? Record your answer as a whole number. mL

Correct answer: 80 mLSet-up equation to solve for unknown mL.Known: 50 mL contain 12.5 gramsUnknown: ? mL contain 20 gramsEquation: 20 grams x 50 mL, divided by 12.5 grams = 80 mL Incorrect LESSON Pharmacological (and Parenteral Therapies) Dosage Calculation COURSE RN Review KEYWORDS dosage calculation

During an assessment of a postpartum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. The nurse identifies which condition as the most likely cause of these findings? Retained placenta Uterine atony Clotting disorder Genital lacerations

Genital lacerations Correct Response Continuous trickling of blood in the absence of a boggy fundus indicates undetected genital tract lacerations. The nurse should notify the health care provider as the client may need surgical intervention to stop the bleeding. The nurse should begin to weigh peripads to document blood loss. All other options would present with a boggy fundus due to impeding contractions of the uterus or it filling with blood. LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS postpartumfunduspalpatelaceration

A client is being prepared for an above-the-knee amputation. Which actions by the nurse would represent appropriate care of this client? Select all that apply. Have the client confirm his or her identity, the surgical site and the procedure before administration of any medications Explain the procedure, including any risks, before the client signs the surgical consent form Verify that the informed consent form is signed Verify the surgical leg is marked with indelible marker over, or as close as possible to, the surgical incision site Verify any allergies

Have the client confirm his or her identity, the surgical site and the procedure before administration of any medications Verify that the informed consent form is signed Correct! Verify the surgical leg is marked with indelible marker over, or as close as possible to, the surgical incision site Correct! Verify any allergies Correct! Prior to surgery, the nurse can witness the client's signature on the consent form, but explanation of the procedure, including risks and benefits, needs to come from the health care provider. Any allergies must be noted and verified prior to surgery. The surgeon must use an indelible marker on the surgical leg to indicate the incision site; sometimes the nonsurgical leg will be marked with a "NO." In the operating room, a surgical checklist is completed with a nurse and anesthesiologist. Prior to administration of anesthesia, there is another check with the client to verify identify, the correct surgical site and procedure. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review KEYWORDS amputationsurgerysafety

The nurse is providing education about nutrition to the parents of a child with cystic fibrosis. The nurse should emphasize increased intake of which foods? Dairy-free foods High-fat foods Low sodium foods Sugar-free foods (1 attempt remaining)

High-fat foods The child with cystic fibrosis requires a well-balanced diet that is high in calories (approximately 2,900 to 4,500 calories a day) to help decrease the loss of appetite and weight loss that are often part of the condition. The other food choices are not appropriate for a child with cystic fibrosis. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM respiratory KEYWORDS cystic fibrosisdietfat

The nurse is working to establish a therapeutic relationship with a client. Which approach would be most effective in establishing a therapeutic relationship? Implement active listening Share a personal story Wait for the client to approach Ask yes or no questions (1 attempt remaining)

Implement active listening a; Establishing therapeutic relationships is done through making appropriate eye contact, using open ended questions, displaying positive non-verbal cues and utilizing active listening strategies. All other options are counterproductive to establishing a therapeutic relationship. Incorrect LESSON Psychosocial Integrity Therapeutic Environment COURSE RN Review KEYWORDS self-esteemtherapeuticrelationship

The nurse is reviewing the medical record of a client who received a new prescription for benztropine. For which condition in the client's record should the nurse clarify the prescription with the health care provider? Glaucoma Cataracts Schizophrenia Parkinson's disease

LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS benztropinecogentincontraindicateglaucoma a; Benztropine is an anticholinergic medication used to treat extrapyramidal disorders caused by antipsychotic medications or Parkinson's disease. Use of benztropine or other anticholinergics is contraindicated for individuals diagnosed with glaucoma, ileus and prostatic hypertrophy. Adverse effects include tachycardia, urinary retention and increased intraocular pressure.

The nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which point should the nurse emphasize? Carry the nitroglycerine with you at all times Keep the medication bottle in the refrigerator Take the medication at the same time each day Rest in bed for an hour after taking medication

LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS nitroglycerinsublingual a. the medication should be kept in its original dark-colored glass container. Nitroglycerin should be carried by the client at all times so it can be used when anginal pain occurs. When needed, the client should sit and place tablet under his or her tongue. Sitting is safe because the drug can cause lightheadedness or dizziness, but it's not necessary to rest in bed. The client should never pack this and any other medications in a checked a bag when traveling.

A healthy 18-year-old who is entering college in the fall presents to the clinic for immunizations. Which immunization(s) does the nurse anticipate the health care provider recommending prior to college? Select all that apply. Meningococcal conjugate vaccine (MCV4) Pneumococcal polysaccharide vaccine (PPSV23) Shingles vaccine Seasonal influenza vaccine Human papillomavirus (HPV) vaccine Tetanus, Diphtheria, Pertussis vaccine (Tdap)

Meningococcal conjugate vaccine (MCV4) Seasonal influenza vaccine Correct! Human papillomavirus (HPV) vaccine Correct Response Tetanus, Diphtheria, Pertussis vaccine (Tdap) Adults older than age 50 should get the shingles vaccine. The PPSV23 is given to adults older than age 65. (The pneumococcal vaccine PCV13 is routinely given to infants/children.) An 18 year-old who is going to college should receive the TDAP, MCV4 and seasonal influenza vaccine. He or she should also receive the HPV vaccine if s/he has not already received it. Incorrect LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN & PN Review BODY SYSTEM immune KEYWORDS immunizationTdapinfluenzavaccineHPV

The nurse is caring for a client who is prescribed an antipsychotic medication. Which statement correctly identifies why it is important for the nurse to monitor the client's blood pressure? Orthostatic hypotension is a common side effect Blood pressure will determine if dietary restrictions should be implemented Most antipsychotic medications cause wide fluctuations in blood pressure throughout the day Rising trends in blood pressure will indicate when an antiparkinsonian medication is needed (1 attempt remaining)

Orthostatic hypotension is a common side effect Clients should be made aware of the possibility of dizziness and syncope from postural hypotension for about an hour after taking an antipsychotic medication. Clients should be advised to get up slowly from a sitting or lying position. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS blood pressureantipsychotichypotension

An 80-year-old client who is taking digoxin reports nausea, vomiting, abdominal cramps and halo vision. Which laboratory result should the nurse evaluate first? Magnesium levels Potassium levels Blood pH Blood urea nitrogen

Potassium levels Nausea, vomiting, abdominal cramps and halo vision are classic signs of digitalis toxicity. The most common cause of digitalis toxicity is a low potassium level. Clients are to be taught that it is important to have adequate potassium intake, especially if taking loop or thiazide diuretics that enhance the loss of potassium. Correct! LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS digitalisLanoxinnauseavomitpotassium

The nurse is caring for a 69-year-old client who is experiencing hyperglycemia. Which activity or task is appropriate to delegate to the unlicensed assistive personnel (UAP)? Assess the condition of the client's skin on the lower extremities Record dietary intake Review the initial signs of hyperglycemia with the client's family Monitor the client for altered levels of consciousness (LOC) (1 attempt remaining)

Record dietary intake The UAP can perform routine activities with predictable outcomes, such as recording dietary intake. Although the UAP can usually assist clients with personal hygiene and would be able to identify a change in LOC (for example, the client does not respond appropriately to questions), their role is to inform the nurse about changes in the client's condition. The nurse must follow up on this information and perform a focused assessment, communicate changes in the client's condition with the health care team and then develop a revised plan of action for client care. Incorrect LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review BODY SYSTEM endocrine KEYWORDS assignUAPpredictable CONFIDENCE

The nurse is providing postoperative care for a client following a laparoscopic cholecystectomy. Which assessment finding should be of highest concern? Client has absent bowel sounds. Client reports right upper quadrant pain. Client is drowsy. Client reports shoulder discomfort. (1 attempt remaining)

Shoulder pain or discomfort is a common complaint following laparoscopic surgery due to the effects of carbon dioxide gas used during the procedure. Postoperative drowsiness is expected. The absence of bowel sounds immediately after surgery is not a cause for alarm. Right upper quadrant pain could be from a retained gallstone or bile duct injury; therefore postoperative pain in the right upper quadrant should be of highest concern. Correct! LESSON Physiological Adaptation Unexpected Response to Therapies COURSE RN & PN Review BODY SYSTEM gastroinstestinal KEYWORDS cholecystectomypostoperativecomplicationspaingallstonelaparoscopy

A 76-year-old client who smokes one pack of cigarettes per day is diagnosed with chronic obstructive pulmonary disease (COPD). The nurse is teaching the client and family members about the use of oxygen by nasal cannula in the home. Which information is most important for the nurse to include in the discharge instructions? Adjust the liter flow to 5 L as needed for shortness of breath Turn the oxygen off during every meal The client should not smoke while wearing oxygen The client will need to make arrangements for portable oxygen when traveling

The client should not smoke while wearing oxygen; Because oxygen supports combustion, there is a risk of fire if anyone smokes near the oxygen equipment. The client should take off the oxygen, turn off the flow meter and go to another part of the home or outside to smoke. Smoking cessation should be encouraged and supported in ways that are appropriate for the client's readiness to quit. The most important teaching point at discharge is to stress not smoking while wearing oxygen for the client's safety. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM respiratory KEYWORDS pulmonaryCOPDoxygengeriatric

The nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which point should the nurse emphasize? Rest in bed for an hour after taking medication Carry the nitroglycerine with you at all times Take the medication at the same time each day Keep the medication bottle in the refrigerator

The medication should be kept in its original dark-colored glass container. Nitroglycerin should be carried by the client at all times so it can be used when anginal pain occurs. When needed, the client should sit and place tablet under his or her tongue. Sitting is safe because the drug can cause lightheadedness or dizziness, but it's not necessary to rest in bed. The client should never pack this and any other medications in a checked a bag when traveling. Correct! LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM cardiovascular

The nurse is caring for a client with Legionnaire's disease. Which finding would require the nurse's immediate attention? Dry mucous membranes in the mouth Pleuritic pain on inspiration Decreased chest wall expansion A decrease in respiratory rate from 34 to 24

The respiratory status of a client with this acute bacterial pneumonia known as Legionnaires' disease is critical. Note that all of these findings would be of concern, but a decrease in chest wall expansion is the priority because it reflects a possible decrease in the depth and effort of respirations. Further findings of restlessness, including low oxygen saturation, would indicate hypoxemia. The client may need to have oxygen titrated to maintain adequate O2 saturation. Mechanical ventilation may be needed for signs of respiratory failure. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM respiratory KEYWORDS Legionnaire's diseasepneumoniahypoxiaprioritization

The nurse is providing education to a client with asthma who is allergic to house-dust mites. Which information about the prevention of an asthma attack would be the most important for the nurse to include during teaching? Change the pillow covers every month Open the curtains to let the sunlight in each morning Wash and rinse the bed linens in hot water Choose 100% cotton linens with a low thread count. (1 attempt remaining)

Wash and rinse the bed linens in hot water; For asthma clients who are allergic to house-dust mites, the mattresses and pillows should be encased in allergen-impermeable covers. All bed linens such as pillow cases, sheets and blankets should be washed and rinsed weekly in hot water at temperatures above 130 F (54.4 C), the temperature necessary to kill the dust mites. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM respiratory KEYWORDS environmentasthmadust mitemattresspillowwash

The nurse is teaching a parent about side effects of routine immunizations. Which finding should be immediately reported to the primary health care provider? Fatigue Seizure activity Irritability Localized tenderness

While severe complications are rare, any seizure activity must be immediately reported; seizures can occur up to 7 days after injection. Other reactions that should be reported include crying for more than three hours, temperature over 105 F (40.5 C) following DTaP immunization, and tender, swollen, reddened areas where the shot was given. Correct! LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS immunizationside effect

The nurse is speaking with a group of teenagers about chemotherapy treatment. The nurse anticipates this group will be most interested in discussing which side-effect of the treatment? Hair loss Mouth sores Fatigue Diarrhea

a

When admitting a client to the ambulatory surgery unit, the nurse notices the client has painted fingernails. The nurse reviews the pre-op orders and notes that pulse oximetry is prescribed. Which statement by the nurse is appropriate? "May I remove the polish from at least two nails?" "I am sorry. All your nail polish must be removed." "We can monitor your oxygen levels with lab work instead of pulse oximetry." "I will ask your health care provider if we can discontinue the pulse oximetry."

a In order to effectively measure pulse oximetry, there can be no nail polish on the finger fitted with the reading device. The client should be approached using therapeutic communication skills. The other options are inappropriate. Incorrect LESSON Reduction of Risk Potential Diagnostic Tests COURSE RN Review KEYWORDS fingernailoximetryoxygen

A newly admitted client reports gaining 5 pounds (2.27 kg) over the past week despite not being very hungry. The nurse observes edema in the client's feet and ankles. The nurse identifies which condition as the most likely explanation for the weight gain? Congestive heart failure Acromegaly Malnutrition Hyperthyroidism

a The unexplained rapid weight gain is probably due to fluid retention. Clients who gain as little as two pounds (0.9 kg) in a week may require hospitalization due to worsening heart failure. The lack of appetite (or a feeling of being full) and edema are also signs of worsening heart failure. Hypothyroidism, and not hyperthyroidism, can lead to low body temperature, which causes fluid retention or bloating. Low protein levels in the blood caused by malnutrition can cause edema. However, there's not enough information given in the question to know if this client is malnourished or not. Acromegaly is characterized by overgrowth of body tissues, not edema, and is caused by excessive secretion of growth hormone. LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN & PN Review KEYWORDS weightgainfluidheart failure

The nurse is preparing to suction a client's tracheostomy. Which interventions should the nurse implement? Select all that apply. Hyperoxygenate the client prior to suctioning Explain the procedure to the client Auscultate lung sounds before and after Administer a mild sedative prior to suctioning Use a sterile suction catheter Instill a small amount of saline prior to inserting the catheter

a,b,c.e ; Suctioning a tracheostomy should be done with a sterile catheter, unless the client has a closed suction system connected to the tracheostomy. Hyperoxygenation for a few minutes prior to suctioning is recommended to prevent hypoxia during the procedure. The nurse should assess the client's lung sounds before and after and should explain to the client what the nurse is about to do. According to evidence-based practice, the use of saline is no longer recommended during routine suctioning. A sedative is not routinely given for suctioning a tracheostomy. LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM respiratory KEYWORDS tracheostomysalinemucousplug

The nurse is caring for a client who is withdrawn. Which nursing intervention would be most effective to help the client develop relationship and interpersonal skills? Offer the client frequent opportunities to interact with one person Schedule the client multiple experiences to interact with groups of clients Inform the client that other clients have similar problems Assist the client to analyze the meaning of the withdrawn behavior

a; A withdrawn client is uncomfortable in social interaction. The nurse-client or a one-on-one relationship is a corrective relationship in which the client learns tolerance and skills for relationships. Incorrect LESSON Psychosocial Integrity Therapeutic Environment COURSE RN Review KEYWORDS withdrawnrelationshipskillinteraction

A newly appointed nurse manager is having difficulties with time management. Which advice from an experienced manager should the new manager implement first? Keep a time log of your day in hourly blocks for at least one week Ask for additional assistance when you feel overwhelmed Complete each task before beginning another activity Set daily goals and establish priorities for each hour and every day

a; Begin by applying the nursing process to the problem of time management. The initial step would be to assess current activities. This allows the nurse manager to establish a baseline of how his/her time is spent. This also aids in identifying where changes can be made. Incorrect LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS managertime managementassess CONFIDENCE

The nurse is providing education to the parents of a 10-year-old child who is diagnosed with diabetes insipidus (DI) and has been prescribed vasopressin. What priority information should the nurse include regarding this medication? The family must monitor the child for arrhythmias The child will need intravenous therapy for several weeks Parents should administer the daily intramuscular injections The child should be observed for dehydration

a; Diabetes insipidus is characterized by a decreased secretion of antidiuretic hormone (ADH). Decreased ADH results in polyuria and polydipsia; the person is unable to concentrate urine. Vasopressin is the drug of choice to treat central DI. At home, it can be administered 2-3 times a day, either IM, subQ or intranasally. Not drinking enough fluids can cause arrhythmias, fatigue and muscle pain. Other serious side effects include chest pain, skin discoloration and paresthesia. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM endocrine KEYWORDS diabetes insipidusvasopressinintranasalsubQIM

The hospital staff requests that parents who have a Greek heritage remove the amulet from around their infant's neck. The parents refuse. The nurse should understand the parents may be concerned about which factor? Evil eye or envy of others Mental development delays Fright from spiritual beings Balance in body systems

a; In the Greek heritage the matiasma, "bad eye" or "evil eye, " results from the envy or admiration of others. The belief is that the eye is able to harm a wide variety of things, including inanimate objects and that children are particularly susceptible to attacks. Persons of Greek heritage employ a variety of preventive mechanisms to thwart the effects of envy. One of these is the protective charm in the form of an amulet that consists of blessed wood or incense. Incorrect LESSON Psychosocial Integrity Religious, Spiritual Influences on Health COURSE RN Review KEYWORDS Greekamuletinfanteyeevil

The nurse works in an assisted living facility and cares for older adults. The nurse understands that older adults are at a greater risk for drug toxicity than younger adults due to which physiological change associated with aging? Older adults have less body water and more fat Older adults are often malnourished and anemic Drugs are absorbed more readily from the gastrointestinal tract Older adults have more rapid hepatic metabolism

a; Because older adults have decreased lean body tissue and water in which to distribute medications, more drug remains in the circulatory system, creating a potential for drug toxicity. Increased body fat results in greater amounts of fat-soluble drugs being absorbed, leaving less medication in circulation, thus increasing the duration of action of the drug. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review KEYWORDS toxicdrugaging

The nurse admits a 3-week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis? The infant received mechanical ventilation for two weeks Phototherapy was used to treat Rh incompatibility Gestational age assessment suggested growth retardation Meconium was cleared from the airway at delivery

a; Bronchopulmonary dysplasia (BPD) is an iatrogenic disease caused by mechanical ventilation. When the prematurely born infant is treated with mechanical ventilation, over time the pressure from the ventilation and excess oxygen can injure the infant's lungs, causing BPD. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM respiratory KEYWORDS infantbronchopulmonary dysplasiaventilation

The nurse is teaching a smoking cessation class and notices there are two pregnant women in the group. Which information is a priority for these women? There is a relationship between smoking and low birth weight Low tar cigarettes are less harmful during pregnancy The placenta serves as a barrier to nicotine Moderate smoking is effective in weight control (1 attempt remaining)

a; Nicotine reduces placental blood flow and may contribute to fetal hypoxia or placenta previa, which results in decreased growth potential of the fetus. Nicotine readily crosses the placenta and any form of nicotine should be avoided during pregnancy. Incorrect LESSON Health Promotion and Maintenance High Risk Behaviors COURSE RN Review BODY SYSTEM reproductive KEYWORDS smokingcessationpregnant

A 72-year-old client is admitted for possible dehydration. The nurse knows that older adults are particularly at risk for dehydration due to which physiologic change? A decreased sensation of thirst An increased need for extravascular fluid A decreased metabolic rate An increase in diaphoresis

a; Older adults have a reduction in thirst sensation and this causes them to consume less fluids. Other risk factors may include fear of incontinence, inability to drink fluids independently, increased frequency to void with increased fluid intake, and lack of motivation. Correct! LESSON Health Promotion and Maintenance Aging Process COURSE RN Review KEYWORDS dehydrationadultthirst

The nurse is giving instructions to the parents of a child who has cystic fibrosis. Which information should the nurse emphasize about administration of pancreatic enzymes? They are to be taken with every meal or snack Administer each time a high-carbohydrate meal is eaten Dispense once daily with breakfast Crush the tablet and sprinkle on food three times a day

a; Pancreatic enzymes are necessary for digesting fat, starch and protein. They should be taken with each meal and most snacks to allow for the proper digestion of the food. If taken on an empty stomach, they may cause gastric irritation and possibly ulcers. Enzyme capsules should be swallowed whole, not crushed or chewed, and the microspheres should not be sprinkled on or mixed with the whole meal. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN & PN Review BODY SYSTEM respiratory KEYWORDS cystic fibrosispancreasenzymechild CONFIDENCE

A licensed practical nurse (LPN) from the float pool is sent to an adult medical-surgical unit. With this newly added staff, the charge nurse needs to revise assignments for the shift. Which clients are appropriate to assign to the float pool LPN? A middle-aged client who has a gastrostomy tube and has been diagnosed with hemiplegia and a client with a below-the-knee amputation (BKA) who will begin physical therapy A trauma victim newly admitted with a diagnosis of quadriplegia and a client one day postoperative after a radical neck dissection A young adult client with a history of schizophrenia who is experiencing alcohol withdrawal syndrome and a client diagnosed with chronic renal failure and anemia. A geriatric client with newly diagnosed type 2 diabetes and a client who is positive for Human Immunodeficiency virus with a diagnosis of pneumonia. (1 attempt remaining)

a; The client diagnosed with hemiplegia (and a gastrostomy tube) and the client who is starting physical therapy following a BKA require supportive care and interventions that are within the scope of practice of a LPN. These clients are the most stable and have a minimal risk of complications. The clients in the other options require RN care. Some of the clues are: "newly admitted," "newly diagnosed" and "current alcohol withdrawal" - each of these clients have a high risk of instability and/or require the specialized nursing knowledge, skill or judgment of a registered nurse. LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS assigninterventionLPN

The nurse is caring for a client who is unconscious and receiving gastric tube feedings. Which assessment finding requires an immediate action from the nurse? Decreased breath sounds in the right lower lobe Formula residual volume of 100 mL Decreased bowel sounds in all quadrants Urine output of 250 mL in the past eight hours

a; The most common problem associated with enteral feedings is aspiration with resulting atelectasis and pneumonia. A nursing action should be to maintain clients at a minimum of 30 degrees of head elevation during feedings and up to two hours afterwards. The nurse should verify tube placement prior to each feeding or every four to eight hours if the client receives a continuous feeding. Incorrect LESSON Reduction of Risk Potential Potential for Alterations in Body Systems COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS tube feedingunconsciousassesspneumonia

The nurse is planning to give a 3-year-old child oral digoxin. Which action is the best approach by the nurse? "You will feel better if you take your medicine." "Would you like to take your medicine from a spoon or a cup?" "This is your medicine, and you must take it all right now." "Do you want to take this pretty red medicine?"

a;At 3 years of age a child often feels a loss of control when hospitalized. Giving a choice about how to take the medicine allows the child to express an opinion and have some control. Incorrect LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS childoraldigoxinchoice

The pediatric nurse is teaching the parents of a 6-year-old child with recurrent otitis media about tympanostomy tubes. Which instructions should the nurse include? "You will continue to see ear drainage for up to 7 days." "Your child should not swim in the pool while the tubes are in place." "The tubes will have to be surgically removed in a few years." "The tubes are sutured in place to prevent them from falling out."

a; Tympanostomy tubes are pressure equalization devices (grommets) that facilitate drainage and ventilation of the middle ear. Their placement may be indicated with chronic otitis media (OM) (three episodes in 6 months or four episodes in 1 year). Most children's hearing improves right after placement and ear drainage is common up to 1 week after insertion. They are not sutured in place. The tube is eventually pushed out of the eardrum, usually 8 to 18 months after tube placement. Parents should be aware of the appearance of a tympanostomy tube (usually a tiny plastic spool-shaped tube) so they can recognize it if it falls out. Most clients, including very young children, typically do not require special water precautions. LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM nervous KEYWORDS tympanostomyeartubeswimchild

The nurse is teaching a parent about side effects of routine immunizations. Which finding should be immediately reported to the primary health care provider? Seizure activity Fatigue Localized tenderness Irritability

a; While severe complications are rare, any seizure activity must be immediately reported; seizures can occur up to 7 days after injection. Other reactions that should be reported include crying for more than three hours, temperature over 105 F (40.5 C) following DTaP immunization, and tender, swollen, reddened areas where the shot was given. Correct! LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS immunizationside effect

The nurse is caring for a client who has decreased adrenal function. Which intervention should the nurse include in the client's plan of care? Limit the number of visitors Place the client in reverse isolation Encourage physical activity Prevent constipation

a; Any stress, either physical or emotional, places additional stress on the adrenal glands, which could precipitate an Addisonian crisis in this client. The plan of care should protect the client from stress by avoiding the emotional stress of (too many) visitors and by reducing physical activity until the client's condition stabilizes. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM endocrine KEYWORDS adrenalAddisonian crisisstress

The nurse is teaching a client with migraine headaches about almotriptan. Which statement by the client indicates that the teaching was effective? "I will take the medication as soon as I notice migraine symptoms." "I will take a dose every morning to make sure to prevent an acute attack." "If the first dose does not help, I can take two more doses 15 minutes apart." "I will wait to take the medication until the pain has become unbearable."

a; Almotriptan and other triptans are serotonin receptor agonists that work by causing vasoconstriction of intracranial arteries. The drug is most effective when taken as soon as migraine symptoms start but before the onset of acute pain. It will not prevent headaches or reduce the number of attacks. One of the most common side effects of this medication is dry mouth. After taking a dose, if the headache goes away and comes back, it is acceptable to take a second dose. The client should not take more than two doses of any triptan in 24 hours. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS headachemigrainetriptanteaching

The nurse is caring for a client who has been prescribed atropine preoperatively. The nurse understands the intended purpose for administering this preoperatively is to induce which effect? Decrease secretions Elevate blood pressure Reduce heart rate Enhance sedation

a; Atropine is a common anesthesia adjunct. It decreases the amount of secretions which, in turn, decreases the risk of aspiration during the operative procedure. Incorrect LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review KEYWORDS atropinesecretionaspiration

The nurse is providing education to the parents of a 10-year-old child who is diagnosed with diabetes insipidus (DI) and has been prescribed vasopressin. What priority information should the nurse include regarding this medication? The family must monitor the child for arrhythmias The child will need intravenous therapy for several weeks The child should be observed for dehydration Parents should administer the daily intramuscular injections

a; Diabetes insipidus is characterized by a decreased secretion of antidiuretic hormone (ADH). Decreased ADH results in polyuria and polydipsia; the person is unable to concentrate urine. Vasopressin is the drug of choice to treat central DI. At home, it can be administered 2-3 times a day, either IM, subQ or intranasally. Not drinking enough fluids can cause arrhythmias, fatigue and muscle pain. Other serious side effects include chest pain, skin discoloration and paresthesia. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM endocrine KEYWORDS diabetes insipidusvasopressinintranasalsubQIM

A client is prescribed heparin therapy for a deep vein thrombosis (DVT). Which laboratory value should the nurse monitor closely? Bleeding time Activated partial thromboplastin time Platelet count D-dimer

a; Heparin is used to prevent further clots from being formed and to prevent the present clot from enlarging. The activated partial thromboplastin time (APTT) test measures the time it takes blood to clot and is used to monitor the effectiveness of heparin therapy. The therapeutic range is about 1 1/2 to 2 or 2 1/2 times the normal values. D-dimer is used to evaluate blood clot formation. Platelet counts are used to evaluate abnormal bleeding times. Bleeding time refers to the time it takes for a pinprick to stop bleeding (normally, about 2 1/2 minutes.) LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS heparinthrombosisDVTlabaptt

A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is approximately 1.5 x 2.7 inches (4 cm x 7 cm) in size, the wound base is red and moist with no exudate and the surrounding skin is intact. Which wound dressing should the nurse select for this wound? Occlusive, moist dressing Leave open to air Transparent dressing Dry, sterile dressing with antibiotic ointment

a; The wound as described has granulation tissue present (red and moist wound base without exudate) which indicates the wound is healing and this new tissue must be protected. The use of an occlusive, moist dressing is the best choice because this type of dressing will protect the wound and new tissue and the moisture will support continued wound healing. LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM integumentary KEYWORDS ulcersacrumgranulationdressing

A mother asks the nurse if she should be concerned about her child's tendency to stutter. Which assessment data would be the most useful in counseling the parent? Age of the child Parental discipline strategies Current family stressors Sibling position in family (1 attempt remaining) Help|Terms & Trademarks © 2021 NCSBN. All rights reserved.

a;During the preschool period children use their rapidly growing vocabulary faster than they can produce their words. This failure to master sensorimotor integrations results in stuttering. This dysfluency in speech pattern is a normal characteristic of language development. Therefore, knowing the child's age is most important in determining if any true dysfunction might be occurring with stuttering. Incorrect LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review BODY SYSTEM nervous KEYWORDS childstuttercounselassess

The nurse is evaluating an adult client who is receiving continuous enteral nutrition (EN) through a nasogastric tube. Which findings indicate that the client may be experiencing a complication from the EN? Select all that apply. A weight loss of 2 kg in 24 hours Aspirated gastric fluid has a pH of 4 Gastric residual volume of 100 mL Pale and dry oral mucous membranes 200 mL dark yellow urine voided in the last eight hours New onset adventitious lung sounds

a;Pale and dry oral mucous membranes Correct Response 200 mL dark yellow urine voided in the last eight hours Correct Response New onset adventitious lung sounds; Pulmonary aspiration of enteral feeding formula is a risk for clients receiving EN. New onset of adventitious or abnormal lung sounds on auscultation in a client receiving EN are indicative of possible aspiration. Due to the nutrient-dense, hypertonic composition of enteral feeding formulas, clients on EN are at risk for developing hyperosmolar dehydration. Signs and symptoms of clinical dehydration include: weight loss, postural hypotension, tachycardia, thready pulse, dry mucous membranes, poor skin turgor, slow vein filling, flat neck veins when supine and dark yellow urine. If the dehydration is severe, the symptoms will include thirst, restlessness, confusion, hypotension, oliguria (urine output below 30 mL/hr) and cold, clammy skin. LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN & PN Review BODY SYSTEM gastroinstestinal KEYWORDS nasogastric tubeenteral feedingscomplication

The nurse is caring for a child who requires chest physiotherapy (CPT). Which nursing action is appropriate? Confine the percussion to the rib cage area Schedule the therapy 30 minutes after meals Place the child in a prone position for the duration of the therapy. Teach the child not to cough during the treatment

a;Percussion (clapping) should be done in the area of the rib cage anterior and posterior. This often requires various positions to remove all secretions. This therapy should be done one hour prior or two hours after meals. Children are encouraged to cough during treatments to help expel mucous. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM respiratory KEYWORDS physiotherapyCPTrib

The nurse is developing a plan of care for a client who has developed blisters and sores in the mouth after receiving chemotherapy. Which interventions should the nurse include? Select all that apply. Avoid spicy or acidic foods. Use strong mouthwashes to kill bacteria. Visit a dental hygienist weekly. Drink 2 or more liters of water per day. Suck on ice chips during chemotherapy. Examine your mouth frequently.

acde; Mucositis is a complex, multiphase process at the cellular level started in response to cytotoxic chemotherapy. The epithelial cells in the mouth are very sensitive to chemotherapy due to their high rate of cell turnover. Oral cryotherapy using ice water or ice chips can be used for the prevention of mucositis. It is believed that vasoconstriction caused by the cold temperature decreases exposure of the oral mucous membranes to the mucositis-causing agents. Frequent mouth assessment, and good and frequent oral hygiene are key in managing mucositis. The client should avoid the use of "strong" mouthwashes that often contain alcohol. Mucositis can be managed at home and does not require seeing a dental hygienist. Increased hydration is generally recommended. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM integumentary KEYWORDS chemotherapymucositis

The nurse is caring for clients in an inpatient mental health unit. In order to develop a therapeutic milieu, the nurse should include which intervention in the client's plan of care? Form a group forum in which clients decide on unit rules, regulations and policies Provide a testing ground for new patterns of behavior while clients take responsibility for their own actions Discourage expressions of anger to avoid disrupting other clients. Offer a businesslike atmosphere where clients can work on individual goals

b A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior while holding client's responsible for their actions. The other approaches are part of various types of therapy. LESSON Psychosocial Integrity Therapeutic Environment COURSE RN Review KEYWORDS inpatienttherapeuticresponsibilitygoal

The nurse is reinforcing teaching to a 24-year-old woman receiving acyclovir for a Herpes Simplex Virus type 2 infection. Which instructions should the nurse provide the client with? Stop treatment if she thinks she may be pregnant Begin treatment with acyclovir at the onset of symptoms of recurrence Complete the entire course of the medication for an effective cure Continue to take prophylactic doses for at least five years after the diagnosis

b When the client is aware of early symptoms, such as pain, itching or tingling, treatment is very effective. Medications for herpes simplex do not cure the disease. They simply decrease the intensity of the symptoms. Acyclovir (Zovirax) is not known to have an impact on the fetus. Acyclovir should not be taken for preventive purposes, regardless of the date of diagnosis. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM lymphatic KEYWORDS acyclovirZoviraxherpesteach

The nurse is caring for a client who is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which problem should be addressed as a priority in planning care? Skin irritation Leukopenia Fatigue Esophagitis

b Clients being treated by radiation over the sternum, which is a bone marrow producing area, develop leukopenia due to the depressant effect of radiation therapy on the bone marrow function. With the resultant low white counts, infection is a potential outcome. The other options are possible complication outcomes of radiation therapy on this part of the body. However, they are not the priority because leukopenia is a threat to the entire body and the other options are more of a local problem. Incorrect LESSON Reduction of Risk Potential Potential for Alterations in Body Systems COURSE RN Review BODY SYSTEM respiratory KEYWORDS cancerradiationtreat

The nurse is providing discharge education to a client diagnosed with fibromyalgia syndrome (FMS). Which statement by the client indicates that additional teaching is needed? "I will take an exercise class - maybe I'll sign up for a yoga class." "If my pain stays the same, I will take an extra dose of the pregabalin." "I should take the duloxetine once a day, every day." "I will avoid caffeine, sugar, and alcohol before bedtime."

b; Fibromyalgia Syndrome (FMS) or fibromyalgia is a chronic pain syndrome, characterized by pain in the lower back, neck, or head that can be triggered by pressure, noxious stimuli, or stress. The client will often complain of sleep cycle disturbance and moderate to severe fatigue. Treatment for fibromyalgia is varied, but medications such as duloxetine and pregabalin are FDA-approved for the treatment of FMS. Pregabalin [Lyrica] reduces GABA neurotransmitter release, helping to relieve neuropathic pain seen with FMS. Pregabalin has the potential for abuse and physical dependence and is classified as a Schedule V controlled substance. The client should be instructed not to take additional doses if pain is not relieved and to notify their health care provider instead. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS fibromyalgiafatiguepregabalinduloxetine

The nurse is caring for a client who has been prescribed atropine preoperatively. The nurse understands the intended purpose for administering this preoperatively is to induce which effect? Reduce heart rate Decrease secretions Enhance sedation Elevate blood pressure

b; Atropine is a common anesthesia adjunct. It decreases the amount of secretions which, in turn, decreases the risk of aspiration during the operative procedure. Incorrect LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review KEYWORDS atropinesecretionaspiration

The nurse is teaching a client diagnosed with type 2 diabetes mellitus about the prescribed diet. Which instructions should the nurse include? Have something sweet available at all times for hypoglycemic episodes. Keep a regular schedule of meals and snacks. Reduce carbohydrate intake to 25% of total calories. Maintain previous calorie intake but add more protein. (1 attempt remaining)

b; Currently, calorie-controlled diets with strict meal plans are rarely suggested for clients diagnosed with type 2 diabetes mellitus. The proper approach to eating is an incorporation of a schedule with food changes into clients' existing dietary patterns. Client's should learn to read labels and identify specific canned foods, frozen entrees, or other foods that are acceptable. Many clients can manage type 2 diabetes mellitus with diet and exercise, eliminating the need for insulin therapy and the risk of hypoglycemia. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM endocrine KEYWORDS diabetestype 2teachdiet

A 23-year-old single client in the 33rd week of her first pregnancy tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize? Focus on fetal development Anticipation of the birth Ambivalence about pregnancy Acceptance of the pregnancy (1 attempt remaining)

b; Directing activities toward preparation for the newborn's needs and personal adjustment are indicators of appropriate emotional response in the third trimester and a part of "nesting" according to Rubin. Ambivalence about pregnancy is an expected emotion during the first trimester. Acceptance of the pregnancy with a focus on fetal development are important in the second trimester. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS pregnancyemotionalreaction

The nurse is assessing a 6 year-old child for the first time in the clinic and finds that the child has deformities of the joints, limbs and fingers; a thinned upper lip; and small teeth with poor enamel. The mother states: "My child struggles with counting and color recognition." Based on this data, the nurse suspects that the child is most likely displaying the effects of which problem? Fetal alcohol syndrome (FAS) Congenital abnormalities Lead poisoning Chronic toxoplasmosis

b; Major features of fetal alcohol syndrome (FAS) are facial and other malformed physical features, such as small head circumference and brain size (microcephaly), small eyelid openings, a sunken nasal bridge, an exceptionally thin upper lip, a short, upturned nose and a smooth skin surface between the nose and upper lip. Vision difficulties include nearsightedness (myopia). Other findings are mental retardation, delayed development, abnormal behavior such as short attention span, hyperactivity, poor impulse control, extreme nervousness and anxiety. Behavioral problems, cognitive impairment and psychosocial deficits are also associated with this syndrome. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM nervous KEYWORDS FASalcoholdeformitieslipteethassesschild

The nurse manager uses a block scheduling plan for staffing. Staff have asked for many changes and exceptions to the schedule over the past few months and the nurse manager is considering self-scheduling. Which type of effect does the nurse manager anticipate with self-scheduling? Reduced overtime payouts Improved team morale Improved quality of care Decreased staff turnover

b; Nurses in direct care positions are more satisfied when opportunities exist for autonomy and control. The nurse manager becomes the facilitator rather than the decision maker of the schedule for unit needs when self-scheduling exists. Peer pressure and team work are the driving forces during self-schedule approaches. Incorrect LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS managerschedulechange

The parent of a 2-year-old hospitalized child asks the nurse why the child starts screaming every time the parent gets ready to leave the hospital room. How should the nurse respond? "I think it would be best not to stay with the child while in the hospital." "At this age, this is a normal response to fear of being separated from you." "Don't worry, that behavior will stop in a few days with patience from you." "You might want to "sneak out" of the room once the child falls asleep."

b; The protest phase of separation anxiety is a normal response for a child this age. In toddlers, ages 1 to 3, separation anxiety is at its peak. After three years of age it begins to diminish until the adolescent years, when the behavior is minimal. In addition, the stress of being hospitalized is most likely adding to the child's separation anxiety. The other responses are incorrect and nontherapeutic. Incorrect LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS toddlerseparation anxiety

The nurse is teaching a smoking cessation class and notices there are two pregnant women in the group. Which information is a priority for these women? The placenta serves as a barrier to nicotine There is a relationship between smoking and low birth weight Low tar cigarettes are less harmful during pregnancy Moderate smoking is effective in weight control

b; Nicotine reduces placental blood flow and may contribute to fetal hypoxia or placenta previa, which results in decreased growth potential of the fetus. Nicotine readily crosses the placenta and any form of nicotine should be avoided during pregnancy. Incorrect LESSON Health Promotion and Maintenance High Risk Behaviors COURSE RN Review BODY SYSTEM reproductive KEYWORDS smokingcessationpregnant

The nurse is caring for a client who was in a motor vehicle accident. Which finding should be the highest priority if newly identified by the nurse? Reduced sensory responses Pupils fixed and dilated Flaccid paralysis Diminished spinal reflexes

b; ' Pupils that are fixed and dilated indicate overwhelming injury and intrinsic damage to the upper brain stem, and would be the highest priority as it is a poor prognostic sign. The other findings are more consistent with partial dysfunction of the brain or spinal cord. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM nervous KEYWORDS pupilsparalysisassessment

The nurse is assessing a 6 year-old child for the first time in the clinic and finds that the child has deformities of the joints, limbs and fingers; a thinned upper lip; and small teeth with poor enamel. The mother states: "My child struggles with counting and color recognition." Based on this data, the nurse suspects that the child is most likely displaying the effects of which problem? Chronic toxoplasmosis Fetal alcohol syndrome (FAS) Lead poisoning Congenital abnormalities

b; Major features of fetal alcohol syndrome (FAS) are facial and other malformed physical features, such as small head circumference and brain size (microcephaly), small eyelid openings, a sunken nasal bridge, an exceptionally thin upper lip, a short, upturned nose and a smooth skin surface between the nose and upper lip. Vision difficulties include nearsightedness (myopia). Other findings are mental retardation, delayed development, abnormal behavior such as short attention span, hyperactivity, poor impulse control, extreme nervousness and anxiety. Behavioral problems, cognitive impairment and psychosocial deficits are also associated with this syndrome. LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM nervous KEYWORDS FASalcoholdeformitieslipteethassesschild

The nurse is teaching a school-aged child and family members about the use of inhalers prescribed for asthma. Which statement made by a family member indicates an understanding of the nurse's instructions? "We can rely on our child's self-report of symptoms." "We will keep a chart of daily peak flow meter results." "Monitoring our child's pulse rate is not necessary." "Skin color changes in our child is an early warning sign for airway constriction."

b; The peak flow meter can help determine if the symptoms of asthma are in control or are worsening. It works by measuring how fast air comes out of the lungs when the client forcefully exhales (the peak expiatory flow or PEF). The client should record the highest of three readings in an asthma diary daily. Children ages 4 and up should be able to use a peak flow meter. A decrease in PEF is an early warning sign for airway constriction and should be immediately addressed. Family members should monitor the child's pulse rate and changes in skin color is a late sign. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM respiratory KEYWORDS asthmachildinhalerpeak flow meter

The nurse is auscultating the heart of a client who has dilated cardiomyopathy. Which finding should the nurse expect to hear? Diastolic murmur Ventricular gallop of S3 Split S2 Apical click

b;A ventricular gallop, S3 is caused by blood flowing rapidly into a distended noncompliant ventricle. This is the most common sound with left-sided heart failure. Increased left heart pressures may cause dilation of the mitral valve in the client with heart failure resulting in a systolic murmur. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS auscultationheart failureS3heart sounds

The nurse in a primary care clinic is reviewing the medical record of a client with chronic gastroesophageal reflux disease (GERD). Which findings are risk factors for developing GERD? Select all that apply. Diabetes mellitus type 2 Being overweight or obese Taking a calcium channel blocker Smoking Essential hypertension Helicobacter pylori infection

bcdf Gastroesophageal reflux disease or GERD occurs as a result of backward flow of stomach contents into the esophagus. The most common cause of GERD is excessive relaxation of the lower esophageal sphincter (LES), which allows the reflux of gastric contents into the esophagus and exposure of the esophageal mucosa to acidic gastric contents. A number of factors can decrease LES pressure including calcium channel blockers, smoking and alcohol. Clients who are overweight or obese are at highest risk for development of GERD because increased weight increases intra-abdominal pressure, which contributes to reflux of stomach contents into the esophagus. Helicobacter pylori infection can also contribute to GERD. Diabetes and hypertension are not considered risk factors for GERD. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS GERDrisk factors

The nurse is caring for a client who has gastroesophageal reflux disease (GERD). The primary health care provider's orders include omeprazole twice a day, Maalox prior to meals, elevation of the head of the bed, an acid-reflux diet, and no alcohol. Which order should the nurse question? Schedule for the proton-pump inhibitor Bed position Schedule for antacid Prescribed diet

c All of the options listed are potential recommendations but the schedule for antacids should be one to three hours after eating and at bedtime as needed. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS pharmacologygastroesophageal reflux diseaseomeprazolePrilosecMaalox

The home health nurse is developing a plan of care for a client with osteoarthritis. What should be the priority goal for this client? Take medications as prescribed Maintain and preserve functional status Exhibit healthy coping mechanisms Maintain a healthy weight

c Osteoarthritis (OA) is the progressive deterioration and loss of cartilage and bone in one or more joints. The client with OA is expected to maintain or improve a level of mobility/functional status and activity that allows him or her to function independently with or without an assistive ambulatory device for as long as possible. Management of the client with OA often requires an interprofessional health team effort. If needed, the nurse should consult and collaborate with the physical therapist (PT) and occupational therapist (OT) to meet the outcome of independent function and mobility. Major interventions include therapeutic exercise and the promotion of ADLs and ambulation by teaching about health and the use of assistive devices. LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN & PN Review BODY SYSTEM musculoskeletal KEYWORDS osteoarthritis

The nurse is developing a plan of care for a client who is on complete bed rest due to an unstable spinal cord injury at the T-7 level. Which intervention is the priority? Assist the client with eating as needed Increase fluid intake to 3 to 4 liters per day Place the client on a pressure-reducing mattress Monitor the client for constipation (1 attempt remaining)

c The priority intervention shall focus on maintaining skin integrity because this client is at high risk for skin breakdown related to prolonged immobility and decreased sensation below the level of injury. The initial approach should be the selection and then placement of the client on the best support surface or mattress for the relief of pressure, shear and friction forces. Incorrect LESSON Basic Care and Comfort Mobility, Immobility COURSE RN Review BODY SYSTEM integumentary KEYWORDS spinal cord injuryskin integrityimmobility

The labor and delivery nurse is counseling a couple who experienced the loss of their fetus at 28 weeks gestation. Which suggestion would be most appropriate? Plan for another pregnancy within two years and maintain physical health Focus on the other children and move through the loss quickly Discuss feelings with each other and use grief support resources Seek an explanation for the death and come to an acceptable conclusion

c To communicate in a therapeutic manner, the nurse should help the couple begin the grieving process by suggesting that the couple communicate with each other and seek out grief support resources. To ignore the loss or focus on "why" the death occurred when there often isn't an identifiable cause or to suggest to plan for another pregnancy are nontherapeutic and inappropriate suggestions. Incorrect LESSON Psychosocial Integrity Grief, Loss COURSE RN Review BODY SYSTEM reproductive KEYWORDS fetal deathgrief processtherapeutic communication

The nurse is caring for a client who has gastroesophageal reflux disease (GERD). The primary health care provider's orders include omeprazole twice a day, Maalox prior to meals, elevation of the head of the bed, an acid-reflux diet, and no alcohol. Which order should the nurse question? Prescribed diet Bed position Schedule for antacid Schedule for the proton-pump inhibitor

c; All of the options listed are potential recommendations but the schedule for antacids should be one to three hours after eating and at bedtime as needed. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS pharmacologygastroesophageal reflux diseaseomeprazolePrilosecMaaloxGERD

A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should include which focus? Talk with the father and help him accept the wife's decision Discuss sharing parenting responsibilities with the mother Encourage the mother to express her feelings and concerns Arrange for the parents to attend infant care classes

c; Encouraging the mother to express her feelings may lead to resolution of competitive feelings in a new family. Cultural influences may also be clarified at this time. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS newborninterventionpostpartum

The nurse is performing an admission assessment on an older adult male client who reports frequent episodes of constipation. Which initial information should the nurse obtain? Family history Trends in weight gain or loss Health history and client's diet. Elimination pattern over the past week

c; Initially, the nurse should obtain the client's health history, noting risk factors, comorbid conditions, and medications that can contribute to constipation. The nurse should also assess the client's diet, including fiber intake. Then the nurse should determine what the client's elimination pattern has been. Incorrect LESSON Basic Care and Comfort Elimination COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS constipationassessmenthealth history

The nurse is teaching a pregnant woman who follows a vegetarian diet about prevention of iron-deficiency anemia. Which food selection indicates that the woman understood the teaching? Whitefish with potatoes Cereal with dried fruits Whole grain bread with butter Scrambled eggs with cheese (1 attempt remaining)

c; Iron is found in both plant and animal sources. Heme iron, found in animal sources of meat, fish, and poultry, is more easily absorbed than nonheme iron found in plant foods. Animal sources of iron also contain nonheme iron in addition to heme iron. Although egg yolks contain iron, the iron in them is not absorbed as well as other heme from other sources. Nonheme iron plant sources include vegetables, legumes, dried fruits, whole-grain cereals, and enriched grain products, especially iron-fortified dry cereals. For this client (vegetarian), cereals with dried fruits represent a food selection as a good source of iron. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS iron-deficiencypregnancyvegetarian

The charge nurse in a critical care unit is making assignment for a group of nurses. One of the nurses usually works on an oncology unit but was "floated" to the critical care unit due to staffing needs. Which of the following clients is most appropriate to assign to the oncology nurse? A client 4 hours post-thoracic surgery A client on a continuous infusion of diltiazem A client admitted with a pulmonary embolism A client on mechanical ventilation due to COVID-19

c; A nurse who is unfamiliar with clients typically found in a critical care unit should be assigned the most hemodynamically stable, least critically ill client. Although all of the clients require close monitoring, the client with the pulmonary embolism appears the most stable at this time. The other clients require specialized nursing skills and knowledge and should not be assigned to the oncology nurse. Incorrect LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS assignUAProutinepredictable

The nurse is caring for a client who is actively dying and has been receiving high doses of opioid analgesics. The client has become unresponsive to verbal stimuli. What action should the nurse take? Decrease the analgesic dosage by half Stop giving the analgesic Continue the analgesic at the current dose Give an extra dose of the analgesic (1 attempt remaining)

c; Clients who are actively dying and have been experiencing chronic pain, will probably continue to experience pain even though they cannot communicate this. Pain medication should be continued at the same dose as long as it is effective at that dose; some adjustment may be needed based on the client's physical manifestations of pain, such as grimacing or moaning. Incorrect LESSON Pharmacological (and Parenteral Therapies) Pharmacological Pain Management COURSE RN Review KEYWORDS opioidanalgesicterminal CONFIDENCE

An experienced nurse manager is explaining a reward-feedback system to a new manager. Which statement best describes the characteristic of an effective reward-feedback system? Performance goals should be higher than what is attainable Staff are given feedback in equal amounts over time Specific feedback is given as close to the event as possible Positive statements should precede a negative statement

c; Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if what constitutes appropriate behavior is clearly understood. Correct! LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS rewardfeedbackevent

The nurse admits a 50-year-old client with a three-day history of swelling of the face, hands and feet; foamy brown urine; fever and malaise. Which information obtained in the admission interview alerts the nurse that these findings may reflect a diagnosis of acute glomerulonephritis? Type 1 diabetes since age 15 Travel to a foreign country Sore throat two weeks ago History of mild hypertension

c; Glomerulonephritis commonly presents with proteinuria (foamy urine) that is rusty or brownish in appearance and swelling due to the systemic protein loss. In the majority of cases of acute glomerulonephritis, there is a history of an untreated streptococcal throat infection preceding the onset of symptoms by two to three weeks. The other options are not directly related to the development of acute glomerulonephritis. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM urinary KEYWORDS kidneyswellingproteinuriapainglomerulonephritis

The nurse is assessing a client during a visit to a community mental health center. The client discloses that "I have been thinking about ending my life." Which statement would be the nurse's best response to this information? "We will help you deal with those thoughts." "Is your life so terrible that you want to end it?" "Have you thought about how you would do it?" "Do you want to discuss this with your pastor?" (1 attempt remaining)

c; Most experts believe that people who commit suicide don't want to die; they just want to stop hurting. When a client tells you s/he is thinking about death or suicide, you must evaluate the immediate danger the person is in. The correct option provides an opening to discuss the plan, the means (pills, gun, etc.), time set for doing it, and intent to commit suicide. Clients who have formulated a suicide plan are closer to suicidal behavior than those who have vague, nonspecific thoughts. Incorrect LESSON Psychosocial Integrity Crisis Intervention COURSE RN Review KEYWORDS suicideassessmental

The community health nurse is preparing to teach a group of new parents about infant nutrition. Which information should the nurse include? Give a gummy multivitamin once a day Add egg whites early to increase protein intake Introduce solid foods one at a time, beginning with cereal Mix infant cereal with 2% or skim milk

c; Solid foods should be added, one at a time, between 4 to 6 months. If the infant is able to tolerate the food, another is then added each week. Iron-fortified cereal is the recommended first food; rice cereal is recommended due to the low risk of food allergies. Teach parents to mix the cereal flakes with either breast milk or formula, not cow's milk. After the baby is eating cereal, pureed meat, vegetables and fruits can be introduced. Egg whites and wheat products should not be given before the baby is at least a year old because these foods are more commonly associated with allergies. Supplemental vitamins are generally not needed, as long as the child is receiving a well-balanced diet. LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review KEYWORDS cerealfeedteach

A licensed practical nurse (LPN) from the float pool is sent to an adult medical-surgical unit. With this newly added staff, the charge nurse needs to revise assignments for the shift. Which clients are appropriate to assign to the float pool LPN? A young adult client with a history of schizophrenia who is experiencing alcohol withdrawal syndrome and a client diagnosed with chronic renal failure and anemia. A trauma victim newly admitted with a diagnosis of quadriplegia and a client one day postoperative after a radical neck dissection A middle-aged client who has a gastrostomy tube and has been diagnosed with hemiplegia and a client with a below-the-knee amputation (BKA) who will begin physical therapy A geriatric client with newly diagnosed type 2 diabetes and a client who is positive for Human Immunodeficiency virus with a diagnosis of pneumonia.

c; The client diagnosed with hemiplegia (and a gastrostomy tube) and the client who is starting physical therapy following a BKA require supportive care and interventions that are within the scope of practice of a LPN. These clients are the most stable and have a minimal risk of complications. The clients in the other options require RN care. Some of the clues are: "newly admitted," "newly diagnosed" and "current alcohol withdrawal" - each of these clients have a high risk of instability and/or require the specialized nursing knowledge, skill or judgment of a registered nurse. Incorrect LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS assigninterventionLPN

The nurse is planning to administer otic drops to a 6-year-old child. Which action is part of the correct procedure? Insert cotton in the inner ear after giving medication Place several drops in the outer ear Hold the pinna up and back to instill the drops Assist the child to lie on the affected side afterward

c; The external auditory canal should be straightened by gently pulling the pinna up and back for otic drop administration. In children who are under three years of age, the pinna should be pulled down and back. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM nervous KEYWORDS oticdropschildpinnaear

The nurse is providing education for a client who has asthma. Which factor is a priority for the client to monitor daily? Pulse oximetry Respiratory effort Peak air flow volumes Respiratory rate

c; The peak air flow volume decreases about 24 hours before clinical manifestations of exacerbation of asthma. Note that the question asks for a priority so all of the options would be monitored. However, the peak air flow is the priority. Correct! LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM respiratory KEYWORDS asthmamonitorpeak air flow volume

A child with Tetralogy of fallot visits the clinic several weeks before a scheduled surgery. The nurse should give priority attention to which focus? Maintenance of adequate nutrition Observation for developmental delays Assessment of oxygenation Prevention of infection

c; All of the responses would be important for a child diagnosed with tetralogy of Fallot. However, persistent hypoxemia causes acidosis, which further decreases pulmonary blood flow. Additionally, low oxygenation leads to development of polycythemia and may result in neurological complications. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS tetralogy of Fallotsurgeryoxygenheartcongenitalchildclinic

The nurse is caring for a postoperative client who had a laparotomy six hours ago. Which nursing intervention is the most effective in preventing atelectasis from developing? Maintain adequate hydration Splint the incision with a pillow Assist the client to slowly deep breathe and cough Ambulate the client within 24 hours postoperative

c; Deep air excursion by slow deep breathing and coughing expands the lungs and stimulates surfactant production. This is the priority to prevent pulmonary complications along with the use of an incentive spirometer. The nurse should instruct the client on how to splint the abdomen when coughing. Maintaining hydration is also an important role in preventing atelectasis. Postoperative patients should be encouraged to ambulate early to promote bowel motility and lung expansion. LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN Review BODY SYSTEM respiratory KEYWORDS atelectesispostopdeep breathecough

The nurse is providing education for a client who has asthma. Which factor is a priority for the client to monitor daily? Pulse oximetry Respiratory rate Peak air flow volumes Respiratory effort

c; The peak air flow volume decreases about 24 hours before clinical manifestations of exacerbation of asthma. Note that the question asks for a priority so all of the options would be monitored. However, the peak air flow is the priority. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM respiratory KEYWORDS asthmamonitorpeak air flow volume

The nurse has completed discharge teaching to a client who had a total hip arthroplasty. Which statement made by the client indicates further teaching is needed? "I'll use an electric razor to shave." "If my hip pain gets worse I should call my doctor." "Now I will be able to bend forward to tie my shoes without pain." "When I go home, I should not stand for long periods." (1 attempt remaining)

c;Someone who had a total hip replacement should not sit or stand for prolonged periods of time to help prevent thromboembolism and muscle fatigue. Because anticoagulants are typically used postoperatively, the use of an electric razor is indicated. Any increase in hip pain must be evaluated for complications. Following hip replacement surgery, a person should never bend at the waist more than 90 degrees, which would mean the person should not bend over to tie shoes. Incorrect LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS hiparthoplastyteach CONFIDENCE

A client states, "People think I'm no good, you know what I mean?" Which response by the nurse would be the most therapeutic? "I think you are good. Now, there is one person who likes you." "We can discuss possible reasons you create this impression on people." "People often take their own feelings of inadequacy out on others." "I am not sure what you mean. Tell me more about that."

d Asking the client to explain in more detail allows the nurse to gain insight into why the client feels this way. Therapeutic communication techniques elicit more information from the client, especially when delivered in an open, nonjudgmental fashion. By seeking more information, the nurse is applying the first step of the nursing process which is assessment. Correct! LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS therapeuticcommunication

The nurse is taking a health history from a Native American client. It is critical for the nurse to remember that eye contact with such clients may be interpreted as which behavior? Professional Expected Enjoyable Rude

d Native Americans tend to consider direct eye contact to be impolite or aggressive among strangers. The nurse should not misinterpret lack of direct eye contact as a clinical symptom. Correct! LESSON Psychosocial Integrity Religious, Spiritual Influences on Health COURSE RN Review KEYWORDS Native Americaneye contactbehavior

The nurse works in an assisted living facility and cares for older adults. The nurse understands that older adults are at a greater risk for drug toxicity than younger adults due to which physiological change associated with aging? Drugs are absorbed more readily from the gastrointestinal tract Older adults have more rapid hepatic metabolism Older adults are often malnourished and anemic Older adults have less body water and more fat

d; Because older adults have decreased lean body tissue and water in which to distribute medications, more drug remains in the circulatory system, creating a potential for drug toxicity. Increased body fat results in greater amounts of fat-soluble drugs being absorbed, leaving less medication in circulation, thus increasing the duration of action of the drug. Correct! LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review KEYWORDS toxicdrugaging

The nurse is teaching the parents of a 3-month-old infant about nutrition. During this time in infancy, the most ideal source of nutrition should come from which source? Whole milk Commercial formula Infant cereal Breast milk

d; Human milk is the most desirable complete diet for the infant during the first 6 months. An acceptable alternative to breastfeeding is commercial iron-fortified formula. Whole cow's milk, low-fat cow's milk, skim milk, other animal milks are not acceptable as a major source of nutrition for infants because of their limited digestibility, increased risk of contamination, and lack of components needed for appropriate growth. Whole milk can cause iron deficiency anemia in infants, possibly as a result of occult gastrointestinal blood loss. Pasteurized whole cow's milk is deficient in iron, zinc, and vitamin C and has a high renal solute load, which makes it undesirable for infants less than 12 months of age. The addition of solid foods before 4 to 6 months of age is not recommended. Correct! LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review KEYWORDS infantnutritionfluid

The nurse is performing an admission assessment on an older adult male client who reports frequent episodes of constipation. Which initial information should the nurse obtain? Family history Elimination pattern over the past week Trends in weight gain or loss Health history and client's diet.

d; Health history and client's diet. Correct! Initially, the nurse should obtain the client's health history, noting risk factors, comorbid conditions, and medications that can contribute to constipation. The nurse should also assess the client's diet, including fiber intake. Then the nurse should determine what the client's elimination pattern has been. LESSON Basic Care and Comfort Elimination COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS constipationassessmenthealth history

The nurse is providing anticipatory guidance to the parents of a 6-month-old infant. Which intervention should the nurse recommend to support the development of trust? Do not allow the child to be held for too long Provide warm blankets to facilitate sleep Offer feedings on a strict, set schedule Tend to the child quickly when it begins to cry

d; Social and emotional development is based in trust, love, and security. The best way to develop trust is to consistently and promptly meet the infant's needs. When an infant cries, it is a way for the infant to communicate a need such as being hungry, wet, in pain or scared. By attending to a crying infant quickly, it will help to establish trust. The other interventions will not help to promote the development of trust in the child.

The nurse is about to administer medications to a client when the client states, "I do not want to take that medication today." Which statement is the nurse's best response? "I will have to call your doctor and report this." "Do you understand the consequences of refusing your prescribed treatment?" "That's OK, its all right to skip your medication now and then." "Is there any particular reason why you don't want to take your medicine?"

d; When a new problem is identified, it is important for the nurse to collect accurate information directly from clients. This is crucial to ensure that clients' needs are adequately identified in order to select the best nursing care approaches. The nurse should pursue a conversation with the client to reveal any reasons for the medication refusal. It may be that the client has developed untoward side effects. Correct! LESSON Management of Care or Coordinated Care Client Rights COURSE RN Review KEYWORDS administrationmedication

The nurse is caring for a client admitted to the hospital with severe left-sided flank pain and hematuria. Diagnostic tests indicate a kidney stone partially obstructing the left ureter. Which outcome is the most important for this client? Pain controlled with medication Tolerates diet without nausea and vomiting Verbalizes understanding of the disease process Adequate urinary elimination is maintained (1 attempt remaining)

d; While all options are appropriate to the care of this client, urinary elimination is the nursing priority. A stone that completely obstructs the ureter can cause hydronephrosis and potential kidney damage. Remember Maslow - physiologic needs are more important than nutritional needs. Pain control and teaching are lower priorities. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM urinary KEYWORDS hematuriakidney stoneureter

A child with Tetralogy of fallot visits the clinic several weeks before a scheduled surgery. The nurse should give priority attention to which focus? Prevention of infection Observation for developmental delays Maintenance of adequate nutrition Assessment of oxygenation

d; All of the responses would be important for a child diagnosed with tetralogy of Fallot. However, persistent hypoxemia causes acidosis, which further decreases pulmonary blood flow. Additionally, low oxygenation leads to development of polycythemia and may result in neurological complications. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS tetralogy of Fallotsurgeryoxygenheartcongenitalchildclinic

The nurse has completed discharge teaching to a client who had a total hip arthroplasty. Which statement made by the client indicates further teaching is needed? "When I go home, I should not stand for long periods." "If my hip pain gets worse I should call my doctor." "I'll use an electric razor to shave." "Now I will be able to bend forward to tie my shoes without pain."

d; Someone who had a total hip replacement should not sit or stand for prolonged periods of time to help prevent thromboembolism and muscle fatigue. Because anticoagulants are typically used postoperatively, the use of an electric razor is indicated. Any increase in hip pain must be evaluated for complications. Following hip replacement surgery, a person should never bend at the waist more than 90 degrees, which would mean the person should not bend over to tie shoes. Incorrect LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS hiparthoplastyteach

The nurse is teaching a client with migraine headaches about almotriptan. Which statement by the client indicates that the teaching was effective? "I will wait to take the medication until the pain has become unbearable." "If the first dose does not help, I can take two more doses 15 minutes apart." "I will take a dose every morning to make sure to prevent an acute attack." "I will take the medication as soon as I notice migraine symptoms."

d; Almotriptan and other triptans are serotonin receptor agonists that work by causing vasoconstriction of intracranial arteries. The drug is most effective when taken as soon as migraine symptoms start but before the onset of acute pain. It will not prevent headaches or reduce the number of attacks. One of the most common side effects of this medication is dry mouth. After taking a dose, if the headache goes away and comes back, it is acceptable to take a second dose. The client should not take more than two doses of any triptan in 24 hours. Correct! LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS headachemigrainetriptanteaching