Done: Practice Question Banks 76-90 (Not Required)

The nurse is preparing to administer hydromorphone IV push to a client with severe pain due to osteosarcoma. The prescription reads: Administer hydromorphone 1.5 mg IV every 3 hours as needed for pain. The supplied vial contains hydromorphone 2 mg in 1 mL. How many mL shall the nurse draw up per dose? Record your answer to one decimal point. mL

Correct answer: 0.8 mLSet-up equation to solve for unknown.Known: 1 mL contains 2 mgUnknown: ? mL contains 1.5 mgSet-up equation to solve for unknown: 1 ml x 1.5 mg, divided by 2 mg = 0.75 or 0.8 mL Incorrect LESSON Pharmacological (and Parenteral Therapies) Dosage Calculation COURSE RN & PN Review KEYWORDS dosage calculation

The nurse is preparing to start a blood transfusion for a client with severe anemia. To reduce the risk of adverse transfusion reactions, which interventions are essential to include? Select all that apply. Maintaining the client on complete bed rest during the transfusion Verification of client by name, blood band number, blood type compatibility Monitoring of vital signs before, during and after the transfusion Placement of an appropriate size venous access device Use and priming of the appropriate tubing for the prescribed blood component Administration of supplemental oxygen

Monitoring of vital signs before, during and after the transfusion Correct Response Placement of an appropriate size venous access device Correct Response Verification of client by name, blood band number, blood type compatibility Use and priming of the appropriate tubing for the prescribed blood component Nursing actions during blood transfusions focus on prevention or early recognition of adverse transfusion reactions. Preparation of the client for transfusion is critical, and blood product administration procedures must be followed carefully. Human error is the most common cause of ABO incompatibility reactions. A peripheral venous access device should preferably be at least 20-gauge size. Client and blood product verification must be done by two [registered] nurses at the client's bedside. Vital signs should be obtained immediately prior to starting the transfusion, 15 and 30 minutes after start of the transfusion and hourly during the transfusion. Supplemental oxygen and bed rest are generally not required during a blood transfusion and will not prevent adverse transfusion reactions. Incorrect LESSON Pharmacological (and Parenteral Therapies) Blood and Blood Products - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS blood transfusion

The nurse is assigned to care for a client who was diagnosed with an intracranial aneurysm that has since resolved. To minimize the risk of another rupture, the nurse should plan to take which action? Avoid arousal of the client except for family visits Keep the client in a upright sitting position Apply a warming blanket for temperatures of 98 °F (36.6 C°) or less Treat any elevation in blood pressure (1 attempt remaining)

dTreating any blood pressure elevation and reducing stress by maintaining a quiet environment, including during family visits, will assist in minimizing the risk of a cerebral bleed. An upright sitting position with the pressure on the hip area can lead to increased intracranial pressure; this position should be avoided. A warming blanket is inappropriate to use. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS intracranialaneurysmbleed CONFIDENCE

A client has been prescribed alendronate for osteoporosis. Which statements indicate that the client understands how to safely take this medication? Select all that apply. "I will always eat breakfast before taking the pill." "I will stand or sit quietly for 30 minutes after taking the pill." "I will notify my doctor if I experience worsening heartburn." "I will take the pill with an antacid to prevent stomach upset." "I will swallow the pill with a full glass of water." (1 attempt remaining)

"I will stand or sit quietly for 30 minutes after taking the pill." Correct Response "I will notify my doctor if I experience worsening heartburn." "I will swallow the pill with a full glass of water." Alendronate is a bisphosphonate used to treat osteoporosis. It can cause esophagitis or esophageal ulcers unless precautions are followed. The client must sit upright or stand for at least 30 minutes after taking the medication. The client should take the medication with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication. Antacids will interfere with absorption and should not be taken at the same time. Incorrect LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN & PN Review BODY SYSTEM musculoskeletal KEYWORDS alendronateosteoporosis

The pediatric nurse is caring for an 18-month-old child admitted for severe dehydration. The health care provider has prescribed an intravenous (IV) replacement bolus of normal saline of 25 mL/kg to be infused over 2 hours. The child weighs 26 lbs. At what rate (mL/hour) shall the nurse program the infusion pump? Record your answer as a whole number.

Correct answer: 150 mLSteps to calculate hourly infusion rate:Step 1: Convert the child's weight from pounds to kilograms: 26 divided by 2.2 = 12Step 2: Calculate the total amount of IV fluid to be infused: 12 x 25 = 300Step 3: Calculate the hourly rate for a total infusion time of 2 hours (120 minutes): 300 divided by 2 = 150 mL/hour Incorrect LESSON Pharmacological (and Parenteral Therapies) Dosage Calculation COURSE RN Review KEYWORDS dosage calculation

The nurse is assessing a client who was admitted to the hospital with a diagnosis of right-sided heart failure. Which assessment findings should the nurse expect? Select all that apply. Cough Dependent edema Ascites Anorexia Orthopnea Polyuria

Dependent edema Correct Response Ascites Correct Response Anorexia The classic findings of right-sided heart failure arise from blood backing up into the portal and systemic circulation, resulting in abdominal organ engorgement, ascites, loss of appetite (anorexia), and dependent edema. Orthopnea and cough are more commonly seen with left-sided heart failure. Polyuria is not a manifestation of right-sided heart failure. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS heart failureassessmentorthopneaedema

A client who has returned from surgery reports feeling nauseated and later has an emesis. The nurse administers promethazine per standing orders. In addition to relief from nausea, what other effects of this medication does the nurse expect? Select all that apply. Sedation Dry mouth Rhinorrhea Pinpoint pupils Heart palpitations

Sedation Correct Response Dry mouth Heart palpitations; Promethazine is used as an antihistamine, sedative and antiemetic. It produces anticholinergic effects, such as dry mouth and reduced nasal congestion, dilated pupils and urinary retention. Although promethazine is a sedative, the nurse should understand that it can cause some people to have heart palpitations and to feel restless and unable to sleep. Incorrect LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review KEYWORDS nauseapromethazinesedationantihistamine

An older adult client, admitted after a fall at home, begins to seize and loses consciousness. What action should the nurse do next? Collect pillows and pad the side rails of the bed Stay with client and monitor the condition Place an oral airway in the mouth and suction Announce a cardiac arrest and plan to assist with intubation (1 attempt remaining)

Stay with client and monitor the condition;For the client's safety, remain at the bedside and observe respirations, the movements of the extremities and level of consciousness. Prepare to clear the airway or suction if obstructed. If suction equipment is not at the bedside, request that someone else get it for you, rather than leaving the client. Do not place anything in the client's mouth. For safety, do not leave the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the seizure. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM nervous KEYWORDS seizurelevel of consciousnessgeriatric

While working a 12-hour night shift, the nurse has a "near miss" and catches an error before administering a new medication to the client. Which factors could have contributed to the near miss? Select all that apply. The nurse has worked on the same unit for five years The nurse works in the intensive care unit (ICU) The nurse has worked four 12-hour night shifts in a row The nurse was interrupted when preparing the medication The nurse is assigned more clients than usual due to staffing issues

The nurse works in the intensive care unit (ICU) Correct Response The nurse has worked four 12-hour night shifts in a row Correct Response The nurse was interrupted when preparing the medication Correct! The nurse is assigned more clients than usual due to staffing issues Correct Response There are a number of reasons for near misses and making medication errors, including heavy workload and inadequate staffing, distractions, interruptions and inexperience. Fatigue and sleep loss are also factors, especially for nurses working in units with high acuity clients such as the ICU. Incorrect LESSON Safety and Infection Control Reporting of Incident, Event, Irregular Occurrence, Variance COURSE RN & PN Review KEYWORDS near missmedication error

The nurse is preparing to obtain an aerobic wound culture from a stage IV pressure ulcer. After removing the wound dressing, the nurse observes a moderate amount of purulent, foul-smelling exudate. Which action should the nurse take to ensure the best specimen? Using soap and water, wash the wound edges and wound bed first. Using a dry gauze pad, gently pat the wound to remove the exudate. Using a culture swab, obtain a scraping of tissue from the edges of the wound. Using a piston syringe, gently irrigate the wound with sterile normal saline.

Using a piston syringe, gently irrigate the wound with sterile normal saline.;Due to the presence of purulent exudate, the wound should first be irrigated with sterile normal saline to remove surface pathogens and exudate that will alter the wound culture. This is the best approach to obtain a noncontaminated specimen. Using dry gauze to remove the exudate can irritate the wound bed and cause bleeding. The specimen should ideally be taken from the wound bed, not the edges. Washing a stage IV pressure ulcer is not appropriate. Incorrect LESSON Reduction of Risk Potential Diagnostic Tests COURSE RN & PN Review BODY SYSTEM integumentary KEYWORDS specimen collectionwound culture

The nurse has an order to insert an indwelling urinary catheter for a male client. What is the best reason for lubricating the tip of the catheter prior to insertion? Reduce the friction within the urethra Minimize risk for infection Diminish the leakage of urine around the catheter Prevent bladder distention

a Due to the somewhat long length of the male urethra, lubrication reduces potential discomfort and localized tissue irritation as the catheter is passed. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM urinary KEYWORDS urethralcatheterindwelling

The nurse is preparing to administer acetaminophen liquid to a child with a fever. The prescription reads to administer 160 mg acetaminophen every 6 hours as needed for fever or pain. The supplied vial contains 80 mg acetaminophen in 10 mL solution. How many mL shall the nurse administer per dose? Record your answer as a whole number. mL

Correct answer: 20 mLSet-up equation to solve for unknown. Step 1: Known: 10 mL contain 80 mgStep 2: Unknown: ? mL contain 160 mgStep 3: Set-up equation: 160 mg x 10 mL, divided by 80 mg = 20 mL Incorrect LESSON Pharmacological (and Parenteral Therapies) Dosage Calculation COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS dosage calculation

The nurse is assessing a client who was admitted with suspected Guillain-Barré syndrome. Which assessment findings should the nurse expect? Select all that apply. Paresthesia Diarrhea Hyporeflexia Hypotonia Weakness Seizures

Paresthesia Hyporeflexia Correct Response Hypotonia Correct Response Weakness Guillain-Barré syndrome (GBS) is an autoimmune process that occurs after a viral or bacterial infection, causing acute inflammatory demyelinating polyneuropathy. Transmission of nerve impulses is stopped or slowed. This leads to flaccid paralysis with muscle denervation and atrophy. The main features of GBS include acute, ascending, rapidly progressive, symmetric weakness of the limbs. The first symptoms are weakness, paresthesia (numbness and tingling), and hypotonia (reduced muscle tone) of the limbs. Reflexes in the affected limbs are weak or absent. Diarrhea and seizures are not typically associated with GBS. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM nervous KEYWORDS Guillain-Barré syndrome

The nurse is caring for a 4-year-old child two hours after a tonsillectomy and adenoidectomy. Which finding must be reported to the health care provider immediately? Increased restlessness Complaints of throat pain Apical heart rate of 110 Vomiting of dark emesis (1 attempt remaining)

a ; Increased restlessness with increased respiratory and heart rates are often early signs of active bleeding. The other options are expected findings at this time in the postop period for this surgery. The dark emesis indicates old blood that most likely was swallowed during surgery. Incorrect LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN Review BODY SYSTEM lymphatic KEYWORDS restlesstonsillectomyassessment

The nursing home case management team including the client's spouse, are discussing the plan of care for a client with advanced dementia due to Alzheimer's disease. The client is exhibiting disorientation, agitation and hallucinations that noticeably worsen in the evening. Which intervention should the team recommend to be tried initially? A. Encourage the client's spouse to stay with the client in the evening. B. Administer a psychotropic medication in the late afternoon. C.Initiate transfer of the client to the 'locked' dementia unit. D. Serve the client dinner in their room.

a; Behavioral problems occur in about 90% of patients with Alzheimer's disease (AD). These problems include repetitiveness or asking the same question repeatedly, delusions, hallucinations, agitation, aggression, altered sleeping patterns, wandering, hoarding, and resisting care. When these behaviors become problematic, interventions must be planned carefully and should start with the least restrictive or invasive interventions. Having a calming family member stay with the client in the evening is a good, initial intervention to try. The other interventions are more restrictive/invasive and should be reserved for when all other measures have been exhausted. Correct! LESSON Psychosocial Integrity Therapeutic Environment COURSE RN Review KEYWORDS Alzheimer's diseasedementia

A client with angina has been instructed about the use of sublingual nitroglycerin. Which statement by the client indicates the need for additional teaching? A. "I understand that the medication should be kept in the dark bottle." B. "I can swallow two or three tablets at once if I have severe pain." C. "I'll call the health care provider if pain continues after three tablets five minutes apart." D. "I will rest briefly right after taking one tablet."

b Clients must understand that just one sublingual tablet should be taken at a time. Clients must also understand that they should rest when experiencing angina. Two or three tablets should not be used at once, even in the setting of severe pain, as this can lead to significant hypotension. The client should notify their primary healthcare provider should they not have a relief of symptoms with nitroglycerin use. Correct! LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS anginanitroglycerinsublingual

The nurse is reviewing the nutrition needs for a child diagnosed with cystic fibrosis. The nurse anticipates that the client is at risk for which vitamin deficiencies? A. A, B1 and C B. A, D and K C. A, C and D D. B12, D and K

b The uptake of fat-soluble vitamins, A, D and K, is decreased in children with cystic fibrosis. Vitamin B12 is deficient in clients who have had bariatric surgery or various degrees of a gastrectomy. Vitamin B1 is often deficient in clients who have an alcohol addiction. These clients are given thiamine (B1) injections three time daily to prevent Korsakoff syndrome. Vitamin D may be deficient in people who do not get at least 10 to 15 minutes of sunlight on the arms each day. Vitamin C deficit is associated with less than the needed intake of foods with vitamin C. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM respiratory KEYWORDS cystic fibrosisvitamindiet

The nurse assesses delayed gross motor development in a 3-year-old child. The inability of the child to do which action confirms this finding? Ride a bicycle Stand on one foot Catch a ball Skip on alternate feet

b; At this age, gross motor development allows a child to balance on one foot. Incorrect LESSON Health Promotion and Maintenance Techniques of Physical Assessment or Data Collection COURSE RN Review KEYWORDS motordevelopmentchildassess

The nurse is caring for a client who is receiving procainamide intravenously. It is most important that the nurse monitors which parameter? Serum potassium levels Neurological signs Continuous ECG readings Hourly urinary output

c; Procainamide is used to suppress cardiac arrhythmias. When administered intravenously, it must be accompanied by continuous cardiac monitoring. Incorrect LESSON Pharmacological (and Parenteral Therapies) Parenteral, Intravenous Therapies - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS pronestylprocainamideintravenousarrhythmiaECG CONFI

The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism after treatment for chronic renal disease. Which serum lab data should receive priority attention by the nurse? Osmolality and sodium Glucose and potassium Calcium and phosphorus Blood urea nitrogen and magnesium

c;The parathyroid gland regulates calcium and phosphorous levels. Clients with hyperparathyroidism often present with an elevation in both calcium and phosphorous levels. In clients with hypoparathyroidism, calcium and phosphorous serum levels may be low. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM endocrine KEYWORDS parathyroidcalciumphosphorusrenal

The nurse is caring for a client admitted with a diagnosis of Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in which substance? Carbohydrates Calcium Fiber Sodium

d;The client with Meniere's disease has an alteration in the balance of the fluid in the inner ear (endolymph). A low-sodium diet will aid in reduction of the fluid. Sodium restriction is commonly ordered as adjunct to diuretic therapy in the acute and chronic treatment. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM nervous KEYWORDS Meniere'sfoodsodium

The nurse checks lab results for an adult client with suspected cancer prior to a liver biopsy. Which finding requires immediate notification of the health care provider? Activated partial thromboplastin time (aPTT) of 50 seconds Hemoglobin of 11 g/dL (110 g/L) Increased serum ammonia Elevated blood urea nitrogen (BUN) and creatinine (1 attempt remaining)

Activated partial thromboplastin time (aPTT) of 50 seconds Because the liver is a vascular organ and a biopsy is an invasive procedure, bleeding is one of the risks. An elevated aPTT increases the risk of bleeding. Abnormal findings in the other labs would not increase the client's risk of complications following a liver biopsy. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN & PN Review BODY SYSTEM gastroinstestinal KEYWORDS partial thromboplastin timePTTaPTTliverbiopsy

The client is diagnosed with tuberculosis (TB). The nurse understands that the treatment plan for this client will involve what type of drug therapy? A. An anti-inflammatory agent B. Aminoglycoside antibiotics C. Administering two antituberculosis drugs D. High doses of B complex vitamins

Administering two antituberculosis drugs;In order to prevent drug-resistant strains of TB, clients are always prescribed at least two different anti-tubercular medications. Rifampin and isoniazid are the most effective drugs used to treat TB and are always used together, for at least six months. Additional medications, such as pyrazinamide and either streptomycin or ethambutol, may also be prescribed. Vitamin B6 is usually prescribed to help prevent expected side effect of isoniazid. Incorrect LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM respiratory KEYWORDS tuberculosisTBisoniazidtreatment

The nurse is caring for an 80-year-old client with community acquired pneumonia. Since admission, the client has been confused, pulling on tubes including his oxygen mask and peripheral venous access device. The client keeps trying to get out of bed unassisted and has had several near falls. Which interventions should the nurse include in the client's plan of care? Select all that apply. Request an order for a sedative medication at bedtime Request electronic or in-person client safety monitoring Request a PRN order for restraints Place a protective sleeve or elastic bandage over the peripheral venous access device Provide frequent reorientation to the environment Discontinue the oxygen since the client has a Do Not Resuscitate order

Request an order for a sedative medication at bedtime Correct Response Request electronic or in-person client safety monitoring Place a protective sleeve or elastic bandage over the peripheral venous access device Correct Response Provide frequent reorientation to the environment ;Older adult clients are at risk for developing delirium when they experience an acute infection and require hospitalization. The unfamiliar environment will contribute to any anxiety, fear and disorientation. It is challenging to care for clients with delirium and the nurse shall implement interventions that preserve the client's dignity and rights while also maintaining the client's safety and ensuring that the client receives all ordered medical therapies. A calm, soothing approach will help to establish trust and although not ideal, a mild sedative to facilitate sleep can be helpful. Many hospitals today utilize electronic or in-person client safety monitors to prevent falls and injury. The client safety monitor remains with the client at all times and verbally reorients the client and provides reminders for the client to wait for assistance. Oxygen therapy should be continued, regardless of resuscitation status, and restraints should never be ordered as needed or PRN. Incorrect LESSON Safety and Infection Control Accident, Error, Injury Prevention COURSE RN Review BODY SYSTEM respiratory KEYWORDS deliriumsafetyfall prevention CONFIDENCE

The client underwent a laparoscopic removal of the appendix. Which post-operative instructions will the nurse reinforce? Select all that apply. Restrict diet to bland, easily digestible food for a few days Use 2 tablespoons of Milk of Magnesia (MOM) if no bowel movement (BM) 3 days after surgery No showering for 48 hours after surgery Gently scrub off the "skin glue" when you feel able Maintain bedrest for 24 hours before gradually resuming regular activities Some shoulder discomfort can be expected (1 attempt remaining)

Restrict diet to bland, easily digestible food for a few days Correct Response Use 2 tablespoons of Milk of Magnesia (MOM) if no bowel movement (BM) 3 days after surgery Correct Response No showering for 48 hours after surgery Some shoulder discomfort can be expected laparoscopic surgery involves using carbon dioxide gas to open the inside of the abdomen, which pushes up the diaphragm; this may cause shoulder discomfort postoperatively. Clients should keep the dressings clean and dry for 48 hours before they can shower, but no tub baths for a few weeks. If "skin glue" is used over the incision(s), the client should not try to scrub it off because it will wear off on its own. Clients may resume normal activities as soon as they are able but no heavy lifting or aerobic exercise for about 2 weeks. If they do not have a BM after 2-3 days, clients can take 2 tablespoons of MOM several times a day until they have a BM. Diet can be advanced as tolerated but it's best to stick to non-greasy, non-spicy foods for a few days. Incorrect LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN & PN Review KEYWORDS appendixlaparoscopicpostop

The labor and delivery nurse is assessing a client in labor and notes a loop of the umbilical cord protruding from the vagina. Which action should the nurse take first? Place the client in a knee-chest position Notify the health care provider Apply oxygen by mask Check the fetal heart rate

a; A prolapsed umbilical cord is a medical emergency, which can result in brain damage or death to the fetus if not treated promptly and properly. Immediate action is needed to relieve pressure on the cord to prevent the risk of fetal hypoxia. A Trendelenburg or knee-chest position accomplishes this and should be done first. Then the nurse should implement the other actions. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM reproductive KEYWORDS pregnancyumbilical cordlaborhypoxiaTrendelenburg

The mother of a 2-month-old child calls the nurse at a pediatrician's office two days after the child received the DTaP, inactivated polio vaccine (IPV), hepatitis B vaccine, and haemophilus influenzae type B (HIB) immunizations. The mother reports that the baby feels warm, has cried inconsolably for three hours, and has had several shaking spells. Which immunization would the nurse expect to be responsible for these findings? DTaP IPV HIB Hepatitis B

a; DTaP immunization is a vaccine that protects against diptheria, tetanus and pertussis (whooping cough). The majority of reactions described in this question occur with the administration of the DTaP vaccination. Contraindications to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose, as well as signs of encephalopathy within seven days of the immunization. Correct! LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS babyimmunizationreactionDTaP

A client with anemia has a new prescription for ferrous sulfate. When teaching the client about diet and iron supplements, what should the nurse emphasize about taking an iron supplement? Take the iron tablet with a glass of orange juice Lie down for about 10 minutes after taking the pill Take the iron tablet with a glass of low-fat milk Take an antacid with the iron supplement to reduce stomach upset (1 attempt remaining)

a; Iron is best taken on an empty stomach, one hour before or two hours after meals, with a full glass of water or orange juice (ascorbic acid enhances the absorption of iron.) The client should not take the medication with antacids, dairy products, coffee or tea because these will decrease the effectiveness of the medicine. The client should not lie down for at least 10 minutes after taking the medicine. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS anemiaferrous sulfatedietiron

A 57-year-old male client has a hemoglobin of 10 g/dL (6.21 mmol/L) and a hematocrit of 32% (0.32). What would be the most appropriate follow-up by a home care nurse? Ask the client if the client has noticed any bleeding or dark stools Call 911 and send the client to the emergency department Schedule a repeat hemoglobin and hematocrit in one month Refer the client to schedule an appointment with a hematologist

a; Normal hemoglobin for males is 14-18 g/dL (8.69-11.17 mmol/L). Normal hematocrit for males is 42-52% (0.42-0.52). The lab values for this client are below normal and indicate mild anemia. The nurse should ask if the client has noticed any bleeding or change in stools that could indicate bleeding from the GI tract. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS hemoglobinhematocrithomeanemia

A client is scheduled for a transesophageal echocardiogram (TEE). Prior to the procedure, which activity could be delegated to the unlicensed assistive person (UAP)? A.Remove the pitcher of water from the bedside table B. Provide basic instructions about the procedure C. Assess the client's psychological state D. Obtain a signed consent

a; Removing the water pitcher would be an appropriate task because the client would be NPO. The health care provider is responsible for instructions about the procedure and needs to address client questions or concerns. The nurse is typically responsible to obtain a signed consent form and to assess the client both physically and psychologically before the procedure. Incorrect LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN & PN Review KEYWORDS UAPunlicensed assistive personnelassignmenttask

The nurse is working with clients who are experiencing intimate partner violence. The nurse should understand that intimate partner violence remains frequently undetected for which reason? There are typically many series of minor, vague complaints The expenses due to police and court costs are prohibitive Little knowledge is known about batterers and battering relationships Few people who have been battered seek medical care

a; Signs of intimate partner violence may not be clearly manifested, or may be vague, and often include a series of minor complaints such as headache, abdominal pain, insomnia, muscle pain, and dizziness. These may be cover indications of violence that go undetected. These complaints may be vague and reflect ambivalence or apprehension about the disclosure of intimate partner violence. Incorrect LESSON Psychosocial Integrity Abuse, Neglect COURSE RN Review KEYWORDS abuseviolencevague complaint

A client has a history of chronic obstructive pulmonary disease (COPD). The nurse enters the client's room to find that the nasal cannula is in proper position with the oxygen set at 6 liters per minute, the client's color is flushed, and the client's respirations are 8 breaths per minute. What should the nurse do first? A. Remove the nasal cannula for at least five minutes B.Lower the oxygen's flow rate C. Check the client's pulse for strength and rate D. Place client in a higher sitting position

a; The client has findings of oxygen toxicity so the nurse should first remove the cannula for a least five minutes. Then the nurse should perform these next sequence of actions: pulse assessment, change of position and then lower the oxygen flow rate and reapply if respirations are within normal parameters. A higher concentration of supplemental oxygen removes the hypoxic drive to breathe and leads to increased hypoventilation, respiratory decompensation, and the development or worsening of respiratory acidosis. Incorrect LESSON Reduction of Risk Potential Changes, Abnormalities in Vital Signs COURSE RN Review BODY SYSTEM respiratory KEYWORDS COPDnasal cannulaoxygen

The nurse is caring for a pregnant woman. She is currently 42 weeks pregnant. The nurse knows that which factor could result in negative outcomes for the fetus? Low blood sugar levels Progressive placental insufficiency Excessive fetal weight Depletion of subcutaneous fat

b; The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long-term effects may be related to hypoxia. These newborns are typically meconium stained. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS fetusriskhypoxiaplacental insufficiency

The nurse has been caring for the same client for 5 days. The client has been exhibiting manipulative behaviors. The nurse becomes aware of feeling reluctant to interact and care for the client. Which action should the nurse take? Report the feelings of reluctance to an objective peer or supervisor. Talk with the client about the negative effects of their manipulative behaviors. Develop a behavior modification plan for the client. Limit contact with the client to avoid reinforcement of the behaviors.

a; The nurse who experiences stress in a professional relationship with a client can gain objectivity through discussion with other professionals. The nurse may wish to have a peer observe the nurse-client interactions with this client for a shift and then have a debriefing of reactions that can influence the nurse-client relationship in positive and negative ways. Incorrect LESSON Psychosocial Integrity Therapeutic Environment COURSE RN Review KEYWORDS manipulativebehavior

After placement of a ventriculoperitoneal (VP) shunt as a treatment for hydrocephalus, the parents of an infant ask the nurse: "Why is there a small incision on the abdomen?" Which response by the nurse is most appropriate for explaining the purpose of the incision? "It's used to pass the catheter into the abdominal cavity." "It's used to visualize the abdominal organs for correct catheter placement." "It's there so the tubing can be inserted into the urinary bladder." "That's what is used for insertion of the catheter into the stomach."

a; The preferred procedure in the surgical treatment of hydrocephalus is the placement of a ventriculoperitoneal shunt. This shunt procedure provides primary drainage of the cerebrospinal fluid from the ventricles to an extracranial compartment, which is commonly the peritoneum. A small incision is made in the upper quadrant of the abdomen so the shunt tip can be guided into the peritoneal cavity. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS shuntventriculoperitonealhydrocephalus

An unlicensed assistive person (UAP) is giving a bath to a 5-year-old client with Wilms tumor. The UAP asks the nurse why there is a sign above the bed that says, "Do not palpate/press on abdomen." What is the best response by the nurse? "Pressing on the abdomen could cause the tumor to spread." "Pressing on the abdomen will cause the tumor to bleed." "Pressing on the abdomen might cause a bowel obstruction." "Pressing on the abdomen would be very painful for the child."

a; Wilms tumor (nephroblastoma) is a childhood cancer. It is the most common kidney tumor of childhood. The most common presenting sign is swelling or mass within the abdomen. The mass is characteristically firm, nontender, confined to one side and deep within the flank. The mass usually is discovered during routine bathing or dressing of the child.When caring for a child with Wilms tumor, it is important not to palpate the tumor or press on the abdomen, because manipulation of the mass may cause dissemination of cancer cells. To reinforce the need for caution, a sign should be posted near the bed that reads "Do not palpate/press on abdomen." Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM urinary KEYWORDS Wilms tumor

The nurse is providing preprocedural education to the client preparing for a barium enema. What statement made by the client indicates a need for further education? "A barium enema is used to examine the upper and lower GI tracts." "I will need to drink plenty of fluids and eat foods high in fiber after the procedure." "I will not eat or drink anything after midnight before the procedure." "I will use the prescribed laxative before the procedure."

a;A barium enema involves filling the large intestine (lower GI tract) with diluted barium liquid while X-ray images are taken. After the procedure, a small amount of barium will be immediately expelled and the remainder will be excreted in the stool. Because barium liquid may cause constipation, clients should eat foods high in fiber and drink plenty of fluids to help expel the barium from the body. Incorrect LESSON Reduction of Risk Potential Diagnostic Tests COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS bariumeducationGI

The nurse in a labor and delivery unit is assessing a client who is in the first stage of labor. The client reports that they felt their "water break" a few moments ago. On visual inspection, the nurse notes a short loop of the umbilical cord protruding from the vagina. Which action should the nurse take first? A. Insert a gloved hand into the vagina and hold the presenting part off the cord. B. Place the client in a knee-chest position. C. Administer hi-flow oxygen to the mother. D. Notify the health care provider immediately.

a;A prolapsed cord is a medical emergency. The prolapsed part of the cord is being compressed by the presenting part of the fetus, causing occlusion of blood flow and fetal hypoxia. If not relieved within a few minutes, it will result in central nervous damage or death of the fetus. Pressure on the cord must be relieved first and can be accomplished by the nurse placing a gloved hand or fingers into the vagina and holding the presenting part off the umbilical cord. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM reproductive KEYWORDS prolapsed cordlaborprioritization

A staff nurse on a busy inpatient hospital unit observes a coworker placing a syringe with an opioid medication into their pocket and going into an empty patient room. Which is the best action for the nurse to take? Report the observation to the nursing supervisor immediately. Wait until things quiet down and then talk to the coworker about getting help. Ask another staff member for advice on what to do. Follow the coworker and confront them about their addiction. (1 attempt remaining)

a;Although the nurse's observation appears to point toward a coworker who might be diverting opioids, it is presumptive to jump to the conclusion that the coworker's action is malicious. The best course of action is to follow facility protocol which typically consists of notifying the next person in the chain of command such as a manager or supervisor. This should be done immediately to give that person the opportunity to come to the unit right away and assess the situation. If it turns out that the nurse's coworker appears impaired, they should be immediately removed from the patient care area and drug tested. Incorrect LESSON Management of Care or Coordinated Care Legal Rights and Responsibilites COURSE RN & PN Review KEYWORDS medicationauditdivert

The home care nurse is reviewing the medical record of a new client with a history of chronic obstructive pulmonary disease, atrial fibrillation and gout. After reviewing the client's medication list, for which medications should the nurse arrange to monitor blood levels? Select all that apply. Theophylline Montelukast Beclomethasone Digoxin Allopurinol

ad;It is necessary to monitor blood levels for theophylline and digoxin to prevent toxicity. Both of those drugs can accumulate in the blood and reach toxic levels. The other medications are not known to accumulate and cause toxicity if taken as prescribed. Incorrect LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN & PN Review KEYWORDS theophyllinedigoxintherapeutic drug level

The nurse is providing education to a patent diagnosed with chronic kidney disease, stage 5. Which statement made by the client indicates that teaching has been effective? "I have to go for epoetin (Procrit) injections at the health department." "I can expect to have periods of little urine and then sometimes a lot of urine." "I know I have a high risk of clot formation since my blood is thick from too many red cells." "My bones will be stronger with this disease since I will have higher calcium than normal."

a;Anemia in end-stage renal failure is caused by reduced endogenous erythropoietin production in the kidney. Anemia in primary end-stage renal disease is treated with subcutaneous injections of Procrit or Epogen to stimulate the bone marrow to produce red blood cells. With kidney failure, too much phosphorus can build up in the blood and calcium is pulled from the bones, resulting in weakened bones. The statement about producing variable amounts of urine is incorrect, as the client will produce little to no urine at this stage of the disease. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM urinary KEYWORDS renal failureanemiaProcritepoetin

The community nurse is teaching a group of older adults about healthy nutrition. Which general recommendation should the nurse include? Make at least half your grains whole grain Increase intake of foods fortified with iron Add high protein supplements to your diet Follow the D.A.S.H. eating plan

a;Anyone, regardless of age, should eat a balanced diet of nutrient-dense foods. However, the diet of the older adult without other chronic health issues should include a general increase of fiber and whole grains to prevent such age-related problems as constipation. The other diet recommendations are more specific to certain chronic diseases. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS teachdietfibergrain

The nurse is working with clients who are diagnosed with eating disorders. Which eating disorder would the nurse expect to cause the greatest fluctuation in serum potassium levels? Bulimia nervosa Anorexia nervosa Binge eating disorder Dysthymic disorder (1 attempt remaining)

a;Hypokalemia can be caused by prolonged fasting and starvation, but is more common in those who exhibit binging and purging behaviors. Binging and purging, common in bulimia nervosa, result in dehydration and potassium loss. Hypokalemia can result in weakness, abdominal cramping and arrhythmias. Incorrect LESSON Reduction of Risk Potential Potential for Alterations in Body Systems COURSE RN Review BODY SYSTEM nervous KEYWORDS potassiumbulimiaeatingdisorder

A 3-year-old child presents with exam findings that may suggest a neuroblastoma. The nurse is collecting information from the child's parents. Which statement by the parent is suggestive of neuroblastoma and requires follow-up by the health care provider? "We keep having to buy him larger size pants because he's growing so big around the waist." "He seems to be getting weaker and weaker and is sometimes unsteady on his feet." "Our child has been quieter than normal lately and has lost weight." "He doesn't seem to be going to the bathroom as much and his urine is dark yellow in color."

a;One of the most common signs of neuroblastoma is increased abdominal girth due to the mass or tumor in the abdomen. The mass can cause pain and/or a feeling of fullness and the pressure may affect the child's bladder or bowel. Although the child with a neuroblastoma may not want to eat (which can lead to weight loss), this finding could have many causes. A more significant finding would be if the parents reported that child keeps outgrowing clothing or that clothing is tight around the abdomen. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM nervous KEYWORDS neuroblastomapediatricabdominal girthchildtumor

A client is scheduled to have a blood test for cholesterol and triglycerides the next day. What statement should the nurse include in the directions for the client? "Do not eat or drink anything but water for 12 hours before the test." "Be sure and eat a fat-free diet until the test." "Have the blood drawn within two hours of eating breakfast." "Stay at the laboratory so two blood samples can be drawn an hour apart." (1 attempt remaining)

a;Serum lipid levels should be obtained from clients who have been fasting for at least 12 hours. Incorrect LESSON Reduction of Risk Potential Diagnostic Tests COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS cholesteroltriglyceridestest

The nurse is caring for a client with suspected tuberculosis (TB). The nurse is aware of diagnostic tests to evaluate for active TB. Which should the nurse anticipate be ordered to evaluate for the presence of active TB? Sputum culture for cytology White blood cell count Chest X-ray anterior/posterior and lateral Tuberculin skin testing

a;The sputum culture is the method for determining if active TB is present. Tuberculin skin testing can demonstrate false positives, and chest X-rays cannot differentiate live from latent TB. White blood cell count can indicate infection, but is not specific to TB. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM respiratory KEYWORDS tuberculosisTBtest

The nurse is caring for a client who is receiving a blood transfusion. The client develops urticaria 30 minutes after the transfusion began. What is the first action the the nurse should take? Stop the infusion Slow the rate of infusion Administer Benadryl and continue the infusion Take vital signs and observe for further deterioration

a;This is an indication of an allergy to the plasma protein. The priority action of the nurse is to stop the transfusion by disconnecting at the IV insertion site. The nurse should then start a saline line at the IV insertion site and notify the health care provider. Incorrect LESSON Pharmacological (and Parenteral Therapies) Blood and Blood Products - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS bloodtransfusionuticaria

The nurse is admitting a 10-month-old infant with suspected bacterial meningitis. Which intervention should the nurse implement first? Initiate droplet precautions Measure head circumference Administer analgesics and antipyretics as needed Establish a peripheral venous access device (1 attempt remaining)

aBacterial meningitis is an acute inflammation of the meninges and cerebrospinal fluid (CSF). Meningitis is contagious and can be transmitted by droplets from nasopharyngeal secretions of infected individuals. The first intervention should be to place the child on droplet precautions to prevent the transmission to others and spread the infection. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS meningitisprecautiondropletcircumferenceinfant

A parent asks the nurse about a Guthrie Bacterial Inhibition test that was ordered for her newborn. Which point(s) should the nurse discuss with the client prior to the test? Select all that apply. The test will be delayed if the baby's weight is less than 5 pounds (2.27 kg) The urine test can be done after six weeks of age Positive tests require dietary control for prevention of brain damage Routine screening of newborn infants is not mandatory in the United States This test identifies an inherited disease Best results occur after the baby has been breastfeeding or drinking formula for two full days

all but d ;Screening for PKU is mandated in all 50 states, though methods of screening vary. The Guthrie Bacterial Inhibition Assay (BIA) is one test used to diagnose phenylketonuria (PKU), a disease characterized by an enzyme deficiency. A blood sample is taken from the baby's heel shortly after birth, with a follow-up test 7 to 10 days later. Test results are more accurate if the baby weighs more than 5 pounds and has been regularly drinking milk for more than 24 hours. A urine test is normally done after six weeks of age if a baby did not have the blood test. Incorrect LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS GuthriePKUnewborn

The nurse suspects that the client is in cardiogenic shock, following a massive myocardial infarction. Which finding would support the nurse's suspicion? Increased cardiac output Decreased or muffled heart sounds Bradycardia Bounding pulses

b; Cardiogenic shock involves decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume; it is the leading cause of death in acute myocardial infarction. Findings of cardiogenic shock include hypotension, rapid and faint peripheral pulses, distant-sounding, decreased heart sounds, cool and mottled skin, oliguria and altered mental status. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN & PN Review BODY SYSTEM cardiovascular KEYWORDS cardiogenic shockMI

The nurse observes cloudy drainage from an abdominal catheter that was inserted two days ago for peritoneal dialysis. What other data should the nurse assess? Bowel sounds Temperature Breath sounds Urine output

b; Cloudy drainage may indicate a peritoneal infection, so it is essential to evaluate the client's temperature before notifying the health care provider. In a client on dialysis for renal failure little to no urine output would be an expected finding. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM urinary KEYWORDS catheterdialysisdrainageinfectiontemperaturefever

Upon completing an admission, the nurse identifies that an older adult client does not have an advance directive. Which action should the nurse take? Refer this issue to the nurse manager and the risk manager Give the client written information about advance directives Assume that the client wishes full resuscitation efforts Document this information on the chart

b; For each admission, nurses should request a copy of a client's current advance directive. If there is none, the nurse must provide written information about what an advance directive implies. It is then the client's choice to sign the forms. Note that a standard is for non-direct care providers to witness these forms; a social worker or other health care professional would need to witness a client's signature. Correct! LESSON Management of Care or Coordinated Care Advance Directives COURSE RN Review KEYWORDS advance directives

A Latino couple confides in the nurse about their concern with staff giving their 9-month-old infant the "evil eye." What should the nurse communicate to the other staff members who are involved in the care of this family? Avoid touching the infant above the waist Touch the infant while performing a visual assessment Look only at the parents and not the infant Talk very slowly while speaking to the infant

b; In some Spanish-speaking cultures, there is a belief that an "evil eye" is cast when looking at a person without touching them. The spell is believed to be broken by touching the person while looking at or assessing them. The nurse should communicate this belief to other staff members and instruct them to be sure to touch the child while looking or assessing them to ease the parents' concern. Incorrect LESSON Psychosocial Integrity Religious, Spiritual Influences on Health COURSE RN Review KEYWORDS Latino culture

The nurse working in a primary care clinic is reviewing a client's blood glucose log and notices that the client is not consistently monitoring their blood glucose. Which diagnostic test would assist the nurse in evaluating the client's overall diabetes management? Hemoglobin Hemoglobin A1C Fasting blood sugar White blood cell count

b; The hemoglobin A1C is the best indicator of glycemic control because it reflects an average of the blood sugar over the life of a red blood cell (approximately 90 to 120 days). The fasting blood sugar will only evaluate the client's blood sugar at that specific testing time. Hemoglobin and a white blood cell count are not used to determine blood sugar levels. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN & PN Review BODY SYSTEM endocrine KEYWORDS diabeteshemoglobin A1Cblood sugar

The nurse is teaching the client about dietary changes needed to manage Addison's disease. Which statement by the client indicates that teaching has been effective? A. "I will increase fluids and restrict sodium and potassium." B. "I will increase sodium and fluids and restrict potassium." C. "I will increase potassium and sodium and restrict fluids." D. "I will increase sodium, potassium and fluids."

b; The manifestations of Addison's disease (also called adrenal insufficiency or hypocortisolism) are due to mineralocorticoid deficiency that results in renal sodium wasting and potassium retention. Other findings are dehydration, hypotension, hyponatremia, hyperkalemia and metabolic acidosis. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM endocrine KEYWORDS teachdietrestrictionAddison's

A client is admitted directly from surgery in skeletal traction for a fractured femur. Which nursing intervention is priority? Maintain proper body alignment Perform frequent neurovascular assessments of the affected leg Inspect the pin sites for evidence of drainage or inflammation Apply an overhead trapeze to assist with movement in bed

b; The priority postoperative action is to assess the neurovascular status of the leg after a fracture. Nursing management of a client in skeletal traction also includes assessing and caring for pin sites, and educating the client and family about skeletal traction. The overhead trapeze helps the client move in bed and proper body alignment is important, but these are not the priority. Correct! LESSON Basic Care and Comfort Mobility, Immobility COURSE RN & PN Review BODY SYSTEM musculoskeletal KEYWORDS femurfractureskeletaltraction

When assessing vital signs in children, the nurse knows that the apical pulse is preferred until the radial pulse can be accurately assessed at about what age? One year Two years Four years Three years (1 attempt remaining)

b;A child should be at least 2 years old to use the radial pulse to assess heart rate. Incorrect LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS apicalradialpulseassesschild

The nurse is evaluating a stage III pressure ulcer. Which assessment finding would indicate that the prescribed treatment is working? The periwound texture is moist and soft The edge of the wound appears rolled or curled under Soft yellow tissue seen in wound bed The size of the wound is decreasing (1 attempt remaining)

b;A wound that is decreasing in size is healing. "Slough" is yellow, tan or green tissue that is not healing. Soft and denuded tissue in the periwound area indicate tissue breakdown due to excessive moisture from wound drainage. Curled or rolled wound edges (epibole) prevents epithelial cells from migrating to close the wound, preventing the wound from healing. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN & PN Review BODY SYSTEM integumentary KEYWORDS pressure ulcerwound healing CONFIDENCE Need Help

A client with chronic pain asks the nurse, "What is your opinion about acupuncture to help with chronic pain?" The nurse responds, "I think some of those complementary treatments can be scary." The nurse's response is an example of what perspective? Prejudice Ethnocentrism Discrimination Cultural insensitivity

b;Ethnocentrism is the universal unconscious tendency of human beings to think that their ways of thinking, acting, and believing are the only right, proper and natural ways. It can be a major barrier to the provision of culturally conscious care. Ethnocentrism perpetuates an attitude that beliefs that differ greatly from one's own are strange, bizarre or unenlightened, and therefore wrong. At a more complex level, ethnocentric people regard others as inferior or immoral and believe their own ideas are intrinsically good, right, necessary, and desirable, while remaining unaware of their own value judgments. Incorrect LESSON Psychosocial Integrity Sensory, Perceptual Alterations COURSE RN & PN Review KEYWORDS painacupunctureperspectiveethnocentrism

A nurse is providing information to a client who is newly diagnosed with tuberculosis (TB). The nurse should be sure to include which statement when teaching the client about managing this disease? "Follow up with your primary care provider in three months." "Continue to take your medications even when you are feeling fine." "Continue to get yearly tuberculin skin tests." "Isolate yourself from others until you are finished taking your medication."

b;The client with TB needs is to understand the importance of medication compliance, even when the client is no longer having any symptoms. TB treatment usually requires a combination of medications with treatment for at least six months. Stopping treatment or skipping doses can lead to a drug-resistant form of TB. Clients are most infectious early in the course of therapy but the numbers of acid-fast bacilli are greatly reduced as soon as two weeks after therapy begins. Once clients no longer have a productive cough, they are not considered contagious. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM respiratory KEYWORDS tuberculosisTBmedication

The home health nurse observes the client change an ileostomy pouch? Which action is best to help prevent skin breakdown? Use deodorant soaps the contain lotion to clean the stoma Make sure the skin around the stoma is wrinkle-free Change the stoma pouch daily Apply antiseptic cream to reddened stoma

b;The ileostomy pouch should be changed approximately every 5 to 7 days; the bag should be emptied about every 4 to 6 hours. Before applying a pouch, the stoma and skin around the stoma should be gently cleaned using mild soap and water and allowed to dry. A skin barrier powder or other skin prep can be applied to intact skin around the stoma - but not to the stoma. The skin around the stoma should be dry and wrinkle-free before applying a new pouch or wafer to ensure a tight, leak-free seal. Incorrect LESSON Health Promotion and Maintenance Self-Care COURSE RN & PN Review BODY SYSTEM gastroinstestinal KEYWORDS stomaileostomyskinbreakdown

The nurse is evaluating an older adult client who had a generalized, tonic-clonic seizure. The client is drowsy, but moves all extremities. Vital signs are stable and there is vomit on the client's clothes and face. Which complication is the priority to monitor the client for? Dehydration Pneumonia Increased intracranial pressure Urinary incontinence

b;The presence of vomitus indicates that the client vomited during the seizure and the likelihood of aspiration is high. Therefore, the priority is to monitor the client for development of pneumonia. Aspiration pneumonia results from the abnormal entry of material from the mouth or stomach into the trachea and lungs. Conditions that increase the risk for aspiration include decreased level of consciousness (e.g., seizure). The aspirated material (food, water, vomitus, oropharyngeal secretions) triggers an inflammatory response. The most common form of aspiration pneumonia is a primary bacterial infection. The other complications are not typically associated with a seizure. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM nervous KEYWORDS seizureaspirationpneumonia

The nurse is caring for a client with left ventricular heart failure. The client's ejection fraction is 40%. Which assessment finding is an early indication of inadequate tissue perfusion? Distended jugular veins Use of accessory muscles Confusion and restlessness Crackles in the lungs (1 attempt remaining)

c; Neurological changes, including impaired mental status, are early signs of inadequate tissue perfusion due to decreased oxygenation of brain tissues. Other signs of low ejection fraction (EF) include shortness of breath, dependent edema, and arrhythmias. The low EF indicates that this client has severe damage to the left ventricle. Normal EF is about 55-70%. Correct! LESSON Reduction of Risk Potential System Specific Assessments - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS heartfailureoxygenrestlessness

The nurse is working in an inpatient psychiatric setting and understands that touching clients should be limited to a quick handshake for which reason? Refraining from touching signals the termination of the nurse-client relationship. A handshake allows the use of therapeutic touch while maintaining boundaries. Touching a client, other than a handshake, can set off a violent episode. A handshake will not be misinterpreted as an invitation to more sexual behavior.

b;The therapeutic use of touch is a basic part of the nurse-client relationship. However, in a psychiatric setting, the extent of physical contact should be limited to handshakes. Some facilities may even have a no-touch policy, especially when working with clients who have a history of sexual trauma. Even reassuring touching can be misinterpreted by the client. Incorrect LESSON Psychosocial Integrity Therapeutic Communication COURSE RN & PN Review KEYWORDS handshaketouchpsychiatric

A client admitted with congestive heart failure is experiencing severe dyspnea and states, "I feel like something is terribly wrong!" The client is restless and begins to cough up large amounts of pink, frothy sputum. The client's skin is a dusky, gray color. His oxygen saturation levels have decreased from 92% to 76% in the last hour. Which action should the nurse implement first? Check vital signs Administer the PRN ordered oxygen Place the bed in high Fowler's position Call the health care provider

b;When dealing with a medical emergency, the rule is to assess airway first, then breathing, and then circulation. Starting oxygen is the priority. The other actions should also be implemented as quickly as possible, including activation of the rapid response team. The client is experiencing an acute episode of fulminant pulmonary edema, likely as a result of a new and severe cardiac event and possible cardiogenic shock. Emergency assessment and intervention is indicated to prevent cardiac arrest and possible death. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS heartfailureoximetrypulmonary edema

The nurse is caring for a 17-month-old child diagnosed with acetaminophen poisoning. Which of these lab reports should the nurse review first? A. Blood urea nitrogen (BUN) and creatinine clearance B. Prothrombin Time (PT) and partial thromboplastin time (PTT) C.Aspartate aminotransferase (AST) and Alanine transaminase (ALT) D. Red blood cell and white blood cell counts (1 attempt remaining)

c Acetaminophen is toxic to the liver and causes hepatic cellular necrosis. This causes the liver enzymes AST and ALT to be released into the blood stream, which elevates serum levels. The next lab values to review are those associated with coagulation, then the blood counts and lastly the renal-associated labs, including BUN and creatinine. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS childacetaminophenpoisonlab

The nurse in a primary care office is examining a 15-month-old child with suspected otitis media. Which group of findings should the nurse anticipate? A.Vomiting, pulling at ears and pearly white tympanic membrane B.Periorbital edema, absent light reflex and translucent tympanic membrane C. Irritability, rhinorrhea, and bulging tympanic membrane D. Diarrhea, retracted tympanic membrane and enlarged parotid gland

c Clinical manifestations of otitis media include irritability, rhinorrhea, bulging tympanic membrane, and pulling at the ears. Correct! LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM respiratory KEYWORDS otitis mediachildtympanic

A child is injured on the school playground and appears to have a fractured leg. What is the first action that the school nurse should take? A. Apply cold compresses to the injured area B. Call for emergency transport to the hospital C. Assess the child and the extent of the injury D. Immobilize the limb and joints above and below the injury

c; Assess the child and the extent of the injury;Application of the nursing process dictates that assessment is the first step in the provision of care. The 6 Ps of vascular impairment (pain, pulse, pallor, paresthesia, paralysis and poikilothermia (coolness) can be used as a guide for assessment of the injured leg. The other options would be done in this sequence —immobilize, call 911 and then apply ice as indicated. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS childfractureassess

A client had an open reduction and internal fixation (ORIF) of a femur fracture. During a routine assessment 36 hours after surgery, the nurse finds the client disoriented, short of breath, and warm to the touch. The client's temperature is 102.4°F (39°C). What assessment should the nurse perform next? Assess orientation to time, person and place Perform a neurologic check of bilateral distal extremities Measure oxygen saturation using a pulse oximeter Remove the splint and inspect the incision

c; Based on the client's history and assessment findings, the nurse should suspect fat embolism syndrome (FES). Neurologic changes and respiratory distress are two of the classic findings of FES (the third finding is a characteristic petechial rash.) The nurse should activate the rapid response team. While waiting for the team, the nurse will measure the client's SpO2, as well as pulse and blood pressure, and auscultate the lungs. The nurse will also administer supplemental oxygen and ensure venous access. Correct! LESSON Reduction of Risk Potential System Specific Assessments - RN COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS fracturecastplasterassessreduction

A registered nurse who is functioning as the charge nurse is determining shift assignments. What is the best approach to determine which client assignments are appropriate for the licensed practical nurse (LPN)? A.Refer to the list of technical tasks the LPN is trained to perform B. Ask the LPN about prior experience caring for clients with various diagnoses C. Consider the LPN's scope of practice D. Determine how many unlicensed assistive personnel (UAP) are available to help the LPN with client care

c; LPN scope of practice is the best method to consider when assigning care. While the RN is responsible for ensuring a delegated assignment is completed appropriately and correctly, the LPN must be able to perform the skills or tasks independently and within their scope of practice. Incorrect LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS LPNRNassignmentexperience

A client continuously calls out to the nursing staff when anyone passes the client's door. He has various requests for assistance. The charge nurse should implement which intervention? Keep the client's room door cracked to minimize the distractions of people passing by the room Reassure the client that a staff person will check frequently to see if the client needs anything Assign a nursing staff member to visit the client at regular intervals Arrange for each staff member to go into the client's room to check on needs every hour on the hour

c; Regular, frequent, planned contact by a designated staff member is the best approach to provide a continuity of care and communicate to the client that care will be available as needed. Correct! LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS communicationcontinuity of caredifficult client

The nurse is educating a group of parents about accidental poisoning of children. Which type of accidental poisoning is common in children under the age of six years? Topical contact Eye splashes Oral ingestion Inhalation (1 attempt remaining)

c; The greatest risk for young children is from oral ingestion. While children under age six may come in contact with other poisons or inhale toxic fumes, these are not as common. Correct! LESSON Safety and Infection Control Home Safety COURSE RN Review KEYWORDS poisonaccidentchild

The nurse in a pediatrician's office is assessing the growth of children during their school-age years. Which finding is normal for this age group? Decreasing amounts of body fat and muscle mass Progressive height increase of 4 inches each year Weight gain of about 4 to 6 lb (2 to 3 kg) per year Little change in body appearance from year to year (1 attempt remaining)

c; The segment of the life span that extends from age 6 years to approximately age 12 years has a variety of labels, but is most often referred to as school-age or the school years. Between ages 6 and 12 years, children grow an average of 5 cm (2 inches) per year to gain 30 to 60 cm (1 to 2 feet) in height and will almost double in weight, increasing 2 to 3 kg (4.4 to 6.6 lb) per year. Incorrect LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review KEYWORDS assesschildgrow

A client asks the nurse about including her 12-year-old son in the care of their newborn sister. Which response is an appropriate initial statement by the nurse? "Focus on your son's needs during the first few days at home." "Suggest that your partner spend more time with your son." "Ask your son what he would like to do to help with the baby." "Tell your son what he can do to help with the baby."

c;A 12-year-old boy is at the age where he may be interested in assisting his parents with the care of a newborn sibling, and should be encouraged to do so with supervision. This will promote bonding between all family members, and the older child will feel included with the new changes in the family. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review KEYWORDS newbornchildreassure

The client is taking bupropion to treat depression and is worried about taking the medication. The client tells the nurse a friend said the medication was removed from the market because it caused seizures. What is an appropriate response by the nurse? A. Your health care provider knows the best drug for your condition. B . Omit the next dose until you talk with your health care provider. C. The recommended dose of this medication was changed, which lowered the risk of seizures. D. Ask your friend about the source of this information.

c;Bupropion was introduced in the United States in 1985 and then withdrawn because of the occurrence of seizures in some clients who took the drug. The drug was reintroduced in 1989 with specific recommendations about dose ranges to limit the occurrence of seizures. The risk of seizure appears to be strongly associated with higher dosages. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS bupropiondepressionseizure

The emergency room nurse is assessing a client admitted with unstable angina. Which lab test is the priority for this client? Serum creatinine Serum potassium Troponin Hemoglobin

c;Cardiac-specific troponin is a heart muscle protein released into circulation after injury or infarction. Normally, the level in the blood is very low, so a rise in level is diagnostic of myocardial infarction (MI) or injury. Troponin is the priority biomarker of choice in the diagnosis of acute coronary syndromes. Correct! LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS anginatroponin

The nurse is caring for a client who is experiencing a panic attack. What intervention should the nurse implement? Develop a trusting relationship Assist the client to describe the experience in detail Maintain safety for the client Teach the client to control behaviors

c;Clients who display signs of severe anxiety or who are experiencing a panic attack must be supervised closely. Clients may harm themselves or others during these episodes as perception is skewed and thinking is flawed. All other interventions will be futile and are inappropriate until the client's anxiety has been reduced to a tolerable level. Correct! LESSON Psychosocial Integrity Crisis Intervention COURSE RN Review KEYWORDS panicattacksafety

The nurse is caring for a client who had a central venous catheter inserted at the bedside. Which of these findings requires immediate intervention by the nurse? Involuntary coughing spells Pallor in the extremities Dyspnea at rest Increased temperature by one degree

c;Complications of central catheter insertion include pneumothorax and hemothorax. Air embolism is another potential complication. Dyspnea, shallow respirations, sudden sharp chest pain that worsens with coughing or deep breathing are indications of pneumothorax. Other potential complications of central catheters may include thrombosis, local or systemic infection, or even cardiac tamponade (if the central line perforates the heart). When considering the options listed, the client who is dyspneic after central line insertion would be the greatest concern for the nurse. Incorrect LESSON Pharmacological (and Parenteral Therapies) Central Venous Access Devices - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS centralcatheterdyspnea

The nurse is reviewing client assignments at the beginning of the shift. Which task could be assigned to an unlicensed assistive person (UAP)? Clean and apply a dressing to a small pressure ulcer on the leg Monitor a client's response to passive range of motion exercises Empty a client's colostomy bag Stay with a client during the self-administration of insulin

c;If the UAP has demonstrated competency in the task, s/he may empty a client's colostomy bag. This is an uncomplicated, routine task with an expected outcome. The other tasks involve one or more parts of the nursing process and cannot be assigned to an UAP. Incorrect LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS assignUAPtask

The community health nurse is reviewing the health records of several groups of children. In which age group is noncongenital, idiopathic scoliosis most commonly identified? Early adulthood Preschool age Preadolescence Infancy

c;Scoliosis is a common spinal deformity that can involve lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis. Scoliosis is classified according to age of onset: congenital (present at birth), infantile (birth up to 3 years of age); juvenile (in children 3 to 10 years of age); and adolescent (occurring at 10 years of age or older). Scoliosis may be caused by a number of conditions and may occur alone or in association with other diseases. In most cases, however, there is no apparent cause, hence the name idiopathic scoliosis. Idiopathic scoliosis is most commonly identified during the preadolescent growth spurt period. Correct! LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS scoliosissignschildadolescent

A client is receiving total parenteral nutrition (TPN) via a tunneled catheter. The catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority? Check that the catheter tip is intact Monitor respiratory status Apply a pressure dressing to the site Assess for mental status changes (1 attempt remaining)

c;The client is at risk of bleeding or developing an air embolus if the catheter exit site is not covered with a pressure and occlusive dressing. An occlusive dressing is one that is totally covered by adhesive tape around the edges, as well as over the entire dressing. Correct! LESSON Pharmacological (and Parenteral Therapies) Total Parenteral Nutrition - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS TPNHickmancatheterdislodge

A 4-month-old infant is receiving digoxin. The infant's blood pressure is 92/78 mm Hg; resting pulse is 78 beats per minute; respirations are 28 breaths per minute; and serum potassium level is 4.8 mEq/L. The infant is irritable and has vomited twice since receiving the morning dose of digoxin. Which finding is most indicative of digoxin toxicity? Vomiting Irritability Bradycardia Dyspnea (1 attempt remaining)

c;The most common sign of digoxin toxicity in children is bradycardia which is a heart rate below 100 beats per minute in an infant. Normal resting heart rate for infants 1-11 months-old is 100-160 beats per minute. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS digoxinLanoxintoxicbradycardiainfant

The client is admitted with a pressure ulcer that's two inches in diameter with no tunneling. It is a shallow open ulcer with loss of dermis and a red/pink wound bed. The nurse observes some serous drainage. What intervention does the nurse anticipate will be ordered to treat this wound? Whirlpool treatment and debridement Alginate dressing with silver added Hydrogel dressing Alternating pressure pad overlay for the bed

c;This ulcer is a partial thickness wound. These types of wounds heal by tissue regeneration, which is why the nurse would expect a gel dressing to be ordered. This dressing will keep the wound moist, provide protection from infection and promote healing; also, the cool sensation provided by the gel offers pain relief. Pink/red wound edges are considered normal in the inflammatory stage of healing; the wound does not require debridement. There is nothing to indicate that there's an infection, which is why the alginate with silver is not needed; also, alginate dressings are better for wounds with moderate-to-heavy drainage and are good for filling cavities or tracts. An alternating pressure pad overlay would not treat the wound. Correct! LESSON Physiological Adaptation Alternations in Body Systems COURSE RN & PN Review BODY SYSTEM integumentary KEYWORDS pressureulcerdressinghydrogel

The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring system (eICU). What is one of the best reasons for having access to an eICU? An ICU nurse is on-call to answer questions when needed Clients can ask the intensivist for a second opinion An ICU nurse and intensivist remotely monitor ICU clients around the clock Less staff is needed on site when a remote eICU is available

c;Using cameras, microphones, and high-speed computer data lines, the eICU involves having an experienced ICU nurse and practicing intensivist monitoring ICU clients in remote locations around the clock. The eICU does not change the ratio of nurses to clients at the bedside, but it does make the nurse's bedside time more productive and assistance from their remote colleagues is only a push button away. Incorrect LESSON Management of Care or Coordinated Care Information Technology COURSE RN & PN Review KEYWORDS eICUremoteelectronicintensivist

A one-year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time? Maintain central line catheter integrity Check results of liver enzyme tests Use aseptic technique during dressing changes Monitor serum glucose levels

d; Hyperglycemia may occur during the first day or two as the child adapts to the high-glucose load of the TPN solution. Thus, a priority nursing responsibility is blood glucose testing. Correct! LESSON Pharmacological (and Parenteral Therapies) Total Parenteral Nutrition - RN COURSE RN Review KEYWORDS childTPNcentral lineglucose

A 2-year-old child has been diagnosed with cystic fibrosis. The child's parent asks the nurse what is most concerning about the disease. Which is the appropriate response from the nurse? "Cystic fibrosis results in nutritional concerns that can be dealt with." "You will work with a team of experts and have access to a support group." "There is a high probability of life-long complications." "Thick, sticky secretions from the lungs are a constant challenge."

d The primary factor, and the one responsible for many of the clinical manifestations of cystic fibrosis, is mechanical obstruction caused by the increased viscosity of mucous gland secretions.Because of the increased viscosity of bronchial mucus, there is greater resistance to ciliary action (probably secondary to infection and ciliary destruction), a slower flow rate of mucus and incomplete expectoration, which also contributes to the mucus obstruction. This retained mucus serves as an excellent medium for bacterial growth. Reduced oxygen-carbon dioxide exchange causes variable degrees of hypoxia, hypercapnia and acidosis.In severe cases, progressive lung involvement, compression of pulmonary blood vessels and progressive lung dysfunction frequently lead to pulmonary hypertension, cor pulmonale, respiratory failure and death. Pulmonary complications are present in almost all children with cystic fibrosis, but the onset and extent of involvement are variable. Incorrect LESSON Physiological Adaptation Illness Management (RN) Alteration in Body System (PN) COURSE RN & PN Review BODY SYSTEM respiratory KEYWORDS childcystic fibrosispulmonarysecretions

The nurse and a student nurse are discussing the health issues related to a laboring HBsAg-positive client. Which of these comments by the student is incorrect and indicates a need for further instruction? "The infant will receive the hepatitis B immune globulin within 12 hours after birth." "The HBsAg-positive mother should be reported to the state or local health department." "The infant will receive the hepatitis B vaccine within 12 hours after birth." "The HBsAg-positive mother should not breastfeed her baby."

d ;All persons with HBsAg-positive laboratory results should be reported to the state or local health department. The newborn should receive the hepatitis B immune globulin and hepatitis B vaccine within 12 hours after birth, using different sites (the second vaccine is given between 1 and 2 months; the last vaccine is given between 6 and 18 months). HBV is not spread by breastfeeding, kissing, hugging, coughing, or casual contact. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM immune KEYWORDS hepatitisinfantvaccine

The nurse is evaluating a client admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The client is receiving 2 liters of oxygen per nasal cannula and reports persistent dyspnea. Arterial blood gas results show a PaO2 65, pH 7.38, PaCO2 50, HCO3 28. Which action should the nurse take next? Prepare the client for intubation Encourage the use of incentive spirometry Administer a bronchodilator Increase the oxygen flow rate

d; he client's ABG results show hypoxemia and an expected respiratory acidosis. The likelihood of decreasing the respiratory drive from higher oxygen administration in clients with COPD is low and does not outweigh the potentially serious consequences of untreated hypoxemia. Therefore, the nurse should next increase the oxygen flow rate until an acceptable oxygen saturation level is reached. The other actions are premature at this time or do not address the issue of the hypoxemia. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM respiratory KEYWORDS COPDhypoxemia

A client was recently discharged from a locked inpatient psychiatric facility. During a scheduled outpatient appointment, the client states to the nurse, "I'm afraid I am going to get sick again." Which response by the nurse is most likely to promote recovery? "If you take your medications exactly as your health care provider instructed, you won't get sick again." "I think you are doing well but you can call for an appointment with your health care provider if you think you need help." "You shouldn't fear a relapse because it can happen to anyone and we will be here to help you." "I will provide you with a bus pass and referral to a support group that will help you learn about managing your illness and medications." (1 attempt remaining)

d; Relapse prevention is a priority focus for clients recovering from an acute mental illness episode. Since education plus peer and community support rank high in helping prevent relapse, the priority is to refer the client to after-care and support groups. Additionally, since continuity of care involves access to care, the nurse should address the client's transportation needs by offering them a bus pass so they can attend these meetings. Continuing to take medications is important, but advice and reassurance without tangible follow up is not helpful to clients in early recovery from an acute event. Reassurance and referral to a health care provider may also be inadequate and does not demonstrate the nurse's concrete role in relapse prevention. Telling the client not to fear relapse and providing false reassurance is non-therapeutic. Correct! LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS relapseacutefollow upsupportpsychiat

A client is reported to have a dual diagnosis. The nurse should understand that this indicates a substance use disorder as well as what other type of problem? Medical problem Cross addiction Disorder of any type Mental health diagnosis

d; A dual diagnosis is the concurrent presence of a major psychiatric disorder and a substance use disorder. Incorrect LESSON Psychosocial Integrity Mental Health Concepts COURSE RN Review KEYWORDS substanceabusedual diagnosis

A client who underwent surgery 12 hours ago becomes confused and says: "Giant sharks are swimming across the ceiling." Which assessment should the nurse complete first? Pupillary response Cardiac rhythm strip Peripheral glucose stick Pulse oximetry

d; A sudden change in mental status in any postop client should trigger a nursing intervention directed toward evaluation of the client's respiratory status. Pulse oximetry would be the initial assessment. If available, arterial blood gases would be better. Acute respiratory failure is the sudden inability of the respiratory system to maintain adequate gas exchange, which may result in hypercapnia and/or hypoxemia. Clinical findings of hypoxemia include these findings, which are listed in order of initial to later findings: restlessness, irritability, agitation, dyspnea, disorientation, confusion, delirium, hallucinations and loss of consciousness. While there may be other factors influencing the client's behavior, the first nursing action should be directed toward maintaining oxygenation. Once respiratory or oxygenation issues are ruled out, then significant changes in glucose would be evaluated. Incorrect LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN Review BODY SYSTEM nervous KEYWORDS postopassessconfusionoximetry

The pediatric nurse is screening a child for suspected lead poisoning. Which assessment finding would support this diagnosis? Enuresis Obesity Excessive perspiration Developmental delays

d; Lead can affect any part of the body, including the renal, hematologic, and neurologic systems. Of most concern for young children is the developing brain and nervous system. The lead levels identified in children have declined since the initiation of screening for children at risk for lead poisoning. Long-term neurocognitive signs of lead poisoning include developmental delays, lowered intelligence quotient (IQ), reading skill deficits, visual-spatial problems, visual-motor problems, learning disabilities, and lower academic success. The other findings are not typically seen with lead poisoning. Incorrect LESSON Reduction of Risk Potential System Specific Assessments - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS lead poisoningchild development

The nurse is planning care for a 12-year-old child diagnosed with sickle cell disease who is in a vaso-occlusive crisis of the elbow. Which intervention should be included in the plan of care? A. Cold compresses to elbow B. Passive range of motion exercise C. Fluid restriction D. Pain management

d; Management of a sickle cell crisis is directed towards supportive and symptomatic treatment. The priority of care is pain relief. In a 12-year-old child, patient-controlled analgesia promotes maximum comfort. Fluids are usually increased and range of motion exercises are avoided in the acute phase of the crisis. Cold is avoided because it constricts the vessels and may result in increased pain. Incorrect LESSON Basic Care and Comfort Nonpharmacological Comfort Interventions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS childsicklecrisispain

The client is diagnosed with a large spontaneous pneumothorax. The nurse anticipates that a chest tube will be inserted. The nurse understands that chest tubes are used to treat pneumothorax for which reason? Drain the purulent drainage from the empyema that caused the problem Prevent an accumulation of blood and other drainage into the pleural cavity Increase intrathoracic pressure to allow both lungs to expand equally Drain air from the pleural cavity and restore normal intrathoracic pressure

d; There are no clinical signs or symptoms in primary spontaneous pneumothorax until a cyst or small sac (bleb) ruptures. When air enters the pleural space, the pressure in the space equals the pressure outside the body; the vacuum is lost and the lung collapses. This causes acute onset chest pain and shortness of breath. A small pneumothorax without underlying lung disease may resolve on its own. A larger pneumothorax requires aspiration of the free air and/or placement of a chest tube to evacuate the air. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM respiratory KEYWORDS chest tubepneumothorax

A premature newborn is to be fed breast milk through a nasogastric tube. The nurse knows that breast milk is preferred to formula in premature infants for which reason? Breast milk is higher in calories/ounce Breast milk has less fatty acids Breast milk contains less lactose Breast milk provides antibodies (1 attempt remaining)

d;Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest. Therefore, less residual is left in the infant's stomach. Correct! LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN & PN Review BODY SYSTEM immune KEYWORDS newbornbreast milknasogastricpremature

The nurse is assessing a 1-month-old infant. Which finding should the nurse report immediately? Abdominal respirations Increased heart rate with crying Irregular breathing rate Inspiratory grunt

d;Inspiratory grunt is an abnormal finding and indicates respiratory distress in infants. Other signs of respiratory distress in this age group are nasal flaring, often the initial finding, as well as sternal and intracostal retractions. Abdominal breathing is a normal expected breathing process for infants. The other findings are also normal in infants. Correct! LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM respiratory KEYWORDS infantassessgruntinspiratory

The visiting nurse is evaluating the plan of care for a client who reports that they have decided to stop taking the recently prescribed sertraline due to frequent nightmares. Which action should the nurse take first? A. Request for the medication to be changed to be given intramuscular B. Explore alternative medications C. Initiate transfer to the nearest psychiatric hospital D.Perform a suicide risk assessment

d;Sertraline (Zoloft) is a selective serotonin reuptake inhibitor or SSRI, commonly used to treat depression, general anxiety disorder and other psychiatric disorders. Like all other antidepressants, SSRIs may increase the risk of suicide. To reduce the risk of suicide, clients taking antidepressant drugs should be observed closely for suicidality, worsening mood, and unusual changes in behavior. Close observation is especially important during the first few months of therapy and whenever antidepressant dosage is changed (either increased or decreased). SSRI are given orally, not IM. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS sertralineSSRIsuicide risk

A 52-year-old postmenopausal woman asks the nurse how frequently she should have a mammogram. How should the nurse respond? "Your health care provider will advise you about your risks and the frequency." "Unless you had previous problems, every two years is best." "Once a woman reaches 50, she should have a mammogram yearly." "Yearly mammograms are advised for any women over 35." (1 attempt remaining)

d;The American Cancer Society recommends a screening mammogram by age 40, every one to two years for women 40 to 49, and every year from age 50 onward. If there are family or personal health risks, other more frequent and additional assessments may be recommended. Incorrect LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review BODY SYSTEM reproductive KEYWORDS postmenopausalmammogram

The nurse is assessing a 4-year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and appears to be having severe pain. The foot on the affected extremity is pale, cool to touch and the pulse is barely palpable. What action should the nurse take? Reassess the affected extremity in 15 minutes. Administer the ordered PRN pain medications. Readjust the traction for comfort. Notify the primary health care provider. (1 attempt remaining)

d;The pain and absence of a pulse suggests compartment syndrome. This condition occurs when there is a buildup of pressure within the muscles. This pressure decreases blood flow and can cause muscle, tissue, and nerve damage. Compartment syndrome is a medical emergency. Delaying treatment can lead to permanent damage to the extremity. Therefore, the nurse should contact the primary health care provider (HCP) immediately. Incorrect LESSON Reduction of Risk Potential Potential for Complications of Diagnostic Tests, Treatments, Procedures COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS fracturecompartment syndrome

The nurse is teaching the parents of a child with sickle cell disease about ways to prevent complications and crises. What information would be a priority for the nurse to emphasize to the family? The child may not be able to follow routine immunization schedules The child can maintain normal activity with some restrictions The child should be cautious of being exposed to people with a cold or fever The child should avoid becoming overheated or dehydrated during physical activity and exercise (1 attempt remaining)

d;he goal of sickle cell treatment is to manage and control symptoms and to prevent sickle cell crisis. Fluid loss caused by overheating and dehydration can trigger a sickle cell crisis. People with sickle cell anemia need to keep their immunizations up-to-date, treat infections quickly and avoid too much sun exposure. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS childsickle cell diseasepreventioneducation