LPN NCLEX MULTIPLE CHOICE

Which of the following diseases decreases the metabolic rate? A. Cancer B. Hypothyroidism C. Chronic obstructive pulmonary disease D. Cardiac failure

B. Hypothyroidism Hypothyroidism causes a decreased metabolic demand, so fewer calories are required.

The primary healthcare provider (PHCP) prescribes 125 mcg of digoxin by mouth, daily. The medication label reads digoxin 0.25 mg per tablet. The nurse prepares to administer how many tablet(s)? Fill in the blank.

0.5 First, the nurse must convert the prescription to the same units as the medication label (micrograms → milligrams) 125 micrograms → 0.125 mg (divide 125 micrograms by 1000) Next, take the dose ordered and divide it by the dose on hand and multiply by its volume 0.125 mg / 0.25 mg x 1 tablet = 0.5 tablet i Additional Info Digoxin is a cardiac glycoside indicated for the treatment of atrial fibrillation and congestive heart failure (CHF). This medication has lost popularity in recent decades because newer agents do not require therapeutic monitoring. For a client taking digoxin, the apical pulse needs to be obtained prior to administration. The apical pulse needs to be at least 60/minute for adults; 70/minute for children; 90 for infants.

Which of the following is a cause of hyponatremia? A. Profound sweating B. Dehydration C. Diabetes insipidus D. Salt-water drowning

A. Profound sweating When a patient sweats excessively, sodium is lost in sweat, and their serum sodium levels will decrease, leading to hyponatremia. Hyponatremia refers to decreased serum sodium levels.

The primary healthcare provider (PHCP) prescribes ½ gram of acetaminophen, by mouth, every six hours. The nurse has administered 3 doses. How many total milligrams has the client received?

1500 1 gram = 1000 mg; half of this would be 500 mg Next, multiply the number of doses by the number of milligrams administered 3 doses x 500 mg = 1500 mg i Additional Info The maximum amount of acetaminophen that an adult can receive in a 24- hour period is 4 grams (3 grams is recommended as a limit; but 4 grams is the absolute maximum)

The primary healthcare provider (PHCP) prescribes one liter of 0.9% saline to infuse over 6 hours. How many mL per hour will be administered to the client?

167 1 liter x 1000 mL = 1000 mL Next, divide the prescribed total volume by the infusion time 1000 mL/6 hours = 166.66 Finally, take the mL/hour and round to the nearest whole number 166.66 167 mL/hr i Additional Info 0.9% saline is an isotonic solution utilized in the treatment of standard dehydration.

The nurse is calculating intake for a client. The client received 0.9% saline at 70 mL/hr for four hours, two eight-ounce cups of ice, one eight-ounce cup of coffee, and three eight-ounce cups of water. The nurse should calculate the client's total intake as how many mL?

1480 To calculate the client's total intake, the nurse must recall that one cup is eight ounces, equating to approximately 240 mL. • The client received 0.9% saline infusion at 70 mL/hr for four hours →→ 280 mL total • Two cups of ice → 240 mL total • When determining the total mL for a cup of ice, the nurse should divide the volume by 1/2 since the ice melts • One cup of ice is 240 mL, and it would be divided by half to account for the melt = 120 mL• 120 mL x 2 (number of cups the client consumed) • One cup of coffee → 240 mL • Three cups of water 720 mL When added up, the total intake was 1480 mL i Additional Info When calculating intake, the nurse should consider the amount of volume the client consumes intravenously and by mouth. While intake and output (I&O) help determine a client's condition, I&O is a crude way of a client's status. Weight is the best way to determine fluid volume status as one kilogram equates to 2.2 lb which is one liter of fluid.

The primary healthcare provider (PHCP) prescribes a regular insulin infusion. The prescription is for 4.5 units/hr. The label on the medication reads 250 mL of 0.9% saline containing 100 units of regular insulin. How many mL/hr should the client receive? Fill in the blank. Round your answer to the nearest tenth.

11.3 Divide the prescribed amount of medication by what is on hand 4.5 units / 100 units = 0.045 units Next, take the amount of the medication and multiply it by the volume 0.045 units x 250 mL = 11.25 mL Finally, take the answer and round it to the nearest tenth. 11.25 mL 11.3 mL i Additional Info Regular insulin intravenously is prescribed to correct the acidosis and hyperkalemia. During the infusion of regular insulin, the client should be monitored for hypoglycemia and hypokalemia. Regular insulin is the only insulin that may be administered intravenously.

The primary healthcare provider (PHCP) prescribes 400,000 units of penicillin G benzathine. The label on the medication reads penicillin G benzathine 300,000 units / 10 mL. The nurse prepares how many milliliters to administer the appropriate dose?

13 400,000 units / 300,000 units = 1.3 mL Next, take the amount of the medication and multiply it by the volume 1.3 mL x 10 mL = 13.3 mL Finally, take the dosage and round to the nearest whole number 13.3 mL = 13 mL

The primary healthcare provider (PHCP) prescribes 100 mL of 0.9% saline to infuse over 45 minutes. How many mL per hour will be administered to the client?

133 First, convert the minutes to hours 45 minutes / 60 minutes = 0.75 hrs Next, divide the prescribed total volume by the infusion time 100 mL / 0.75 hours = 133.33 Finally, take the mL/hour and round to the nearest whole number 133.33 133 mL/hr i Additional Info 0.9% saline is an isotonic solution utilized for simple dehydration.

The primary healthcare provider (PHCP) prescribes one liter of 0.9% saline to infuse over 6 hours. How many mL per hour will be administered to the client?

167 Explanation To solve this problem, the formula of volume / time (hours) will be used. First, convert the prescribed liters to milliliters to determine the total volume ordered 1 liter x 1000 mL = 1000 mL Next, divide the prescribed total volume by the infusion time 1000 mL/6 hours = 166.66 Finally, take the mL/hour and round to the nearest whole number 166.66 167 mL/hr Additional Info 0.9% saline is an isotonic solution utilized in the treatment of standard dehydration.

The primary healthcare provider (PHCP) prescribes 100 mg of amoxicillin oral suspension by mouth, four times a day. The medication label reads amoxicillin 250 mg per 5 mL. The nurse prepares to administer how many milliliters per dose?

2 Divide the prescribed amount of medication by what is on hand 100 mg / 250 mg = 0.4 mL Next, take the amount of the medication and multiply it by the volume 0.4 mL x 5 mL = 2 mL iAdditional Info The formula of dose ordered / dose on hand x volume will be utilized to solve this problem. Divide the prescribed amount of medication by what is on hand 100 mg / 250 mg = 0.4 mL Next, take the amount of the medication and multiply it by the volume 0.4 mL x 5 mL = 2 mL

The primary healthcare provider (PHCP) prescribes 250 mL of 0.9% saline to infuse over 75 minutes. How many mL per hour will be administered to the client? Fill in the blank.

200 ml First, convert the minutes to hours 75 minutes / 60 minutes = 1.25 hrs Next, divide the prescribed total volume by the infusion time 250 mL/1.25 hours = 200 mL/hr Additional Info 0.9% saline is an isotonic solution utilized in the treatment of standard dehydration.

The primary healthcare provider (PHCP) prescribes 20 mg/kg of acetaminophen for a child weighing 29 lbs. How many milligrams should the nurse administer to the child? Fill in the blank. Round your answer to the nearest whole number.

264 The primary healthcare provider (PHCP) prescribes 20 mg/kg of acetaminophen for a child weighing 29 lbs. How many milligrams should the nurse administer to the child? Fill in the blank. Round your answer to the nearest whole number. To solve this multistep problem, convert the child's weight from pounds to kilograms 29/2.2 13.18 Next, multiply the prescribed amount by the weight in kg 20 mg x 13.18 kg = 263.60 mg Finally, round the amount to the nearest whole number 263.60 mg = 264 mg

The primary healthcare provider (PHCP) prescribes 30 mg of phenobarbital by mouth, once daily. The medication label reads phenobarbital 10 mg. The nurse prepares to administer how many tablet(s) per dose?

3 30 mg / 10 mg = 3 tablets iAdditional Info Phenobarbital is a barbiturate and indicated in the treatment of epilepsy. This medication suppresses seizure activity and is a central nervous system depressant.

The primary healthcare provider (PHCP) prescribes 150 mL of sterile water to be administered over one hour. The drop factor is 15 gtts/mL. The nurse sets the flow rate at how many drops per minute? Round your answer to the nearest whole number. Fill in the blank.

38 Explanation To solve this problem, the nurse will use the formula of total volume x drop factor / time in minutes First, take the prescribed volume and multiply it by the drop factor 150 mL x 15 gtt = 2250 mL Next, divide the total volume by the minutes 2250 ml / 60 minutes = 37.5 gtts Finally, perform appropriate rounding (if needed) 37.5 gtts = 38 gtts/minute i Additional Info Although rare, sterile water may be administered short-term as it is a hypotonic solution. This is likely to be administered when the client has significant diabetes insipidus.

The nurse is collecting data on a client receiving prescribed lamotrigine. Which client finding requires immediate follow-up? A. Abnormal dreams B. Skin blistering C. Dyspepsia D. Xerostomia

B. Skin blistering Skin blistering associated with lamotrigine therapy is a critical finding to report. This is a feature of Steven-Johnson syndrome (SJS). Lamotrigine has been implicated as causing this adverse finding.

A nurse is preparing to administer vancomycin to a child. The order is for 50 mg/kg/day in three divided doses. The client weighs 13 kg. How medication label indicates vancomycin 500 mg in 100 mL of 0.9% saline. How many mL will the nurse administer per dose?

43 50 mg x 13 kg = 650 mg Next, determine the individual dose. Divide the daily dose by 3. 650 mg/day / 3 doses/day = 216.66 mg Next, divide the prescribed dose by the dose on hand x volume 216.66 / 500 mg x 100 mL = 43.32 mL Finally, round your answer to the nearest whole number. 43.32 mL = 43 mL iAdditional Info Vancomycin is a glycopeptide antibiotic that is effective in the treatment of MRSA infections.

A client is receiving 10 mL/hr of a prescribed regular insulin infusion. The label on the bag reads 50 units of regular insulin in 100 mL of 0.9% saline. How many units of insulin is the client receiving every hour?

5 To solve this multistep problem, the initial step is to determine the concentration of the insulin 100 mL / 50 units = 0.5 unit per mL of 0.9% saline Next, take the mL per hour that the client is receiving and multiply it by the concentration 10 mL x 0.5 unit per mL = 5 units/hour Additional Info When a client is receiving a regular insulin intravenously, it is essential to monitor the client closely for adverse effects such as hypoglycemia and hypokalemia.

The primary healthcare provider (PHCP) prescribes 500 mL of 0.45% saline to be administered over one hour. The drop factor is 10 gtts/mL. The nurse sets the flow rate at how many drops per minute? Round your answer to the nearest whole number. Fill in the blank.

83 To solve this problem, the nurse will use the formula of total volume x drop factor / time in minutes First, take the prescribed volume and multiply it by the drop factor 500 mL x 10 gtt = 5000 mL Next, divide the total volume by the minutes 5000 mL/ 60 minutes = 83 gtts/min Finally, perform appropriate rounding (if needed) iAdditional Info 0.45% saline is a hypotonic solution and is utilized to treat intracellular dehydration.

The nurse reviews prescriptions for assigned clients. Which prescription should the nurse clarify with the primary healthcare provider (PHCP)? A. Albuterol via nebulizer for a patient with hypokalemia. B. Clozapine for a patient with severe schizophrenia. C. Lisinopril for a patient with congestive heart failure. D. Verapamil for a patient with migraine headaches.

A. Albuterol via nebulizer for a patient with hypokalemia. Albuterol is a bronchodilator that is used for asthma exacerbations. Adversely, this medication may lower serum potassium levels. The nurse should question this order as this medication may decrease the potassium further.

Place the following components of alcohol withdrawal in the order you would expect to see them occur: 1. Mild tremors 2. Delirium Tremens 3. Hyperthermia 4. Hallucinations

A is first. Mild tremors -are something you would expect to see at the beginning of alcohol withdrawal in the first stage. This typically starts about 4-12 hours after the patient has stopped drinking and will be accompanied by other symptoms such as nausea, insomnia, and headaches. At this point, the patient is still alert and oriented. C is second. Hyperthermia -will follow the mild tremors. The withdrawal is entering into the second phase or moderate withdrawal. At this point, patients start to get confused and hyperactive. Everything increases, they present with hyperthermia, hyperactivity, hypertension, tachypnea, and tachycardia. D is third. Hallucinations -will begin after the patient becomes hyperthermic and hyperactive. This is a severe withdrawal. Hallucinations and illusions can be auditory or visual and are very scary for the patient. It is essential to stay with the patient at this phase of the withdrawal. B is fourth. The last symptom you would expect to see in this progression is delirium tremens. -This is the most severe and dangerous phase. Delirium Tremens (DTS) is considered a medical emergency. These patients have an altered mental status and sympathetic overdrive, which can progress to cardiovascular collapse. They continue to experience hallucinations and illusions and can have tonic-clonic seizures.

Place the following instructions for the use of a Metered Dose Inhaler (MDI) without a spacer in the correct order: =Wait at least 1 minute between puffs. = Remove the inhaler cap and shake the inhaler. =Tilt your head back and breathe out fully. = Open your mouth and place the mouthpiece 1 to 2 inches away from the mouth. =Hold your breath for at least 10 seconds. = Press down firmly on the canister and breathe deeply through the mouth.

A metered-dose inhaler (MDI) is a device that delivers a specific amount of medication to the lungs in the form of a short burst of aerosolized medicine. It is usually self-administered by the patient via inhalation. A spacer is an extra attachment connected to the inhaler. It creates a chamber-like space that holds the medication and gives the patient time to inhale the medication (instead of having to press down the inhaler while simultaneously inhaling the drug). It is recommended that children of any age use a metered-dose inhaler (MDI) with a spacer. However, if a spacer is not available, medicine can still be delivered through an MDI. Children under the age of 9 usually require assistance to use the inhaler without a spacer. The correct sequence for using an MDI without a spacer is 1. Remove the inhaler cap and shake the inhaler. 2. Open your mouth and place the mouthpiece 1 to 2 inches away from the mouth. 3. Tilt your head back and breathe out fully. 4. Press down firmly on the canister and breathe deeply through the mouth. 5. Hold your breath for at least 10 seconds. Wait at least 1 minute between puffs.

The nurse is preparing to receive a newborn diagnosed with tetralogy of fallot. She knows that to maintain a patent ductus arteriosus the provider will order? A. Alprostadil B. Indomethacin C. Propranolol D. Morphine

A. Alprostadil Alprostadil will be administered to keep the ductus arteriosus open, or patent. This will allow more pulmonary blood flow to the child with low oxygen saturations waiting for surgery.

What question would be most important to ask a male client who is in for a digital rectal examination? A. "Have you noticed a change in the force of urine when you empty your bladder?" B. "Have you noticed a change in tolerance of certain foods in your diet?" C. "Do you notice polyuria in the AM?" D. "Do you notice any burning with urination or any odor to the urine?"

A. "Have you noticed a change in the force of urine when you empty your bladder?" A change in the urinary stream force could indicate a complication associated with BPH (benign prostatic hypertrophy).

What question would be most important to ask a male client who is in for a digital rectal examination? A. "Have you noticed a change in the force of urine when you empty your bladder?" B. "Have you noticed a change in tolerance of certain foods in your diet?" C "Do you notice polyuria in the AM?" D. "Do you notice any burning with urination or any odor to the urine?"

A. "Have you noticed a change in the force of urine when you empty your bladder?" A change in the urinary stream force could indicate a complication associated with BPH (benign prostatic hypertrophy).

The nurse reinforces discharge instructions to a client who underwent left eye cataract surgery with a lens implant. Which statement by the client would indicate a correct understanding of the teaching? A. "I should avoid getting water in the eye for 3 to 7 days after surgery." B. "It is okay for me to resume normal chores such as vacuuming." C. "It is okay for me to have green or yellow, thick drainage from the eye." D. "I may take aspirin for any pain I may experience."

A. "I should avoid getting water in the eye for 3 to 7 days after surgery." This statement indicates effective teaching by the nurse. Following cataract surgery, the client should not get any water in the affected eye for three to seven days. This measure will reduce the potential for infection.

The nurse prepares a client for a scheduled percutaneous coronary intervention (PCI). Which client statement should be reported to the primary healthcare provider (PHCP)? A. "I took my metformin this morning." B. "I get anxious when I am in closed spaces." C. "I am allergic to shellfish." D. "I may feel a warm sensation during the procedure."

A. "I took my metformin this morning." This procedure involves intravenous (IV) contrast and a small chance of acute kidney injury may occur when IV contrast is given within 48 hours of metformin. Thus, the PHCP needs to be notified. Exposure to metformin prior to this procedure is not a contraindication but requires IV fluids to decrease the negative effects on the kidneys.

The newly hired nurse is caring for a client bitten by a venomous snake in the left hand. Which of the following interventions by the newly hired nurse requires follow-up? A. Applying a tourniquet proximal to the bite. B. Removing the client's wristwatch and jewelry. C. Immobilizes the affected extremity. D. Obtaining a type and crossmatch for fresh frozen plasma (FFP).

A. Applying a tourniquet proximal to the bite. Tourniquets should not be used in snake bites. The tourniquet impedes arterial blood flow and can be quite harmful to the extremity. The client should immobilize the affected extremity to decrease the absorption of the venom.

The newly hired nurse is caring for a client bitten by a venomous snake in the left hand. Which of the following interventions by the newly hired nurse requires follow-up? A. Applying a tourniquet proximal to the bite. B. Removing the client's wristwatch and jewelry. C. Immobilizes the affected extremity. D. Obtaining a type and crossmatch for fresh frozen plasma (FFP).

A. Applying a tourniquet proximal to the bite. Tourniquets should not be used in snake bites. The tourniquet impedes arterial blood flow and can be quite harmful to the extremity. The client should immobilize the affected extremity to decrease the absorption of the venom.

The nurse is validating a client's understanding of the management of low back pain. Which of the following statements should the nurse reinforce? A. Avoid bending at the waist and lifting heavy objects. B. Weight-bearing exercises are recommended. C. Increase your sun exposure and calcium intake. D. Lay on your stomach four times a day and flex your legs.

A. Avoid bending at the waist and lifting heavy objects. Low back pain symptoms may be mitigated using activity restriction as well as medications such as nonsteroidal anti-inflammatory drugs (NSAIDs). Bending at the waist and lifting heavy objects would not be recommended for a client with low back pain.

A patient who is taking Lasix knows that he should increase the intake of what food? A. Cantaloupe B. Iceberg lettuce C. Plums D. Apples

A. Cantaloupe Cantaloupe has high levels of potassium in it, which tends to be lower in a patient taking Lasix. Lasix is the most frequently prescribed loop diuretic. It can increase urine output, even when blood flow to the kidneys is diminished. The rapid excretion of large amounts of water caused by loop diuretics may produce adverse effects, such as dehydration and electrolyte imbalances. Potassium loss may result in dysrhythmias. Therefore, potassium supplements and foods high in potassium are encouraged.

The nurse is caring for a client newly diagnosed with mastitis. The nurse anticipates a prescription for which medication? A. Cephalexin B. Acyclovir C. Fluconazole D. Imiquimod

A. Cephalexin Mastitis is commonly caused by Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), E. coli, and streptococci. Thus, antibiotics such as cephalexin are effective in the treatment of mastitis.

The nurse is preparing to administer a scheduled intramuscular injection to an apprehensive child. Which therapeutic action should the nurse take? A. Draw a "magic circle" on the area before the injection. B. Have another nurse hold down the child. C. Apply EMLA cream to the area immediately before the injection. D. Administer the medication right after the child's nap.

A. Draw a "magic circle" on the area before the injection. Techniques to make an intramuscular injection less traumatizing include drawing a magic circle around the area, and after the injection, the nurse may fill in a smiley face.

The nurse is preparing to administer a scheduled intramuscular injection to an apprehensive child. Which therapeutic action should the nurse take? A. Draw a "magic circle" on the area before the injection. B. Have another nurse hold down the child. C. Apply EMLA cream to the area immediately before the injection. D. Administer the medication right after the child's nap.

A. Draw a "magic circle" on the area before the injection. Techniques to make an intramuscular injection less traumatizing include drawing a magic circle around the area, and after the injection, the nurse may fill in a smiley face.

The nurse is caring for a primigravida client with the following clinical data. The nurse should take which of the following actions based on the result? Test : Nonstress Test (NST) Result: Reactive A. Inform the patient of the normal finding. B. Prepare the patient for a contraction stress test. C. Arrange for a repeat test. D. Inquire if the patient ate prior to the test.

A. Inform the patient of the normal finding. A reactive NST is an expected finding and indicates fetal well- being.

Which of the following best describes a newborn's reflex, which includes: hand opening, abducted and extended extremities following a jarring motion? A. Moro reflex B. Grasp reflex C. Babinski reflex D. Rooting reflex

A. Moro reflex The Moro reflex occurs in response to a slight drop, sudden movement of the crib, or a loud noise. The newborn quickly makes a symmetrical abduction of the extremities and places the index fingers and thumbs into a "C" shape. The newborn's neurological system is immature at birth. The nurse may notice periodic jerking or twitching, which is considered normal. Tremors are not considered a normal finding in a newborn. The newborn's cry can provide information about the neurological status. A high-pitched scream can indicate an increase in intracranial pressure. When assessing the reflexes, the nurse needs to consider the gestational age, not the birth weight. Premature infants will have a reduced response to the reflex evaluation. The nurse should document and report the following warning signs: • Tremors -Abnormal pupil responses -Hypertonic or hypotonic positions • Absent newborn reflexes -A high-pitched cry

A client who has recently traveled to another country presents to the emergency room with shortness of breath and suspected severe acute respiratory syndrome (SARS). What should the nurse's first intervention be? A. Place the client on contact and airborne precautions. B. Obtain blood, urine, and sputum for culture. C. Administer methylprednisolone 1 gram/IV. D. Infuse normal saline at 100 mL/hr.

A. Place the client on contact and airborne precautions. Since SARS can be potentially deadly, the nurse's first action should be to place the client in isolation. If an airborne-agent isolation room is not available in the emergency department, droplet precautions should be initiated until the patient can be moved to a negative-pressure room. SARS is a potentially deadly viral illness that quickly spread around the world in 2003. It presents with flu-like symptoms. The virus takes over cells within the body and duplicates itself within the affected cells. It is associated with a viral group known as coronaviruses, which cause the common cold. It is spread through infected droplets when a person coughs, sneezes, or spits when he/she talks. Other people may get the virus by coming in contact with those droplets, then touching their nose, eyes, or mouth.

Which nursing action is performed correctly when providing care for a newly placed gastrostomy tube of a postoperative patient? A. The nurse dips a cotton-tipped applicator into the sterile saline solution and gently cleans around the insertion site. B. The nurse wets a washcloth and washes the area around the tube with soap and water. C. The nurse adjusts the external disk every three hours to avoid crusting around the tube. D. The nurse tapes a gauze dressing over the site after cleansing it.

A. The nurse dips a cotton-tipped applicator into the sterile saline solution and gently cleans around the insertion site. When caring for a new gastrostomy tube, the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage.

The nurse is caring for a client who recently had a partial gastrectomy. Which of the following medications should the nurse anticipate that the primary health care provider (PHCP) will order? A. Vitamin B12 B. Metoclopramide C. Sucralfate D. Hydroxyzine

A. Vitamin B12 Procedures like a gastrectomy put the client at risk for pernicious anemia (B12 deficiency). It is quite common for a client to receive parenteral B12 replacement indefinitely.

The nursing instructor performs client rounds with nursing students, and it would be appropriate for the nursing student to identify which client is at risk for hypokalemia? A client with A. hyperemesis gravidarum. B. renal failure. C. diabetic ketoacidosis. D. third-degree burns.

A. hyperemesis gravidarum. Hyperemesis gravidarum is a pregnancy complication characterized by severe nausea, vomiting, weight loss, and possibly dehydration. The intense vomiting is why this condition puts the client at risk for hypokalemia. Gastrointestinal fluids are rich in potassium. Clients losing large amounts of their stomach acid will be at risk for hypokalemia, including vomiting, NG tube suctioning, or diarrhea.

The nursing instructor performs client rounds with nursing students, and it would be appropriate for the nursing student to identify which client is at risk for hypokalemia? A client with A. hyperemesis gravidarum. B. renal failure. C. diabetic ketoacidosis. D. third-degree burns.

A. hyperemesis gravidarum. Hyperemesis gravidarum is a pregnancy complication characterized by severe nausea, vomiting, weight loss, and possibly dehydration. The intense vomiting is why this condition puts the client at risk for hypokalemia. Gastrointestinal fluids are rich in potassium. Clients losing large amounts of their stomach acid will be at risk for hypokalemia, including vomiting, NG tube suctioning, or diarrhea.

The nurse is precepting a new graduate who will be caring for a patient with bacterial cystitis. Which of the following statements by the new graduate requires follow-up? A. "The client should be counseled to increase their fluid intake." B. "A 24-hour urine will be needed to confirm the diagnosis." C. "Risk factors include frequent intercourse and douching." D. "Cranberry concentrate may be used to prevent future infections."

B. "A 24-hour urine will be needed to confirm the diagnosis." This statement is false and requires follow-up. Bacterial cystitis may be diagnosed based on urine analysis. A simple, clean-catch midstream urine sample is sufficient for diagnosing bacterial cystitis. A 24-hour urine is utilized for diagnosing conditions such as pheochromocytoma and abnormal protein quantification in multiple myeloma - not bacterial cystitis.

The nurse is reviewing leadership and management concepts with a student nurse. It would require further teaching if the student nurse made which of the following statements? A. "The Laissez-faire leadership style is a passive leadership approach. B. "A Registered Nurse (RN) may delegate accountability to a Licensed Practical Nurse (LPN)." C. "The rights of delegation include task, circumstance, person, direction, supervision." D. "The State Nurse Practice Act defines roles and responsibilities of [10%] nursing professionals."

B. "A Registered Nurse (RN) may delegate accountability to a Licensed Practical Nurse (LPN)." An RN may delegate specific responsibilities to an LPN but cannot delegate accountability. The RN retains accountability when delegating client assignments and tasks but maintains accountability.

The nurse is reinforcing teaching with a client who is scheduled for a contraction stress test (CST). Which of the following statements should the nurse include? A. "You will need to consume a liquid with 50 grams of glucose." B. "You may need to stimulate your nipples during this test." C. "A positive result means your baby has had no late decelerations." D. "A negative result means your baby has had variable decelerations."

B. "You may need to stimulate your nipples during this test." A CST is indicated for clients who are high-risk and are in the third trimester. It requires the client to have contractions either through oxytocin administration or nipple stimulation.

The licensed practical/vocational nurse (LPN/VN) is assisting a registered nurse (RN) in gathering supplies for a prescribed transfusion of packed red blood cells (PRBCs). The nurse should obtain which intravenous (IV) fluid to accompany this transfusion? A. Lactated Ringers (LR) B. 0.9% saline C. 0.45% saline D. 3% saline

B. 0.9% saline Normal saline is the most appropriate intravenous fluid for blood transfusions. 0.9% saline (normal saline) is an isotonic solution and will not cause red blood cell (RBC) hemolysis or clumping.

Which of the following patient assignments would be appropriate for unlicensed assistive personnel? A. A 65-year-old male requiring sterile dressing changes. B. A 26-year-old female requiring a one-person assist in ambulating to the restroom. C. An 80-year-old male who is receiving enteral feedings continuously through an NG tube. D. A 16-year-old female who is 4 hours post-cardiac catheterization.

B. A 26-year-old female requiring a one-person assist in ambulating to the restroom. A 26-year-old female requiring a one-person assist in ambulating to the restroom would be an appropriate assignment for unlicensed assistive personnel (UAP). UAP are skilled in assisting clients with ambulation and this is within their scope of practice.

A patient presents to the emergency department with chest pain, syncope, and dyspnea. Upon assessment, the nurse notes the patient to be diaphoretic with blood pressure 94/58 mmHg and respirations 32/min. What should be the nurse's first appropriate action? A. Administer pain medications B. Administer IV fluids C. Administer dopamine D. Administer oxygen via nasal cannula .

B. Administer IV fluids The promotion of adequate oxygenation is the most vital to life and should be given the nurse's highest priority.

How should the nurse assess for the presence of thrombophlebitis in a patient who reports having pain in the left lower leg? A. By palpating the skin over the tibia and fibula. B. By documenting daily calf circumference measurements. C. By recording vital signs obtained four times a day. D. By noting difficulty with ambulation. .

B. By documenting daily calf circumference measurements. Inflammation from thrombophlebitis increases the size of the affected extremity and can be assessed regularly by measuring calf circumference. Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative patients. Manifestations of thrombophlebitis are pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the affected area, elevated temperature, and an increase in the involved extremity's diameter. Each shift, nurses should assess the legs for swelling and tenderness, measure bilateral calf or thigh circumference, and determine if they experience any chest pain or dyspnea. The patient should be instructed not to massage the legs.

The nurse is caring for a client who has sickle cell disease (SCD). Which of the following laboratory findings would require follow-up? A. Hemoglobin 11.2 mg/dL B. Creatinine 2.5 mg/dL C. BUN 19 mg/dL D. Platelet count 150,000 mm3

B. Creatinine 2.5 mg/dL One of the many complications associated with sickle cell disease is renal injury. The significantly elevated creatinine requires follow-up because this is evidence of significant renal insufficiency.

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

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

The nurse is caring for a client who is receiving prescribed methylergonovine. Which of the following findings would indicate a therapeutic response? A. Increased blood pressure B. Decreased post-partum bleeding C. Decreased uterine tone D. Increased urinary output

B. Decreased post-partum bleeding Methylergonovine is an alkaloid medication used to manage postpartum hemorrhage (PPH). This medication causes vasoconstriction, therefore, decreasing postpartum bleeding.

The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. This specimen is then : A. Placed in a separate container and later added to the collection. B. Discarded, then the collection process begins. C. Tested, then discarded. D. Saved as part of the 24-hour collection.

B. Discarded, then the collection process begins. Answer and Rationale: A 24-hour urine collection may be prescribed to evaluate some renal disorders by showing kidney function at different times of the day and night. The nurse is responsible for providing the collection container and educating the patient on how to collect the specimen. • The correct answer is B. The patient should collect the first specimen, which is considered "old urine" or urine in the bladder before the test began. After the first discarded specimen, urine is collected for 24 hours.

The LPN is taking vital signs on a pregnant client in active labor. When she inflates the blood pressure cuff, she looks at the fetal monitor and notices that the fetal heart rate increases above baseline and then returns to baseline about 15 seconds later. What is the priority nursing action? A. Notify the healthcare provider B. Document and continue to monitor C. Place the mother on her left side D. Administer 100% FiO2 via face mask

B. Document and continue to monitor Since the LPN has noted a reassuring sign of the fetal heart rate, it is appropriate for her to document the finding and continue to monitor the mother. If the LPN had noticed a non-reassuring sign, other interventions would be necessary.

The nurse is reviewing labs for a patient with a serum potassium level of 3.3 mg/dL(3.5-5 mEq/L). Which action would the nurse recognize as the highest priority? A. Educate the patient on potassium-rich foods B. Implement telemetry monitoring C. Obtain an order for STAT IM KCI D. Assess the patient's neurological status

B. Implement telemetry monitoring The normal range for serum potassium is between 3.5-5 mg/dL, so this patient's level is low. Hypokalemia can lead to life-threatening cardiac arrhythmias. Of the options provided, initiating telemetry monitoring would be the highest priority in order to assess the patient's heart function and monitor for any changes.

The LPN is caring for an infant who will be going to the operating room the next day for surgical repair of his total anomalous pulmonary venous return. She has finished signing the consent paperwork for the operation. The mother states "I'm not so sure about this. What if my baby dies?!" What is the appropriate action for the LPN? A. Explain the procedure to the mother. B. Notify the surgical team and have them come back to speak with the mother. C. Reassure the mother that everything will go as planned. D. Tell the mother that because she has already signed the consent paperwork she cannot change her mind now. .

B. Notify the surgical team and have them come back to speak with the mother. The LPN has identified that the mother has concerns about the surgery, so it is her responsibility to notify the surgical team and have them come back to speak with the mother.

When teaching parents about the pros and cons of their infant sleeping with them, which of the following information should the nurse give the parents? A. If you give your child more attention during the day, they will not want to sleep with you at night. B. Sleeping with parents can increase the risk of Sudden Infant Death Syndrome (SIDS). C. Children should never be allowed to sleep with their parents. D. You could be accused of sexual abuse if you allow your child to sleep with you.

B. Sleeping with parents can increase the risk of Sudden Infant Death Syndrome (SIDS). Research has shown that infants sleeping with adults can contribute to sudden infant death syndrome. The mechanism is believed to be the rebreathing of carbon dioxide as the sleeping child snuggles against the parent. According to recommendations released by the American Academy of Pediatrics (AAP), babies should stay in their parents' room at night for a full year. Babies shouldn't share a bed with parents because that increases the risk of sudden infant death syndrome (SIDS) according to the guidelines. The safest spot for infant sleep is on a firm surface such as a crib or bassinet without any soft bedding, bumpers, or pillows.

Which of the following would be a priority action for a nurse who sustained a needlestick injury while working with an AIDS patient? A. Contact a social worker right away. B. Start prophylactic AZT. C. Start prophylactic Pentamidine treatment. D. Make an appointment with a psychiatrist.

B. Start prophylactic AZT. AZT (Zidovudine) is the most critical intervention. It is an antiretroviral medication used to prevent and treat HIV/AIDS by reducing the virus's replication.

A patient has been marked as "confidential" due to safety concerns. Which of these actions would be inappropriate for the nurse? A. Keep the patient's name/information out of public areas such as the nurse's station. B. Tell the patient's mother he is okay when she calls to ask if he is still on the unit. C. Deny that the patient is on the unit when visitors come or call. D. Remove the patient from confidential status when he asks to be removed.

B. Tell the patient's mother he is okay when she calls to ask if he is still on the unit. When a patient has asked to be flagged as confidential, no medical personnel can give out any information, including verifying the patient's presence, in the hospital.

The licensed practical/vocational nurse (LPN/VN) cares for a child admitted with severe dehydration secondary to gastroenteritis. Which assessment data would be most reliable in determining the client's response to the prescribed intravenous fluid replacement? A. The number of stools in the past shift B. The current weight compared to the admission weight C. Mucous membrane assessment D. The 24-hour urinary output

B. The current weight compared to the admission weight Weight is the gold standard in determining fluid status. It provides an objective assessment of the client's overall fluid status. As a reminder, One kilogram equals 2.2 pounds, equivalent to one liter of fluid. If the client has an increase in one kilogram, compared to their admission weight, they have responded favorably to the fluid replacement.

According to guidelines issued by the Joint Commission, which of the following represents the proper use of restraints? A. The nurse positions the patient in a supine position before applying wrist restraints. B. The nurse ensures that two fingers can be inserted between the restraint and the patient's ankle. C. The nurse applies a cloth restraint to the left hand of a patient with an IV catheter in the right wrist. D. The nurse ties an elbow restraint to the raised side rail of a patient's bed.

B. The nurse ensures that two fingers can be inserted between the restraint and the patient's ankle. The nurse should be able to place two fingers between the restraint and a patient's wrist or ankle.

The nurse has collected a client's vital signs. The nurse notes that the client's apical pulse was 75 beats per minute, and the radial pulse was 69 beats per minute. The nurse should document this finding as A. a widened pulse pressure. B. a pulse deficit. C. pulsus paradoxus. D. an expected finding.

B. a pulse deficit. A pulse deficit is a difference between the apical and peripheral pulses. This finding may signal that the client has a dysrhythmia, and the nurse should consider obtaining a 12-lead electrocardiogram and/or continuous telemetry monitoring.

The nurse has collected a client's vital signs. The nurse notes that the client's apical pulse was 75 beats per minute, and the radial pulse was 69 beats per minute. The nurse should document this finding as A. a widened pulse pressure. B. a pulse deficit. C. pulsus paradoxus. D. an expected finding.

B. a pulse deficit. A pulse deficit is a difference between the apical and peripheral pulses. This finding may signal that the client has a dysrhythmia, and the nurse should consider obtaining a 12-lead electrocardiogram and/or continuous telemetry monitoring.

The nurse works collaboratively with a pharmacist to identify clients at risk for lithium toxicity. The client at most significant risk for lithium toxicity is a client with A. asthma taking both long- and short-acting bronchodilators. B. chronic migraine headaches and was newly prescribed naproxen. C. hypertension newly prescribed clonidine transdermal patch. D. hypothyroidism and was recently prescribed levothyroxine.

B. chronic migraine headaches and was newly prescribed naproxen. NSAIDs (naproxen, ibuprofen), ACE inhibitors (lisinopril, enalapril), and diuretics (furosemide, hydrochlorothiazide) should be avoided while a client is taking lithium. ACE inhibitors promote sodium wasting, and low levels of sodium precipitate lithium toxicity. NSAIDs reduce renal blood flow, cause lithium retention and raise its serum level to a potentially toxic range. The client with aches and pains should be recommended acetaminophen.

The licensed practical/vocational nurse (LPN/VN) is caring for a client with a tracheostomy. Which of the following items is essential to have at the bedside? A. air humidifier B. inner cannula C. nasal cannula oxygen D. tracheostomy brush

B. inner cannula An inner cannula of the tracheostomy size and one smaller is necessary to keep at the bedside. This is essential in case the inner cannula becomes dislodged.

The licensed practical/vocational nurses (LPN/VN) nurse reviews assigned clients' arterial blood gas (ABG) results. Which ABG requires immediate follow-up? A. pH = 7.46; PaO2 = 90 mm Hg; PaCO2 = 33 mm Hg; HCO3- = 22 mEq/L; SaO2 = 94% B. pH = 7.27; Pa02 = 73 mm Hg; PaCO2 = 50 mm Hg; HCO3- = 25 mEq/L; SaO2 = 85% C. pH = 7.45; PaO2 = 95 mm Hg; PaCO2 = 38 mm Hg; HCO3- = 26 mEq/L; SaO2 = 96% D. pH = 7.32; PaO2 = 93 mm Hg; PaCO2 = 42 mm Hg; HCO3- = 20 mEq/L; SaO2 = 94% Choices A, C, and D are incorrect.

B. pH = 7.27; Pa02 = 73 mm Hg; PaCO2 = 50 mm Hg; HCO3- = 25 mEq/L; SaO2 = 85% This ABG depicts respiratory acidosis (low pH; high PaCO₂) and is concerning because the patient is hypoxic (PaO₂ 73; SaO2 85%). This patient requires immediate intervention because of hypoxia.

The nurse is teaching a client about peptic ulcer disease. Which of the following statements should the nurse include? A. "You should take aspirin if you have mild aches or pains." B. "You will need to consume liquids one hour after each meal." C. "It will be important to reduce the stress in your life." D. "Take your prescribed omeprazole with food."

C. "It will be important to reduce the stress in your life." A client with peptic ulcer disease will need to reduce the amount of stress in their life to mitigate some of the symptoms. Ulcers can be caused by excessive use of non-steroidal anti-inflammatory drugs, alcoholism, and stress.

The licensed/practical vocational nurse (LPN/VN) has attended a staff education program about osteomyelitis. Which of the following statements by the nurse would indicate effective understanding? A. "IV antibiotic therapy is typically given for seven to fourteen days." B. "The most common cause of acute osteomyelitis is a virus." C. "A fever is present with temperatures typically greater than 101° F (38.3° C)." D. "Petechiae on the affected extremity is a common finding."

C. "A fever is present with temperatures typically greater than 101° F (38.3° C)." A cute osteomyelitis is manifested by localized bone pain, a fever, and swelling to the affected extremity.

The nurse observes a parent swaddling their infant with an unrepaired omphalocele. Which of the following statements would be appropriate? A. "Stop, you will kill your baby." B. "That is a nice, tight swaddle. It will help soothe your new baby." C. "May I help you? We will need to be careful with their intestines and we do not want the swaddle to push them back inside." D. "Swaddling is not allowed for these babies. Please stop."

C. "May I help you? We will need to be careful with their intestines and we do not want the swaddle to push them back inside." This is a therapeutic statement. It educates the parent about the need to swaddle the baby only very loosely and avoid any pressure on the exposed intestines so that they do not get pushed back inside of the baby. It also promotes bonding with the infant, as it encourages the parent to touch and care for their baby.

The LPN is tending to a client who is at 20 weeks gestation and has completed patient education. Which of the client's following statements indicates that she has a good understanding of her baby's development? A. "My baby is able to breathe now." B. "My baby can open his eyes." C. "My baby is about 7 ½ inches long." D. "My baby has fully grown fingernails."

C. "My baby is about 7 ½ inches long." By 20 weeks gestation, the fetus is approximately 19.05 cm long or 7 ½ inches. This reflects a proper understanding of the mother regarding fetal development and does not require further teaching.

The LPN is tending to a client who is at 20 weeks gestation and has completed patient education. Which of the client's following statements indicates that she has a good understanding of her baby's development? A. "My baby is able to breathe now." B. "My baby can open his eyes." C. "My baby is about 7½ inches long." D. "My baby has fully grown fingernails."

C. "My baby is about 7½ inches long." By 20 weeks gestation, the fetus is approximately 19.05 cm long or 7 ½ inches. This reflects a proper understanding of the mother regarding fetal development and does not require further teaching.

When teaching medication safety to a toddler's parent, which statement by the parent would be a cause for concern? A. "I always check to make sure the safety cap clicks when I close it." B. "We store all of our medicines on a really high shelf." C. "To get her to take her medicine, we tell her it's candy." D. "We store our medicines and vitamins together."

C. "To get her to take her medicine, we tell her it's candy." Children should never be told that medication is candy.

The licensed practical/vocational (LPN/VN) assists a registered nurse (RN) in planning a community health course about preventing Lyme disease. Which of the following information should be included? A. "You should try limiting your outdoor activities between 10 a.m. and 4 p.m." B. "Wear sunglasses that wrap around and block UVA and UVB rays." C. "Wear long-sleeved clothing when in heavily wooded areas." D. "Apply sunscreen with at least an SPF of 30."

C. "Wear long-sleeved clothing when in heavily wooded areas." Lyme disease is spread by a deer tick commonly found in heavily wooded areas. Wearing long-sleeved clothing, applying tick repellent. and showering after hikes in the woods is an effective strategy in preventing being bitten by a tick and further infected with the bacteria.

You receive an order to administer 600 mg ibuprofen to your patient as needed every 6 hours. You retrieve the medication, which comes in 200 mg tablets. How many tablets do you administer to your patient? A. 1 tablet B. 5 tablets. C. 3 tablets D. 2 tablets.

C. 3 tablets 3 tablets x 200 mg = 600 mg of ibuprofen. This is the correct dose.

When caring for a client on total parenteral nutrition (TPN), what is the nurse's most important action? A. Record the number of stools per day. B. Maintain strict intake and output records. C. A sterile technique for dressing change at the IV site. D. Monitor for cardiac arrhythmias.

C. A sterile technique for dressing change at the IV site. Clients receiving TPN are very susceptible to infection. The concentrated glucose solutions are an excellent medium for bacterial growth. Strict sterile technique is crucial in preventing disease at the IV infusion site.

While assessing a laboring mother during a contraction. The LPN notes a decrease in fetal heart rate from 150 to 120 bpm. The heart rate slows for about 10 seconds and increases back to 150 bpm as the contraction ends. Which of the following correctly classifies this observation? A. Late deceleration B. Moderate variability C. Early deceleration D. Marked variability .

C. Early deceleration Early decelerations occur when the fetal heart rate decreases at the same time as a contraction. In this question, the nurse noted a decrease from 150 to 120 bpm with the diminution, and then a return to baseline. This occurs due to the pressure of the head of the fetus on the pelvis or soft tissue, and no intervention is required by the nurse after an early deceleration.

The emergency department (ED) nurse is triaging a client who reports recent international travel to West Africa and has signs and symptoms of conjunctival infection, fever, rash, vomiting, and blood in their stool. The nurse is concerned that this client may have A. pulmonary tuberculosis. B. encephalitis. C. Ebola virus disease. D. inhalation anthrax.

C. Ebola virus disease. West Africa was a site of a recent Ebola virus disease (EVD) epidemic. The manifestations of ebola include conjunctival injection, fever, rash, vomiting, and blood in their stool. This information makes it reasonable to raise the suspicion that this client may have EVD.

The nurse assists a registered nurse in developing a care plan for a client with schizophrenia. Which of the following interventions would be appropriate? A. Provide therapeutic touch B. Set limits on splitting behavior C. Establish a trusting, non-threatening relationship D. Immediately restrain the client for verbal aggression

C. Establish a trusting, non-threatening relationship The most crucial goal for a person with schizophrenia is establishing a trusting relationship. This therapeutic rapport may help clients decrease their paranoia, which is commonly found in individuals with schizophrenia.

The nurse is caring for a client who is recovering from abdominal surgery. There is a noticeable pinkish fluid oozing from the incision site. Which phase of the inflammatory response does this represent? A. Vascular response B. Cellular response C. Exudate formation D. Healing

C. Exudate formation The fluid and white blood cells that leak from blood vessels in response to injury/inflammation are exudates. Exudates are present in the wounds as they heal. The nature and quantity of exudate depend on the severity of the damage and the tissues involved. For example, a surgical incision may ooze clear or pinkish (serous or serosanguinous) exudate for a day or two. If an exudate becomes purulent (thick, tan, green, or yellow), it is not normal and may suggest infection. In such cases, the nurse should immediately notify the health care provider.

A client has a pressure ulcer with a shallow, partial skin thickness eroded area but no necrotic areas. The nurse would treat the area with which dressing? A. Alginate B. Dry gauze C. Hydrocolloid D. No dressing is indicated

C. Hydrocolloid Hydrocolloid dressings protect shallow ulcers and promote an appropriate healing environment. Several factors contribute to the formation of pressure ulcers: friction and shearing, immobility, inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age, and the presence of certain chronic conditions. The stage of breakdown will determine treatment. Nurses should review standing orders from their facility and any additional physician's orders for pressure ulcer care.

Which of the following does the Apgar scoring system indicate? A. Heart rate, cyanosis, and edema. B. Heart rate, seizure activity, and respiratory effort. C. Irritability, heart rate, respiratory effort, muscle tone, and color. D. Reflex, respiratory rate, and bleeding.

C. Irritability, heart rate, respiratory effort, muscle tone, and color. The APGAR score is a systematic method of assessing a newborn's physical condition at birth. It is used to determine the newborn's heart rate, muscle tone, response to stimuli, and color rating by assigning a score of 0 to 2 for each category. The newborn is assessed at 1 minute after birth and again at 5 minutes after birth. A score between 7 and 1 indicates that the newborn is adjusting to extrauterine life. A score below 7 indicates that medical or nursing interventions may be needed to improve the newborn's cardiorespiratory status. If the 5 minute APGAR score is below 7, the newborn should be assessed every 5 minutes until the count is seven or higher.

The nurse is reassessing her female patient diagnosed with appendicitis. At her last assessment, the patient expressed 8/10 pain but now states that she has no pain. The nurse did not administer any pain medication. What is the priority nursing action? A. Document the pain score and continue monitoring B. Check the white blood cell count C. Notify the healthcare provider D. Palpate McBurney's point

C. Notify the healthcare provider The nurse should immediately notify the healthcare provider of this change in the patient's status. A sudden change of 8/10 pain to zero pain in the patient diagnosed with appendicitis could indicate rupture, and the healthcare provider needs to be immediately notified. This sudden pain relief is usually followed by a gradual increase in pain once again and guarding in the right lower quadrant. A ruptured appendix may result in infection, peritonitis, and abscess. Tachycardia, tachypnea, fever, restlessness, and irritability may follow.

The nurse is caring for a patient who is experiencing acute mania. Which of the following actions should be prioritized by the nurse? A. Plan structured solitary activities B. Redirect the patient's speech and ideas C. Provide high-calorie, small, frequent meals D. Initiate a psychiatry referral ity .

C. Provide high-calorie, small, frequent meals A client experiencing acute mania manifests symptoms such as inflated self-esteem, flight of ideas, psychomotor agitation, and an expansive effect. The client experiencing mania often has difficulty sleeping and exerts excessive physical energy. Thus, the nurse needs to focus on ensuring that the client's need for nutrition is met by offering high-calorie, small, frequent meals. This is the priority based on Maslow's Hierarchy of Needs.

The nurse observes sparks fly from a client's bathroom light. Which action should the nurse take first? A. Obtain a fire extinguisher B. Close the bathroom door C. Remove the client from the room D. Activate the fire alarm.

C. Remove the client from the room The initial action for the nurse to take is to remove the client from the room. This rescues the client from any danger.

The nurse notices bruises on a patient's arm and observes that the patient seems afraid and does not speak much. Because these are possible signs of physical abuse, what is the nurse's most appropriate action? A. Ignore the bruises, as this is not why the patient is being treated, and it is not appropriate for the nurse to address them. B. Report the suspected abuse to one of the other nurses and work together on how to handle it. C. Report the findings to the appropriate authorities based on state requirements and protocols. D. Use therapeutic communication to talk to the patient and attempt to get evidence of suspected abuse.

C. Report the findings to the appropriate authorities based on state requirements and protocols. It is the responsibility of any healthcare provider/team member to report any suspected abuse to the police or designated agency, per state police.

The nurse plans care for a client admitted with Haemophilus influenzae, type b Meningitis. When caring for this client, the nurse should gather which appropriate personnel protective equipment (PPE)? A. Boot (shoe) covers B. Face shield C. Surgical mask D. Gown

C. Surgical mask Haemophilus influenzae, type b Meningi requires droplet precautions. Droplet precautions require the nurse to don a surgical mask upon entry to the client's room. Cohorting with droplet precautions is permitted as long as the other individual has the same pathogen. Clients who require transport or want to ambulate outside their room should don a surgical mask.

A patient with Cushing's disease asks the nurse to help him choose a meal for dinner later. Which of the following meals is the best option? A. Hamburger with french fries and apple slices. B. Pork chops in cream sauce with mashed potatoes and carrots. C. Roasted chicken with corn and green beans. D. Mexican-style beef with guacamole and beans on the side

C. Roasted chicken with corn and green beans. A patient with Cushing's disease needs to eat a low sodium, high protein, and low-fat diet. Roasted chicken is high in protein with low in fat. Cushing's disease is a serious condition of an excess of the steroid hormone cortisol in the blood level caused by a pituitary tumor secreting adrenocorticotropic hormone (ACTH). Since cortisol is essential for metabolic processes, hypercortisolism associated with Cushing's can significantly affect how the body processes nutrients. Patients with Cushing's disease are encouraged to reduce sodium intake (to reduce the risk of hypertension and weight gain), increase calcium and vitamin D (Cushing's disease can cause reduced bone density and osteoporosis). Cortisol stimulates the liver to increase blood sugar levels, so people with Cushing's who have perpetually high cortisol levels may also have elevated blood sugar. Chronic, heavy drinking can damage the hypothalamic-pituitary-adrenal axis hormone network, resulting in symptoms nearly identical to those of Cushing's. The so-called pseudo-Cushing syndrome can intensify the symptoms of existing Cushing's disease and make it more difficult to diagnose and treat. A common symptom of Cushing's is high cholesterol levels. Avoiding fatty foods and eating more high-fiber foods such as kidney beans, apples, pears, barley, and prunes may help offset the effects of higher cholesterol associated with Cushing's.

Which of the following meals would be appropriate for a nurse to assign to a client of Orthodox Judaism faith on a kosher diet? A. Pork belly roast, rice, vegetables, mixed fruit, milk B. Crab salad on a croissant, potato salad, milk, vegetables with dip C. Sweet and sour chicken with rice and vegetables, juice, mixed fruits D. Fettuccini Alfredo with shrimp and vegetables, salad, mixed fruit, iced milk tea

C. Sweet and sour chicken with rice and vegetables, juice, mixed fruits Orthodox Judaism believers adhere to kosher dietary laws; for this group, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed. Other meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and those that are ritually slaughtered.

The nurse reinforces teaching to a client with hypertension about the newly prescribed furosemide. Which of the following should the nurse include in the teaching? A. Limit intake of bananas, cantaloupe, and potatoes B. Avoid taking the medication with grapefruit juice C. Take this medication in the early part of the day D. A nagging cough can occur as a side effect of the medication

C. Take this medication in the early part of the day Furosemide is a loop diuretic and may be indicated for conditions such as heart failure or hypertension. The client should be instructed to take this medication in the earlier part of the day to avoid nocturia.

When providing care for a patient with known IV drug use, which statement would be appropriate for the nurse to highlight this behavior's risk factors? A. The use of these drugs can increase the risk of contracting diseases due to immunosuppression. B. IV drug use can lead to skin infections at injection sites and poor health. C. The risk of contracting and/or spreading blood-borne pathogens such as HIV, which can progress to AIDS, is a huge risk factor with this activity. D. Drug use can lead to unsafe sex practices, increasing the risk of transmission of sexually transmitted diseases/infections.

C. The risk of contracting and/or spreading blood-borne pathogens such as HIV, which can progress to AIDS, is a huge risk factor with this activity. HIV is a blood-borne pathogen, therefore sharing needles with IV drug abusers exponentially increases the risk of contracting the disease.

While working in the emergency department, the nurse sees a 5-year-old patient with a chief complaint of sore throat. The father states that the boy has been complaining of throat pain for 2 days, and when he looks in his throat it appears red with white patches. Which of the following diagnostic tests should be ordered? A. Basic metabolic panel B. Extended respiratory virus panel C. Throat culture D. Complete blood count

C. Throat culture The nurse expects that a throat culture will be ordered to confirm a diagnosis of bacterial tonsillitis. A throat culture will assess for the presence of bacteria on the pharynx, and guide the team in making decisions about treatment and antibiotics for this patient. If the suspected diagnosis of bacterial tonsillitis is not confirmed, other tests may be necessary.

Which of these would be most important to include in discharge teaching for a patient with a platelet count of 40.000 mcL (40 x 10^9/L)? A. Be sure to take your aspirin with meals daily. B. You may continue to shave with a straight-edge razor. C. Use a soft toothbrush and floss gently. D. You should take a multivitamin daily.

C. Use a soft toothbrush and floss gently. This patient has thrombocytopenia and should be on bleeding precautions. Using a soft toothbrush and flossing gently can prevent the gum tissue from bleeding. Platelets (thrombocytes) are important for blood clotting. The normal range for platelets is 150,000-400,000 mcL (150-400 x 10^9/L). Thrombocytopenia is a lower than normal number of platelets (less than 150,000 platelets per microliter) in the blood. It can be inherited or acquired. The causes of thrombocytopenia can be classified into three groups: • Diminished production: caused by viral infections, vitamin deficiencies, aplastic anemia, or drug-induced • Increased destruction: caused by drugs, heparin use, idiopathic, pregnancy, or immune issues • Sequestration: caused by an enlarged spleen, neonatal, gestational, pregnancy Symptoms include: • Petechiae • Fatigue • Purpura • Prolonged bleeding cuts • Spontaneous bleeding • Jaundice • Heavy menses • Bloody stool • Enlarged spleen • Deep vein thrombosis

The nurse caring for a three-year-old with congestive heart failure recognizes which of the following as an early sign of digitalis toxicity? A. Bradypnea B. Tachycardia C. Vomiting D. Failure to thrive

C. Vomiting The earliest sign of digitalis toxicity is vomiting. One episode, however, does not warrant discontinuing the medication. Digoxin increases the force of myocardial contraction, decreases conduction through the SA and AV nodes, and prolongs the refractory period of the AV node. The result is increased cardiac output and reduced heart rate. Therapeutic serum digoxin levels range from 0.5-2 ng/mL. Serum levels may be drawn 6-8 hours after a dose is administered, although they are usually drawn immediately before the next dose. In infants, the first symptoms of overdose are typically cardiac arrhythmias. Gastrointestinal symptoms (like vomiting) are some of the earliest signs.

The nurse has received four physician orders. The nurse should initially implement which order? See the image below. Physician Orders Irrigate a wound for a client with a stage III pressure ulcer Complete pin care for a client with a halo fixation device Insert an indwelling urinary catheter for a client with retention Administer diazepam for a client with delirium tremens (DT). A. irrigate a wound for a client with a stage III pressure ulcer. B. complete pin care for a client with a halo fixation device. C. administer diazepam for a client with delirium tremens (DTs). D. insert an indwelling urinary catheter for a client with retention.

C. administer diazepam for a client with delirium tremens (DTs). Delirium tremens (DTS) is a severe form of alcohol withdrawal. This prescription should be implemented immediately, as the risk of seizure activity is quite significant.

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

C. being treated for aplastic anemia and has a temperature of 101.1° F (38.4° C). Aplastic anemia (AA) can cause a critically low neutrophil count because of the pancytopenia it induces. The low neutrophil count puts the client at risk for a life-threatening infection. The client's remarkable fever warrants prompt follow-up so the nurse may initiate measures such as blood culture collection, administer prescribed antibiotics and antifungals, and provide supportive measures such as antipyretics.

The nurse is providing postmortem care to a client. In preparing the client to be viewed by their family, the nurse should A. remove the client's dentures. B. keep the client's eyes open. C. place the client supine with a pillow under the head. D. light incense to provide aromatherapy.

C. place the client supine with a pillow under the head. To prevent the client's head from becoming discolored, the nurse should place a pillow under the client's head and elevate the head of the bed.

The nurse supervises a student nurse assisting a client with left-sided weakness in performing activities of daily living. Which action by the student nurse requires the nurse to intervene? The student nurse A. puts the client's affected (weaker) arm in the shirt's sleeve first. B. places shoes with velcro straps on the client's feet. C. places the wheelchair as close to the bed as possible on the client's affected (weaker) side. D. places the hairbrush in the client's unaffected (stronger) hand.

C. places the wheelchair as close to the bed as possible on the client's affected (weaker) side. Placing the wheelchair as close to the bed as possible on the client's affected (weaker) side requires follow-up because the client should be mobilized by having the wheelchair on their unaffected (stronger) side. This requires follow-up because the client is at risk of falling and injury.

The primary healthcare provider (PHCP) prescribes 4 mg of morphine intramuscular (IM). The medication vial reads morphine sulfate, 10 mg/mL. The nurse prepares how many milliliters to administer the appropriate dose?

Correct Answer(s): 0.4 First, divide the prescribed amount of medication by what is on hand 4 mg / 10 mg = 0.4 mL Finally, multiply it by the volume. If none is listed, multiply the answer by one (1) 0.4 mL x 1 mL = 0.4 mL i Additional Info Morphine is an opioid utilized for moderate to severe pain. It can be given intravenously, intramuscular, and by mouth. Prior to administering the medication, the nurse should obtain vital signs and pay close attention to the client's respiratory rate and blood pressure, as this medication may lower both. Fall precautions will be necessary after administering this medication.

The nurse has attended a staff education program about managing clients with peripheral arterial disease. Which of the following statements by the nurse would require follow-up? A. "The client should engage in a daily exercise regimen." B. "Smoking cessation is an essential treatment goal for clients who [16%] smoke." C. "Resting in a recliner with the legs dependent should be recommended." D. "Devices that elevate the legs above the heart should be provided at discharge."

D. "Devices that elevate the legs above the heart should be provided at discharge." Peripheral arterial disease is caused by conditions such as hypertension, hyperlipidemia, and diabetes mellitus which cause atherosclerosis of the peripheral arteries. This impeded blood flow may cause the client to experience intermittent claudication (pain with ambulation that is relieved with resting). The client should be educated on self-management strategies, including sleeping or resting with the legs dependent (below the heart) to facilitate blood flow and not wearing constrictive clothing that may further impede blood flow. This statement requires follow-up because the client's legs should be below the heart to facilitate blood flow.

Which of the following statements indicates body image distortion in a patient with anorexia nervosa? A. "I wish I looked like my mom." B. "I hate how my body looks." C. "I wish I could wear tank tops." D. "I'm so overweight."

D. "I'm so overweight." Patients with anorexia perceive themselves to look differently than they do. Despite being too thin, this client will not eat in hopes of getting the perfect body.

Which of the following is the most appropriate way to document a patient's refusal of medication? A. "Patient refused the heparin injection when I tried to give it." B. "Heparin refused during shift. Risks reviewed." C. "Patient stated she did not want the SQ heparin injection at this time." D. "Subcutaneous heparin injection was attempted per the physician's order. Patient refused medication at this time"

D. "Subcutaneous heparin injection was attempted per the physician's order. Patient refused medication at this time" Documentation in healthcare should be objective, thorough, and direct. It should also be articulated with correct grammar and spelling.

A nurse is preparing the plan of care for a client with stage 2 ovarian cancer who is a Jehovah's witness. The client has been told that surgery is necessary. Taking into consideration the client's religious preferences in developing the plan of care, the nurse documents which of the following? A. Religious sacraments and traditions are unimportant. B. Medication administration is not allowed for this group. C. Surgery is strictly prohibited in this religious group. D. Blood transfusion or the administration of blood and blood products is forbidden for this group.

D. Blood transfusion or the administration of blood and blood products is forbidden for this group. For Jehovah's witnesses, surgery is allowed, but the administration of blood and blood products is forbidden.

Malnutrition, wasting, and ill health due to chronic disease are associated with: A. Surgical asepsis B. Catabolism C. Venous stasis D. Cachexia

D. Cachexia Cachexia is associated with malnutrition, wasting, and ill health due to chronic illness. It can also result from the rupture of wound closure or the dehiscence of a surgical wound.

While working in the emergency department the nurse assesses a 3 day old infant brought in by his mother. She states "he is always so sweaty and hot, and just doesn't want to eat! I think something is wrong." The nurse is unable to palpate a femoral pulse, but notes +3 brachial pulses. Which congenital heart defect does the nurse suspect? A. Hypoplastic left heart syndrome B. Patent ductus arteriosus C. Transposition of the great arteries D. Coarctation of the aorta

D. Coarctation of the aorta The nurse suspects that this infant has coarctation of the aorta. In this defect, there is a stricture in the aorta preventing blood flow out of the left ventricle. It usually occurs beyond the blood vessels that branch off to your upper body and before the blood vessels that lead to your lower body. So blood flow to the upper body is abundant, but hardly any can make it to the lower part of the body. Therefore, there are decreased lower extremity pulses and increased upper extremity pulses.

Which of the following lab values would be most significant in determining renal function in a client with a history of polycystic kidney disease? A. BUN 90 mg/dL B. Serum potassium 7.0 MEq/L C. Uric acid 7.5 D. Creatinine 8.7 mg/dL

D. Creatinine 8.7 mg/dL Creatinine is a specific indicator of renal function/failure. Polycystic kidney disease (PKD) is a genetic disorder that causes fluid-filled cysts to grow inside the kidneys. Unlike simple kidney cysts that may develop later in life, PKD cysts can change the shape of organs and alter their function. Several tests can evaluate renal functioning.

Which of the following lab values would be most significant in determining renal function in a client with a history of polycystic kidney disease? A. BUN 90 mg/dL B. Serum potassium 7.0 MEq/L C. Uric acid 7.5 D. Creatinine 8.7 mg/dL

D. Creatinine 8.7 mg/dL Creatinine is a specific indicator of renal function/failure. Polycystic kidney disease (PKD) is a genetic disorder that causes fluid-filled cysts to grow inside the kidneys. Unlike simple kidney cysts that may develop later in life, PKD cysts can change the shape of organs and alter their function. Several tests can evaluate renal functioning.

Increased levels of which of the following hormones is related to hyperemesis gravidarum? A. Testosterone B. Progesterone C. Aldosterone D. Estrogen

D. Estrogen The cause of hyperemesis is related to high estrogen and human chorionic gonadotropin (hCG) levels. Nausea and vomiting, also known as morning sickness, are common during the first trimester of pregnancy for many women. If nausea and vomiting interfere with an inadequate intake of fluid/food and persists past 20 weeks of gestation, it is termed hyperemesis gravidarum. The cause is unknown, but elevated hormone levels and the relaxation of smooth muscles result in delayed gastric emptying, which is believed to contribute to this condition. Hyperemesis can cause problems for the mother and fetus. Severe hyperemesis gravidarum can result in preterm labor. The dehydration that occurs may lead to reduced placental perfusion and inadequate oxygenation to the fetus. Fetal growth can be compromised, leading to an infant who is small for gestational age. Women with hyperemesis gravidarum in the second trimester have an increased risk for preterm labor, pre-eclampsia (i.e. an increase in blood pressure, protein in the urine, and edema), and placental abruption.

The nurse working with geriatric clients understands that falls are likely to occur in elderly patients who are: A. Living on disability insurance B. In their 80s C. Living in their own home D. Hospitalized

D. Hospitalized Unfamiliar surroundings are a significant risk factor for falls, especially in the elderly. The hospitalized patient may become confused or bump into furniture, which could result in a fall. Age-related changes may affect the mobility and safety of older adults. For example, decreased muscle strength, reduced balance, and osteoporosis put older adults at risk for falls and fractures. For health promotion, the nurse assesses the musculoskeletal functioning of the older adult and identifies any risk factors that may contribute to falls or the ability of the older adult to perform ADLs. Health promotion interventions often include providing information about the risk factors for osteoporosis and the importance of adequate calcium and vitamin D intake.

The nurse is caring for a patient newly diagnosed with Rheumatoid Arthritis. The nurse should anticipate a prescription for which of the following medications? A. Calcitonin B. Glucosamine C. Allopurinol D. Methotrexate

D. Methotrexate Disease-Modifying Anti Rheumatic Drugs (DMARDs) are indicated in the treatment of Rheumatoid Arthritis. These medications primarily work by suppressing the immune system from attacking the joint spaces. Drugs within this class include methotrexate and hydroxychloroquine.

A patient in the post-anesthesia care unit is semiconscious and dyspneic. What should the nurse's first action be? A. Place a pillow under the client's head. B. Remove the oropharyngeal airway. C. Administer oxygen by mask. D. Reposition the client to keep the tongue forward.

D. Reposition the client to keep the tongue forward. The tongue can obstruct the airway of a semiconscious client. Repositioning in the side-lying position with the face slightly down will prevent occlusion of the pharynx and allow the drainage of mucus from the mouth.

The nurse reviews newly prescribed medications from the primary healthcare provider (PHCP). The nurse understands that the prescribed etanercept is intended to treat which condition? A. Osteoarthritis B. Diabetes mellitus C. Infective endocarditis (IE) D. Rheumatoid arthritis .

D. Rheumatoid arthritis Etanercept is a biologic intended to treat specific autoimmune conditions such as plaque psoriasis, psoriatic arthritis, and rheumatoid arthritis (RA). This medication decreases the inflammatory process by blocking tumor necrosis factor. This medication is administered subcutaneously on a specified dosing schedule depending on the condition it is intended to treat.

The nurse is caring for a client with schizophrenia. The nurse should anticipate a prescription for which medication? A. Lithium B. Bupropion C. Sertraline D. Risperidone

D. Risperidone chizophrenia is treated with antipsychotic medications. Typical (or first-generation) antipsychotic drugs include haloperidol, fluphenazine, and chlorpromazine. Atypical (second generation) antipsychotic medications include quetiapine, ziprasidone, and risperidone.

While you are in the NICU, an infant is being brought to the unit who is small for gestational age. Which of the following defines this term? A. The infant's weight is less than 3,000 grams. B. The infant's weight is below the 20th percentile. C. The infant's weight is less than 2,000 grams. D. The infant's weight is below the 10th percentile.

D. The infant's weight is below the 10th percentile. When an infant's weight is below the 10th percentile, it is considered small for gestational age.

While you are in the NICU, an infant is being brought to the unit who is small for gestational age. Which of the following defines this term? A. The infant's weight is less than 3,000 grams. B. The infant's weight is below the 20th percentile. C. The infant's weight is less than 2,000 grams. D. The infant's weight is below the 10th percentile.

D. The infant's weight is below the 10th percentile. When an infant's weight is below the 10th percentile, it is considered small for gestational age.

Which statement should the nurse use during client education regarding a vasectomy as a permanent method of contraception? A. If you change your mind in the future, it's simple to reverse the procedure. B. You will need to return for an annual follow-up visit and sperm count. C. If you have a history of cardiac disease, we won't be able to do the vasectomy. D. You'll need to use another type of birth control until your sperm count is zero.

D. You'll need to use another type of birth control until your sperm count is zero. The second method of birth control is necessary until the sperm count is zero. A vasectomy is a form of male birth control that cuts the supply of sperm to your semen. It's done by cutting and sealing the tubes that carry sperm. Vasectomy has a low risk of problems and can usually be performed in an outpatient setting under local anesthesia. Although vasectomy reversals are possible, vasectomy should be considered a permanent form of male birth control. Vasectomy offers no protection from sexually transmitted infections. Vasectomy is a safe and effective birth control choice for men who are sure and don't want to father a child in the future. • Vasectomy is nearly 100 percent effective in preventing pregnancy. • Vasectomy is an outpatient surgery with a low risk of complications or side effects. • A vasectomy cost is far less than the price of female sterilization (tubal ligation) or the long-term value of birth control medications for women.

The nurse is caring for a group of assigned clients. The nurse should immediately follow up on the client who A. has a closed-chest drainage system and has redness at the insertion site. B. is receiving treatment for ulcerative colitis and has had three bloody stools in the past hour. C. is being treated for a concussion and reports a headache rated as 4 on a scale of 0 (no pain) to 10 (severe pain). D. is being treated for an ischemic stroke and has a blood pressure of 100/58 mm Hg.

D. is being treated for an ischemic stroke and has a blood pressure of 100/58 mm Hg. The client with an ischemic stroke will require intense blood pressure monitoring because a low blood pressure will decrease cerebral perfusion, which is necessary for the unaffected areas of the brain. An optimal blood pressure for an ischemic stroke is 150/100 mm Hg to ensure cerebral perfusion. Allowing the blood pressure to be this high is considered permissive hypertension. Blood pressure lower than 150/100 mm Hg may cause further injury because of decreased cerebral perfusion. Likewise, the blood pressure should not exceed 185/110 mm Hg in an ischemic stroke because this may cause an extension of the stroke.

A client presented to the clinic stating that her home pregnancy test was positive. The nurse understands that this is a A. positive sign of pregnancy. B. presumptive sign of pregnancy. C. possible sign of pregnancy. D. probable sign of pregnancy.

D. probable sign of pregnancy. A pregnancy test (urine or serum) is a probable sign of pregnancy. Elevated HCG levels may be caused by other reasons such as ectopic pregnancy, user error, or recent abortion/miscarriage.

A client presented to the clinic stating that her home pregnancy test was positive. The nurse understands that this is a A. positive sign of pregnancy. B. presumptive sign of pregnancy. C. possible sign of pregnancy. D. probable sign of pregnancy.

D. probable sign of pregnancy. A pregnancy test (urine or serum) is a probable sign of pregnancy. Elevated HCG levels may be caused by other reasons such as ectopic pregnancy, user error, or recent abortion/miscarriage.

The nurse is caring for a female patient who is incontinent of urine. The MD orders an indwelling foley catheter to be placed. Place the following actions in the order that the nurse takes to correctly insert the foley catheter: =Secure the catheter to the patient, and initial the securement device with the date and time. =Spread the labia and hold them open. =Cleanse the meatus from front to back on the right side, then left side, and down the center. =Insert the catheter and inflate the balloon. =Perform hand hygiene, identify the patient, explain the procedure to the patient, and wear sterile gloves.

First the nurse should perform hand hygiene, identify the patient using 2 patient identifiers, explain the procedure to the patient, and wear sterile gloves. Second the nurse uses her nondominant hand to spread the labia and hold them open. Third the nurse uses her dominant hand to cleanse the meatus from front to back on the right side, then left side, then down the center. Fourth the nurse will insert the catheter and inflate the balloon. Lastly the nurse will secure the catheter to the patient, and place their initials, date, and time on the securement device.

The nurse is preparing a client for a scheduled colonoscopy. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP) while the client is preparing for this procedure? A. docusate B. loperamide C. polyethylene glycol 3350 D. famotidine

polyethylene glycol 3350 Polyethylene glycol 3350 is an osmotic laxative commonly used before a colonoscopy. This powder is typically dissolved in a sports drink and can be consumed by the client. Efficacy is usually within one hour. Fluid and electrolyte disturbance is unlikely as the powdered solution contains electrolytes.When administering this medication, it should be dissolved in water or Gatorade and may chill in the refrigerator to increase palatability.

The nurse is caring for a client who has just been diagnosed with severe acne vulgaris. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe? A. Isotretinoin B. Acyclovir C. Ketoconazole D. Ethambutol

A. Isotretinoin Isotretinoin is approved for the treatment of moderate to severe acne vulgaris.

The nurse has reinforced medication instruction to a client who has been prescribed enalapril. Which of the following statements, if made by the client, would indicate a correct understanding of the teaching? A. "I will notify my prescriber if I develop swelling of the face." B. "I will need to weigh myself every day while taking this medication." C. "I should eat foods high in potassium while I am taking this medication." D. "I will need lab work done every so often to evaluate my liver function."

A. "I will notify my prescriber if I develop swelling of the face Angioedema is a life-threatening adverse effect that is seen with ACE inhibitors such as enalapril. Angioedema may cause swelling anywhere in the body but swelling in the face, lips, and eyes can be life-threatening.

The nurse is caring for a client with an infected leg pressure ulcer. The initial priority for the nurse is to A. Obtain a wound culture B. Wrap the extremity with a sterile dressing C. Review the client's risk factors for skin breakdown D. Obtain a prescription for antibiotic ointment

A. Obtain a wound culture Obtaining wound culture before wrapping the extremity and applying a prescribed antibiotic ointment is essential. This will assist the primary healthcare provider (PHCP) in determining the most effective antibiotic to administer.

The nurse receives the following critical laboratory result for a client with end- stage renal disease. The nurse anticipates the physician to prescribe which blood product? See the image below. Laboratory Result Hemoglobin 5.6 g/dL Hematocrit 16.8% A. Packed Red Blood Cells (PRBCs) B. Fresh Frozen Plasma (FFP) C. Albumin D. Platelets

A. Packed Red Blood Cells (PRBCs) This hemoglobin and hematocrit are critically low. A transfusion of PRBCs is typically indicated once the hemoglobin is 7 g/dL or less.

What complication should the nurse monitor for during the immediate postoperative time following a thoracentesis? A. Pneumothorax B. Infection C. Dyspnea D. Aspiration

A. Pneumothorax The most immediate postoperative risk factor is pneumothorax. Symptoms of pneumothorax include dyspnea, chest pain, shortness of breath, and pain. Thoracentesis is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove pleural effusion (excess fluid) from the pleural space to ease breathing. Some conditions, such as lung disease/infections, heart failure, and tumors, may cause pleural effusion. All procedures have some risks. The risks of this procedure may include the following: air in the space between the lung covering (pleural space) that causes the lung to collapse (pneumothorax), bleeding, infection, and liver or spleen injury (rare).

The nurse is planning a staff developmental conference about confidentiality. Which of the following scenarios should the nurse include as a violation of client confidentiality? A. Informing a visitor of the room number of a client admitted with pneumonia B. Telling a police officer who brought a client into the emergency department (ED) the urine drug screen results C. Notifying the pharmacist that a client is HIV positive and may have a potential drug interaction D. Informing local authorities that a client is suspected of being a victim of domestic violence

B. Telling a police officer who brought a client into the emergency department (ED) the urine drug screen results The results of a UDS are confidential, and that confidentiality should not be pierced because an individual is a police officer. If the police officer requests the results, they should obtain a legal court order and present it to risk management to obtain the necessary records.

The nurse is reviewing a new prescription for amphotericin b. The nurse understands that this medication treats A. autoimmune infections. B. fungal infections. C. viral infections. D. bacterial infections.

B. fungal infections Amphotericin B is a powerful antifungal indicated in treating systemic fungal infections. This medication requires pre-medication with isotonic saline, diphenhydramine, and acetaminophen to help decrease the symptoms of fever, chills, and rigors associated with the infusion.

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

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

The primary healthcare provider (PHCP) prescribes lidocaine at 2 mg/min. The medication label reads lidocaine 1 gram in 500 mL of 0.9% saline. How many mL per hour will be administered to the client?

Correct Answer(s): 60 First, determine the hourly dosage 2 mg x 60 mins = 120 milligrams Next, convert the milligrams to grams so the units align 120 milligrams/ 1000 = 0.12 grams Finally, divide the dose ordered by the amount on hand x the volume 0.12 grams / 1 gram x 500 mL = 60 mL/hr Additional Info Lidocaine is an antiarrhythmic utilized in the treatment and prevention of ventricular arrhythmias. A similar drug to lidocaine is amiodarone.

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

208ml First, determine how many mL/hr the client is receiving (dose ordered / dose on hand x volume) 1300 units / 25000 units x 500 mL = 26 mL Next, take the mL/hr the client is receiving and multiply it by 8 26 mL x 8 hours = 208 mL ℗ Additional Info ✓ Intravenous heparin is typically administered as a bolus dose first, then as a continuous infusion to achieve therapeutic aPTT ✓ A baseline aPTT should be collected 6 hours after the first dose and 6 hours following any dose adjustments ✓ The goal is to prolong the aPTT from 1.5 to 2.5 times the control value ✓ The normal aPTT value is 30-40 ✓ The reversal agent for heparin toxicity is protamine sulfate

The primary healthcare provider (PHCP) prescribes dopamine at 2.5 mcg/kg/minute. The client weighs 198 lbs. The medication label reads dopamine 800 mg in 500 mL of dextrose 5% water (D5W). How many mL per hour will be administered to the client? Fill in the blank.

8 mL/hr First, convert the weight to kilograms 198/2.2 90 kg Next, determine the hourly dosage 2.5 mcg x 90 kg x 60 minutes = 13500 mcg Next, convert the micrograms to milligrams 13500 mcg/1000 mg = 13.5 mg Next, divide the dose ordered by the amount on hand x the volume 13.5 mg / 800 mg x 500 mL = 8.43 mL/hr Finally, round the answer to the nearest whole number 8.43 mL/hr 8 mL/hr i Additional Info Dopamine is a vasopressor used in the treatment of significant hypotension. It is essential that the client have a patent IV to prevent serious extravasation.

The primary healthcare provider (PHCP) prescribes a bolus of regular insulin prior to a continuous infusion. The prescription is for 0.1 units/kg. The client weighs 256 lbs. How many units of insulin should the nurse administer to the client? . Round your answer to the nearest whole number.

12 units The first step is to convert the client's weight from pounds (lbs) to kilograms(kg) 256 lbs 116.36 kg . Next, multiply the prescribed dosage by the client's weight 0.1 units x 116.36 kg = 11.63 units. Finally, take the answer and round it to the nearest whole number 11.63 units = 12 units Additional Info Regular insulin intravenously is prescribed to correct the acidosis hyperkalemia. During the infusion of regular insulin, the client should be monitored for hypoglycemia and hypokalemia. Regular insulin is the only insulin that may be administered intravenously.

X The nurse has reinforced medication instruction to a client who has been prescribed enalapril. Which of the following statements, if made by the client, would indicate a correct understanding of the teaching? A. "I will notify my prescriber if I develop swelling of the face." B. "I will need to weigh myself every day while taking this medication." C. "I should eat foods high in potassium while I am taking this medication." D. "I will need lab work done every so often to evaluate my liver function."

A. "I will notify my prescriber if I develop swelling of the face." Angioedema is a life-threatening adverse effect that is seen with ACE inhibitors such as enalapril. Angioedema may cause swelling anywhere in the body but swelling in the face, lips, and eyes can be life-threatening.

A client comes to the outpatient clinic complaining of abdominal pain, diarrhea, shortness of breath, and epistaxis. What should the nurse's first action be? A. Ask the client about any recent travel to Asia or the Middle East. B. Screening clients for upper respiratory tract symptoms. C. Determine whether the client has received all the recommended immunizations. D. Call an ambulance to take the client to the hospital immediately.

A. Ask the client about any recent travel to Asia or the Middle East. The client's clinical symptoms suggest possible avian influenza (bird flu). If the client has traveled recently to Asia or the Middle East, where outbreaks of bird flu have occurred, you will need to institute airborne and contact precautions immediately. Nursing priority is always patient safety. This includes not only the patient that the nurse is assessing but also those who are present within the facility and the staff. Determining where a patient has been and their recent activities will help pinpoint the possible illness/infection source.

The nurse has received the following prescriptions for newly admitted clients. It would be a priority for the nurse to administer which prescription? A. Aspirin to a client experiencing an acute myocardial infarction B. Lisinopril to a client with essential hypertension C. Risperidone to a client with schizophrenia D. Levodopa-carbidopa to a client with Parkinson's disease

A. Aspirin to a client experiencing an acute myocardial infarction A client experiencing a myocardial infarction is an acute emergency that requires immediate intervention. The standard treatment includes (in no order) morphine, oxygen, nitroglycerin, and aspirin.

The nurse is collecting data on a client with Paget's disease. Which of the following would be an expected finding? A. Bone deformities B. Berry aneurysm C Heberden's nodes D. Janeway lesions

A. Bone deformities Paget's disease is a disease caused by a bone becoming weakened and remodeled, which may result in deformities. The most common area this inappropriate bone remodeling affects is the skull, pelvis, and spine.

A patient in the post-anesthesia care unit is semiconscious and dyspneic. What should the nurse's first action be? A. Place a pillow under the client's head. B. Remove the oropharyngeal airway. C. Administer oxygen by mask. D. Reposition the client to keep the tongue forward.

D. Reposition the client to keep the tongue forward. The tongue can obstruct the airway of a semiconscious client. Repositioning in the side-lying position with the face slightly down will prevent occlusion of the pharynx and allow the drainage of mucus from the mouth.

The nurse is calculating intake for a client. The client received 0.9% saline at 125 mL/hr for six hours, three cups of cranberry juice, one cup of coffee, and one cup of water. The nurse should calculate the client's total intake as how many mL? Fill in the blank.

1950 To calculate the client's total intake, the nurse must recall that one cup is eight ounces, equating to approximately 240 mL. • The client received a 0.9% saline infusion at 125 mL/hr for six hours → 750 mL total • Three cups of cranberry juice → 720 mL • One cup of coffee → 240 mL • One cup of water → 240 mL When added up, the total intake was 1950 mL i Additional Info When calculating intake, the nurse should consider the amount of volume the client consumes intravenously and by mouth. While intake and output (I&O) help determine a client's condition, I&O is a crude way of a client's status. Weight is the best way to determine fluid volume status as one kilogram equates to 2.2 lb which is one liter of fluid.

The nurse collects data on a client with rheumatoid arthritis (RA). Which of the following findings is consistent with this diagnosis? A. Janeway lesions B. Tophi C. Unilateral joint pain D. Low-grade fever

D. Low-grade fever Rheumatoid arthritis (RA) is characterized by symptoms such as fatigue, weight loss, low-grade fever, and joint pain.

A patient is being discharged from the hospital after being diagnosed with lupus erythematosus. The patient is advised to follow up with what to monitor his condition? A. HgbA1C B. Daily blood pressure checks C. Monthly urine specimens D. Monthly CBC

C. Monthly urine specimens A patient with systemic lupus erythematosus (SLE) needs monthly urine specimens to check for proteinuria to monitor for any kidney damage.

The nurse is calculating intake for a client. The client received 0.9% saline at 125 ml/hr for six hours, three cups of cranberry juice, one cup of coffee, and one cup of water. The nurse should calculate the client's total intake as how many mL? Fill in the blank.

1950 To calculate the client's total intake, the nurse must recall that one cup is eight ounces, equating to approximately 240 mL. • The client received a 0.9% saline infusion at 125 mL/hr for six hours → 750 mL total • Three cups of cranberry juice → 720 mL • One cup of coffee → 240 mL • One cup of water → 240 mL When added up, the total intake was 1950 mL i Additional Info When calculating intake, the nurse should consider the amount of volume the client consumes intravenously and by mouth. While intake and output (I&O) help determine a client's condition, I&O is a crude way of a client's status. Weight is the best way to determine fluid volume status as one kilogram equates to 2.2 lb which is one liter of fluid.

The nurse is calculating the 12-hour intake for a client • The client received 0.45% saline at 85 mL/hr • One eight-ounce cup of ice chips • One eight-ounce cup of coffee • One eight-ounce cup of ice cream • Three eight-ounce cups of water • One eight-ounce cup of pureed vegetables The nurse should calculate the client's total intake as how many mL? Fill in the blank.

2340 The client received 0.45% saline at 85 mL/hr x 12 hours → 1020 mL One eight-ounce cup of ice chips →→ 120 mL When determining the total mL for a cup of ice, the nurse should divide the volume by 1/2 since the ice melts One eight-ounce cup of coffee → 240 mL One eight-ounce cup of ice cream → 240 mL Three eight-ounce cups of water → 720 mL One eight-ounce cup of pureed vegetables → This is excluded from the intake calculation as pureed food(s) are not a liquid at room temperature Total → 2340 mL i Additional Info When calculating intake for a client, the nurse should include - ✓ Oral liquids (anything that is liquid at room temperature) ✓ Oral liquids that should be tracked include ice cream, gelatin, water, juice, cola ✓ For ice chips, half of the total volume should be documented as fluid - 1 cup of ice chips (240 mL) = 1/2 cup of water (120 mL) ✓ Pureed foods are not considered liquid intake ✔ Additional intake that should be counted includes intravenous (IV) fluids, tube feeding, tube feeding irrigations, and blood products

The nurse is caring for a postoperative client at risk for venous thromboembolism (VTE). The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which medication? A. Enoxaparin B. Verapamil C. Tranexamic acid D. Ropinirole

A. Enoxaparin Enoxaparin is a low molecular weight-based heparin (LMWH) indicated for VTE prophylaxis following surgery. This medication is only given subcutaneously in the abdomen.

A client is receiving 10 mL/hr of a prescribed regular insulin infusion. The label on the bag reads 50 units of regular insulin in 100 mL of 0.9% saline. How many units of insulin is the client receiving every hour?

5 100 mL / 50 units = 0.5 unit per mL of 0.9% saline Next, take the mL per hour that the client is receiving and multiply it by the concentration 10 mL x 0.5 unit per mL = 5 units/hour i Additional Info When a client is receiving a regular insulin intravenously, it is essential to monitor the client closely for adverse effects such as hypoglycemia and hypokalemia.

The nurse is caring for a postoperative client at risk for venous thromboembolism (VTE). The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which medication? A. Enoxaparin B. Verapamil C. Tranexamic acid D. Ropinirole

A. Enoxaparin Enoxaparin is a low molecular weight-based heparin (LMWH) indicated for VTE prophylaxis following surgery. This medication is only given subcutaneously in the abdomen.

The primary healthcare provider (PHCP) prescribes a regular insulin infusion. for a client. The prescription is for 2 units/hr. The label on the medication reads 250 mL of 0.9% saline containing 100 units of regular insulin. How many mL/hr should the client receive?

5 ml The formula of dose ordered / dose on hand x volume will be utilized to solve this problem. Divide the prescribed amount of medication by what is on hand 2 units / 100 units = 0.02 units Next, take the amount of the medication and multiply it by the volume 0.02 units x 250 mL = 5 mL/hr i Additional Info Regular insulin intravenously is prescribed to correct the acidosis and hyperkalemia. During the infusion of regular insulin, the client should be monitored for hypoglycemia and hypokalemia. Regular insulin is the only insulin that may be administered intravenously.

Before administering a nasogastric feeding to a preterm infant, the nurse prepares to aspirate the residual fluid from the stomach. Place the following actions in order. =Measure the aspirate. = Position the patient with his head slightly elevated. =Aspirate the gastric contents. =Begin the prescribed nasogastric feeding. = Return the aspirate and subtract the amount of the aspirate from the feeding.

=Position the infant with his or her head slightly elevated to reduce the risk of aspiration. This should be done before the feeding is resumed. If the infant is on "continuous" feeding, it is assumed that the head end is already kept elevated all the time. About 40% of clients on enteral feeding aspirate and have associated complications/morbidity. Elevating the head of the bed to 30-45 degrees helps prevent or reduce the risk of aspiration. =Aspirate the gastric contents. =Measure the aspirate: Aspirate should first be measured so the nurse knows how much to subtract from the feeding. =Return the aspirate and subtract the amount of the aspirate from the feeding. This is done to ensure that the gastric enzymes and acid-base balance are maintained. =Begin the prescribed nasogastric feeding.

The nurse is caring for a client who is receiving prescribed varenicline. Which of the following statements, if made by the client, would indicate a therapeutic response? A. "I am not smoking cigarettes anymore." B. "My depression has gotten better." C. "I am sleeping eight hours a night." D. "I can focus on one task at a time."

A. "I am not smoking cigarettes anymore." Varenicline is a medication intended to reduce nicotine withdrawal symptoms and cravings. Following the initiation of varenicline, the client's comments that they are not smoking cigarettes anymore indicate varenicline has been therapeutically effective. Clients go back to resuming tobacco smoking if the withdrawal symptoms are not appropriately treated.

The school nurse is assessing a 12-year old boy who came into her office for a nose bleed. She notices several bruises on his back and forearms that are in various stages of healing. When she asks the boy about them, he is very deceptive. The nurse notifies child protective services of her suspicion the next day. The boy's mother comes to the nurse's office and yells at her for calling child protective services. Which of the following responses is most appropriate? A. "I am required by law to report any suspected violence." B. "You should have thought about this before you abused your son." C. "I'm so sorry, please don't take this out on me." D. "Don't talk to me about this; I don't want to see you."

A. "I am required by law to report any suspected violence." Parents may become upset and confront the nurse when these allegations come to light, but that should not stop the nurse from saying what she has seen. The nurse should remain non-emotional when the parent confronts her, and it is mandatory to report any suspected violence by law.

A 12-year-old patient with chronic asthma exacerbations has decided to try guided imagery as a way to manage her anxiety contributing to her asthma attacks. Which of the following statements by the patient indicates an understanding of this stress-reduction technique? A. "I can do this anytime and anywhere when I feel anxious." B. "I must be lying down to practice guided imagery." C. "My mom will have to be with me any time I try this." D. "I will play music every time I do my guided imagery to make sure it works."

A. "I can do this anytime and anywhere when I feel anxious." Guided imagery is a stress-reduction technique that can be done in any place at any time. In fact, this is one of the biggest advantages of this technique. Anytime the patient begins to feel anxious, they can practice guided imagery.

The nurse is reinforcing instructions to a client who is scheduled for a nonstress test (NST). Which of the following statements by the client would require a follow-up? A. "I cannot have anything to eat eight hours prior to this test." B. "I will have an external monitor across my abdomen." C. "A reactive result means my baby is doing well." D. "If this test is abnormal, I will need further testing."

A. "I cannot have anything to eat eight hours prior to this test." A Nonstress test does not require a client to abstain from eating or drinking prior to the test. This statement is false and would require follow-up.

The nurse is reinforcing instructions to a client who is scheduled for a nonstress test (NST). Which of the following statements by the client would require a follow-up? A. "I cannot have anything to eat eight hours prior to this test." B. "I will have an external monitor across my abdomen." C. "A reactive result means my baby is doing well." D. "If this test is abnormal, I will need further testing."

A. "I cannot have anything to eat eight hours prior to this test." A Nonstress test does not require a client to abstain from eating or drinking prior to the test. This statement is false and would require follow-up.

The nurse is discussing sudden infant death syndrome (SIDS) with the parents of a newborn. Which of the following statements, if made by the parents, would require follow-up? A. "I have been keeping my baby warm with extra blankets while he sleeps." B. "I give my baby a pacifier at night while he sleeps." C. "I am keeping my baby up to date on his scheduled vaccinations." D. "I replaced my baby's sheepskin bedding with a firm mattress."

A. "I have been keeping my baby warm with extra blankets while he sleeps." Environmental factors such as soft mattresses/bedding, blankets, bumper pads affixed to the crib, and accessories in the crib increase the risk for SIDS dramatically. The recommended sleeping position for an infant is supine, with no stuffed animals, blankets, or accessories.

The nurse prepares a client for a scheduled percutaneous coronary intervention (PCI). Which client statement should be reported to the primary healthcare provider (PHCP)? A. "I took my metformin this morning." B. "I get anxious when I am in closed spaces." C. "I am allergic to shellfish." D. "I may feel a warm sensation during the procedure."

A. "I took my metformin this morning." This procedure involves intravenous (IV) contrast and a small chance of acute kidney injury may occur when IV contrast is given within 48 hours of metformin. Thus, the PHCP needs to be notified. Exposure to metformin prior to this procedure is not a contraindication but requires IV fluids to decrease the negative effects on the kidneys.

Which of the following statements made by a male cancer patient with hair loss secondary to chemotherapy indicates that the goal for new coping patterns is being met? A. "I washed my wig today." B. "I asked my dad to bring me some shampoo." C. "I'm thinking of getting new barrettes for my hair." D. "I'm considering changing my hair color."

A. "I washed my wig today." One of the best indicators that a goal for implementing and meeting objectives of adapting coping mechanisms is that the client is showing a willingness and ability to assume the responsibility of self-care. Setting goals for new coping patterns and monitoring for the development of effective coping mechanisms is crucial for this client. Any indication that the client is accepting the loss of hair and a willingness to participate in self-care activities is a sign that goals are being met.

The nurse is reinforcing teaching to a client who is breastfeeding about ways to prevent mastitis. Which statement, if made by the client, would require follow-up? A. "I will wear a tight fitting bra to provide compression" B. "I must wash my hands thoroughly before breastfeeding." C. "I must change nursing pads as soon as they become wet." D. "I need to feed my baby every 2-3 hours."

A. "I will wear a tight fitting bra to provide compression" This statement is incorrect and requires follow-up. Tight bras can cause pressure on the breasts, making milk expression more difficult and leading to mastitis.

The nurse is reinforcing teaching to a client who is breastfeeding about ways to prevent mastitis. Which statement, if made by the client, would require follow-up? A. "I will wear a tight fitting bra to provide compression" B. "I must wash my hands thoroughly before breastfeeding." C. "I must change nursing pads as soon as they become wet." D. "I need to feed my baby every 2-3 hours."

A. "I will wear a tight fitting bra to provide compression" This statement is incorrect and requires follow-up. Tight bras can cause pressure on the breasts, making milk expression more difficult and leading to mastitis.

While caring for a patient who is suspected of having appendicitis, the nurse overhears his conversation with a loved one. Which of the following statements would prompt immediate intervention? A. "The pain doesn't feel as bad now, I think it was just a stomach ache." B. "Would you mind getting me an ice pack?" C. "I know I'm not supposed to eat anything right now, but I'm hungry." D. "I wonder if I can play in the basketball game on Monday."

A. "The pain doesn't feel as bad now, I think it was just a stomach ache." A patient suspected of having appendicitis that suddenly feels better has likely experienced a rupture of the appendix. This situation warrants immediate attention since surgery will be necessary.

While caring for a patient who is suspected of having appendicitis, the nurse overhears his conversation with a loved one. Which of the following statements would prompt immediate intervention? A. "The pain doesn't feel as bad now, I think it was just a stomach ache." B. "Would you mind getting me an ice pack?" C. "I know I'm not supposed to eat anything right now, but I'm hungry." D. "I wonder if I can play in the basketball game on Monday."

A. "The pain doesn't feel as bad now, I think it was just a stomach ache." A patient suspected of having appendicitis that suddenly feels better has likely experienced a rupture of the appendix. This situation warrants immediate attention since surgery will be necessary.

A client has been placed on a sodium-restricted diet following myocardial infarction. Which of the following would be the most appropriate meals to suggest? A. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange. B. 3 oz. broiled fish, 1 baked potato, ½/2 cup canned beets, 1 orange, and milk. C. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple. D. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice.

A. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange. People with heart failure may improve their symptoms by reducing the amount of sodium in their diet. Sodium is a mineral found in many foods, especially salt. Overeating salt causes the body to keep or retain too much water, worsening the fluid buildup. Patients should be encouraged to follow a low- sodium diet to help manage hypertension symptoms and reduce edema. One of the most natural things a patient can do at home to reduce sodium intake is to eat fresh vegetables rather than canned ones. If canned vegetables are the only option, the patient should rinse the contents with clean water and cook them with new, unsalted water.

A client has been placed on a sodium-restricted diet following myocardial infarction. Which of the following would be the most appropriate meals to suggest? A. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange. B. 3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk. C. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple. D. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice.

A. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange. People with heart failure may improve their symptoms by reducing the amount of sodium in their diet. Sodium is a mineral found in many foods, especially salt. Overeating salt causes the body to keep or retain too much water, worsening the fluid buildup. Patients should be encouraged to follow a low- sodium diet to help manage hypertension symptoms and reduce edema. One of the most natural things a patient can do at home to reduce sodium intake is to eat fresh vegetables rather than canned ones. If canned vegetables are the only option, the patient should rinse the contents with clean water and cook them with new, unsalted water.

The licensed practical/vocational (LPN/VN) nurse is caring for a client with cardiac arrest and assisting the registered nurse (RN) in identifying priorities and delegation. As the LPN/VN assists with assigning roles to other staff, this is demonstrating which leadership style? A. Authoritative B. Situational C. Democratic D. Laissez-faire

A. Authoritative Authoritative leadership is demonstrated in this situation as the nurse assists with the delegation and provides directives to accomplish tasks. This is an appropriate leadership style in an emergency where one individual assigns tasks/roles to decrease confusion and chaos in an emergent situation.

You are taking care of a client who is postoperative day one following a mitral valve replacement. He is getting ready to ambulate for the first time. His heart rate is 102 beats/minute, and the stroke volume based on the echocardiogram is 72 mL. What is his cardiac output (CO)? A. 7.344 L/min B. 30 L/min C. 55% D. 73.444 mL/min

A. 7.344 L/min To answer this question correctly, you must know the right formula for Cardiac Output (CO). CO = Heart Rate (HR) x Stroke Volume (SV). Heart rate is measured in beats per minute, whereas stroke volume is measured in milliliters (ml). The HR is simply the number of times the heart beats per minute. Stroke volume (SV) is the mL of blood that the heart pumps out with each contraction. By multiplying the two together, you get how many milliliters of blood the heart is pumping out each minute. This is the cardiac output. Cardiac output is usually reported in liters/min, and the average is about 5 L/min, but it varies greatly depending on the patient's size. A decreased cardiac output (low- output failure) is seen in congestive heart failure. An increased cardiac output (high- output failure) may be seen in hyperthyroidism, thiamine deficiency, and severe uncorrected anemia. A high cardiac output state refers to a resting cardiac output of more than 8 L/min. For this problem: Cardiac Output (CO) = 102 beats per minute (HR) x 72 mL (SV) = 7,344 mL/min or 7.344 L/min.

The LPN is caring for the following clients. The nurse should identify which client is at the highest risk for falling? A. 88-year-old admitted with a chest tube secondary to pneumothorax and has a history of dementia. B. 44-year-old admitted with heart failure, has a peripheral IV, and receiving IV furosemide. C. 33-year-old admitted with cholecystitis, has a peripheral IV, and is receiving IV hydromorphone. D. 28-year-old admitted with bacteremia, is receiving intravenous fluids via central line, and is diaphoretic.

A. 88-year-old admitted with a chest tube secondary to pneumothorax and has a history of dementia. This client has advanced age, has a medical device that impedes their mobility, and has cognitive impairments. Thus, all these risk factors put this client at a very high risk of falling.

When collecting data about a client's pain, the first step in pain assessment is for the nurse to: A. Accept the client's report of pain. B. Get the description of the location and intensity of the pain. C. Have the client identify coping methods. D. Determine the client's status of pain.

A. Accept the client's report of pain. Assessment of pain is a vital part of any nursing assessment. In fact, pain is often called the "fifth vital sign". If a patient does not immediately report pain, it is still the nurse's responsibility to ask if he/she feels any pain. If the patient reports pain (under any circumstance), the nurse should validate the patient's concern by acknowledging he/she is feeling discomfort and then assess more thoroughly to find out the location and intensity, identify coping mechanisms, and follow up with their pain status.

What would the nurse expect to administer to a client who presents to the emergency department with a toxic acetaminophen level? A. Acetylcysteine B. Deferoxamine mesylate C. Succimer D. Flumazenil

A. Acetylcysteine Acetylcysteine (Mucomyst) is given to convert toxic metabolites to nontoxic. Acetaminophen is one of the most commonly used oral analgesics and antipyretics. It has an excellent safety profile when administered in proper therapeutic doses, but hepatotoxicity can occur after an overdose and when it is misused in at-risk populations. In the United States, acetaminophen toxicity has replaced viral hepatitis as the most common cause of acute liver failure.

The nurse recognizes that the most serious form of bone marrow toxicity is: A. Aplastic anemia B. Leukocytosis C. Thrombocytosis D. Granulocytosis

A. Aplastic anemia Aplastic anemia is the result of a hypersensitivity reaction and is often irreversible. It leads to pancytopenia, a severe decrease in all cell types: red blood cells, white blood cells, and platelets.

The nurse recognizes that the most serious form of bone marrow toxicity is: A. Aplastic anemia B. Leukocytosis C. Thrombocytosis D. Granulocytosis

A. Aplastic anemia Aplastic anemia is the result of a hypersensitivity reaction and is often irreversible. It leads to pancytopenia, a severe decrease in all cell types: red blood cells, white blood cells, and platelets.

A patient with a crush injury to her left arm calls the nurse's station and requests pain medication. An hour after administration, the patient is still complaining of intense pain. What is the next nursing action? A. Ask the patient to describe the pain in quality and intensity. B. Offer the patient a distraction, such as a book or television. C. Tell the patient she can have more medication in three hours. D. Tell the patient crush injury victims should expect intense pain.

A. Ask the patient to describe the pain in quality and intensity. A crush wound is a wound caused by a force that leads to compression or disruption of tissues. It is often associated with fractures. Usually, there is minimal to no break in the skin. While other external symptoms, such as bruising or edema, may be visible, nurses should also rely on subjective symptoms reported by the patient. Choice A is correct. Unrelieved pain is an indication of a complication. Patients who experience a crush injury are at risk for developing compartment syndrome. Therefore, asking the patient to be specific about the quality and intensity of pain is vital in re-evaluating the patient's status.

The nurse has received the following prescriptions for newly admitted clients. It would be a priority for the nurse to administer which prescription? A. Aspirin to a client experiencing an acute myocardial infarction B. Lisinopril to a client with essential hypertension C. Risperidone to a client with schizophrenia D. Levodopa-carbidopa to a client with Parkinson's disease

A. Aspirin to a client experiencing an acute myocardial infarction A client experiencing a myocardial infarction is an acute emergency that requires immediate intervention. The standard treatment includes (in no order) morphine, oxygen, nitroglycerin, and aspirin.

What is the nurse's most appropriate action to take on his/her shift for a client currently in 4 point restraints due to combative behavior? A. Assess the patient's skin integrity around the restraints hourly. B. Ensure that the physician has renewed the order for restraints, as should be done every 12 hours. C. Release the leg restraints to give the patient a break and see if his combative behavior has improved. D. Have the attending physician discontinue the restraints and give the patient a chance to behave better.

A. Assess the patient's skin integrity around the restraints hourly. Combative patients should be assessed hourly and non- combative patients every two hours to ensure that skin breakdown around the restraints has not occurred.

Among Erickson's Stages of Development, which of the following development stages would the nurse expect for her 2-year-old patient to be in? A. Autonomy vs. Shame and Doubt B. Industry vs. Inferiority C. Trust vs. Mistrust D. Initiative vs. Guilt

A. Autonomy vs. Shame and Doubt Autonomy vs. Shame and Doubt is the typical development stage for early childhood, which lasts from ages 2 to 3 years, so this is what the nurse would expect for her 2-year-old patient. In Autonomy vs. Shame and Doubt, children seek to develop a sense of personal control over physical skills and independence knowledge. When they are successful, for example, with a task like toilet training, they feel independent, leading to a sense of autonomy. When they are not successful, they think they are a failure, resulting in shame and self-doubt.

The nurse is validating a client's understanding of the management of low back pain. Which of the following statements should the nurse reinforce? A. Avoid bending at the waist and lifting heavy objects. B. Weight-bearing exercises are recommended. C. Increase your sun exposure and calcium intake. D. Lay on your stomach four times a day and flex your legs.

A. Avoid bending at the waist and lifting heavy objects. Low back pain symptoms may be mitigated using activity restriction as well as medications such as nonsteroidal anti-inflammatory drugs (NSAIDs). Bending at the waist and lifting heavy objects would not be recommended for a client with low back pain.

When providing instructions about the use of an MAO inhibitor to a patient with clinical depression, the nurse should instruct the client to: A. Avoid chocolate and cheese B. Take frequent naps C. Take the medication with milk D. Avoid walking without assistance

A. Avoid chocolate and cheese Foods high in tryptophan, tyramine, and caffeine, such as chocolate and cheese, may precipitate hypertensive crisis. Monoamine oxidase inhibitors (MAOIs) were the first type of antidepressants developed. They ease depression by affecting neurotransmitters in the brain. Although they are active, they've generally been replaced by antidepressants that are safer and cause fewer side effects. MAOIs can cause dangerously high blood pressure when taken with certain foods or medications. Due to this, diet restrictions and avoiding certain other drugs are required while on MAOI therapy. Despite the side effects, these medications are still a good option for some people. In some instances, they relieve depression when other treatments have failed.

Which form of therapy would most likely be used to treat a group of clients affected by phobias? A. Behavioral psychotherapy B. Cognitive-behavioral psychotherapy C. Psychoanalysis D. Cognitive psychotherapy

A. Behavioral psychotherapy Behavioral psychotherapy is useful for patients who are adversely affected by phobias, addictive disorders, and substance-related disorders. Some of the techniques used with behavioral therapy include operant conditioning as put forth by Skinner, aversion therapy, desensitization therapy, modeling, as well as complementary and alternative stress management techniques.

The condition of metabolic acidosis is indicated by which of the following arterial blood gas values? A. Bicarbonate of 15 mEq/L B. CO(2) 47 mmHg C. PaO2 90% D. pH 7.34

A. Bicarbonate of 15 mEq/L The bicarbonate level is well below average, which indicates metabolic acidosis. Normal bicarbonate levels are 22 to 26 mEq/L in adults. Acid- base disorders, including metabolic acidosis, are disturbances in the balance of plasma acidity. Any process that increases the serum hydrogen ion concentration is a distinct acidosis. The term acidemia is used to define the total acid-base status of the serum pH. Acidosis classifies as either a respiratory acidosis that involves changes in carbon dioxide or metabolic acidosis, which is influenced by bicarbonate (HCO3). Metabolic acidosis is a clinical disturbance defined by a pH of less than 7.35 and a low HCO3 level. It is characterized by an increase in the hydrogen ion concentration in the systemic circulation resulting in a serum HCO3 less than 22 mEq/L. Metabolic acidosis is not benign and signifies an underlying disorder that needs to be corrected to minimize morbidity and mortality. The many etiologies of metabolic acidosis are classified into four main mechanisms: increased acid production, decreased acid excretion, acid ingestion, and renal or gastrointestinal (GI) bicarbonate losses.

The nurse cares for a client with polycystic kidney disease (PKD). Which of the following would indicate the client is achieving treatment goals? A. Blood Pressure 128/63 mmHg B. Creatinine 2.3 mg/dl C. Proteinuria D. Sodium 132 mEq/L

A. Blood Pressure 128/63 mmHg Treatment goals for a client with polycystic kidney disease (PKD) include maintaining normotension, the glomerular filtration rate (GFR), and the prevention of sodium wasting, which is evidence of a decline in renal function. Hypertension is a cardinal finding in PKD, and if a client is achieving the treatment goals, they will maintain regulated blood pressure.

The nurse is caring for a child with cystic fibrosis at the outpatient clinic. The nurse anticipates that the primary healthcare provider (PHCP) will order which routine laboratory test? A. Blood glucose B. Total cholesterol C. 24-hour urine D. Blood cultures

A. Blood glucose Diabetes mellitus is a common co-morbidity associated with cystic fibrosis (CF). The damage that CF may cause to the pancreas may induce diabetes. Thus, random blood glucose levels and quarterly hemoglobin A1C levels are commonly ordered throughout the course of the illness. A random blood glucose level greater than 200 mg/dL may suggest the presence of diabetes.

You are caring for a 1 month-old infant who has a sudden cardiac arrest. Which pulse should you palpate to determine circulatory status? A. Brachial B. Femoral C. Carotid D. Popliteal

A. Brachial In infants, the brachial artery is the right site to check for a pulse. This will help determine how to proceed with the code event and if there is a return of spontaneous circulation (ROSC).

A patient who is taking Lasix knows that he should increase the intake of what food? A. Cantaloupe B. Iceberg lettuce C. Plums D. Apples

A. Cantaloupe Cantaloupe has high levels of potassium in it, which tends to be lower in a patient taking Lasix. Lasix is the most frequently prescribed loop diuretic. It can increase urine output, even when blood flow to the kidneys is diminished. The rapid excretion of large amounts of water caused by loop diuretics may produce adverse effects, such as dehydration and electrolyte imbalances. Potassium loss may result in dysrhythmias. Therefore, potassium supplements and foods high in potassium are encouraged.

The nurse is caring for a client newly diagnosed with mastitis. The nurse anticipates a prescription for which medication? A. Cephalexin B. Acyclovir C. Fluconazole D. Imiquimod

A. Cephalexin Mastitis is commonly caused by Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), E. coli, and streptococci. Thus, antibiotics such as cephalexin are effective in the treatment of mastitis.

The nurse performs data collection on an older adult client and observes apnea alternates with periods of rapid breathing. The nurse should document this respiratory pattern as A. Cheyne-Stokes. B. Kussmaul's. C. agonal. D. tachypnea.

A. Cheyne-Stokes. Cheyne-Stokes respirations are characterized when the respiratory rate and depth are irregular and alternate with periods of apnea and hyperventilation. The pattern then reverses, and the breathing slows and becomes shallow, concluding as apnea before respiration resumes. This may occur in older adults without any underlying pathology. This also could be characteristic of the client's critical condition following a neurological injury.

The nurse receives a prescription from the primary healthcare provider (PHCP) for metoprolol 5 mL intravenous (IV) push x 1 dose. The nurse should take which priority action before administering the medication? A. Clarify the prescription with the primary healthcare provider (PHCP) B. Assess vital signs C. Obtain a 5 mL syringe D. Assess the client's allergies.

A. Clarify the prescription with the primary healthcare provider (PHCP) This prescription is inaccurate and requires clarification with the PHCP before moving forward. This medication was prescribed as a volume of 5 mL, not the precise dosage amount to be administered (for example, it is okay to be prescribed 5 mg of metoprolol, not 5 mL). The nurse needs an accurate prescription that is complete before executing other steps in the medication administration process.

The nurse is performing medication administration for four clients. Which client and medication should be administered first? Client One-prednisone 10 mg PO Daily for asthma exacerbation. Client Two-acetaminophen 500 mg PO x 1 dose for fever Client Three-magnesium oxide 250 mg PO Daily for chronic alcoholism Client Four-glargine insulin 15 units SubQ Daily for diabetes mellitus A. Client one B. Client two C. Client three D. Client four

A. Client one This medication is prescribed for a client with an asthma exacerbation which is an acute problem. Additionally, this acute problem is dealing with the client's breathing status, prioritizing a fever, diabetes, and chronic alcoholism.

You are caring for an elderly woman who is a practicing Orthodox Judaism.Which meal would you most likely offer this client? A. Cottage cheese and fruit B. Beef lasagna C. Hamburger and milk D. Pork cutlet parmigiana

A. Cottage cheese and fruit You would offer this client a meal consisting of cottage cheese and fruit because Orthodox Jewish people are not permitted to have dairy products and meat in one meal.

The nurse observes a patient clutching her abdomen and complaining of cramping, accompanied by sharp pain. Which of the following types of pain is the client experiencing? A. Cutaneous or superficial somatic B. Visceral C. Deep somatic D. Radiating

A. Cutaneous or superficial somatic Cutaneous or superficial somatic pain arises in the skin or subcutaneous tissue. Such pain is described as sharp, aching, gnawing, or cramping. It is often localized. The client is experiencing sharp pain, which goes more in favor of cutaneous pain. Physical pain is either nociceptive or neuropathic. These two types of pain differ in how they affect the patient and how they are treated. Nociceptive pain is the most common type of pain experienced. It occurs when pain receptors, which are called nociceptors, respond to potentially damaging stimuli, for example, as a result of noxious thermal, chemical, or mechanical stimuli. Nociceptive pain may occur because of trauma, surgery, or inflammation. Two types of nociceptive pain are: visceral pain (i.e. pain originating from internal organs) and somatic pain (i.e. pain originating from the skin, muscles, bones, or connective tissue).

The nurse is administering medications to her 5-year-old patient diagnosed with pneumonia. The health care provider has ordered a cough suppressant. Which of the following medications does the nurse administer? A. Dextromethorphan B. Guaifenesin C. Dexmedetomidine D. Protonix

A. Dextromethorphan Dextromethorphan is a cough suppressant. It is the ingredient in many over-the-counter cough medicines such as Delsym, Robitussin, and NyQuil. Dextromethorphan works by signaling the brain to stop triggering the cough reflex.

Common side effects of antidysrhythmic medications include: A. Dizziness, hypotension, and weakness B. Headache, hypertension, and fatigue C. Weakness, fatigue, and hypertension D. Anorexia, diarrhea, and hypertension

A. Dizziness, hypotension, and weakness Hypotension may occur when patients are given antidysrhythmics. Hypotension may result in the patient feeling dizzy or weak. Dysrhythmias are abnormalities of electrical conduction in the heart. They encompass several different disorders that range from harmless to life-threatening. They are classified by their location and the type of rhythm abnormality that they produce. Antidysrhythmic drugs are separated into four primary classes and a diverse group, including: Sodium channel blockers Beta-adrenergic blockers • Potassium channel blockers Calcium channel blockers • Miscellaneous antidysrhythmic drugs

The nurse is caring for a client diagnosed with Lyme disease. The nurse anticipates the primary healthcare provider (PHCP) prescribe which medication? A. Doxycycline B. Enalapril C. Simvastatin D. Famotidine

A. Doxycycline Doxycycline is an effective treatment for Lyme disease. Lyme disease is an infectious disease caused by the Borrelia bacterium, spread by ticks. The most common sign of infection is an expanding area of redness on the skin, known as erythema migrans, that appears at the tick bite site about a week after it occurred. The rash is typically neither itchy nor painful. The rash is classically referred to as a bullseye rash.

When an elderly home health client suddenly develops delirium, what is the first thing the home health nurse should assess for? A. Drug intoxication B. Increased hearing loss C. Cancer metastases D. Congestive heart failure

A. Drug intoxication Drug intoxication, from prescription or over-the-counter medications, is more common in the elderly due to slower metabolism and absorption. Combinations of digoxin, diuretics, analgesics, and anticholinergics should be examined. Delirium is an acute and reversible syndrome. It is characterized by changes in memory, judgment, language, mathematical calculation, abstract reasoning, and problem-solving ability. The most common causes of delirium are infection, medications, and dehydration. Some symptoms of delirium include: • Hallucinations Restlessness, agitation, or combative behavior Calling out, moaning, or making other sounds Being quiet and withdrawn- especially in older adults • Slowed movement or lethargy ● ● • Disturbed sleep habits • Reversal of night-day sleep-wake cycle

The nurse is admitting a client who has cryptococcosis pneumonia. Which of the following actions would be appropriate for the nurse to take? A. Ensure a hand sanitizing station is near the client's room. B. Wear a surgical mask when working within three feet of the client. C. Keep the door to the client's room always closed. D. Place the client in a private room with monitored negative airflow.

A. Ensure a hand sanitizing station is near the client's room. Cryptococcosis pneumonia is a fungal infection not transmitted from human to human. Rather, this infection is opportunistic for individuals who are significantly immunocompromised. Standard precautions are necessary, which involve appropriate hand hygiene.

Which action taken by the school nurse will have the most impact on the school's incidence of infectious disease? A. Ensure that students are immunized according to national guidelines. B. Provide written information about infection control to all patients. C. Make soap and water readily available in the classrooms. D. Teach students how to cover their mouths when coughing.

A. Ensure that students are immunized according to national guidelines. The incidence of once-common infectious diseases such as measles, chickenpox, and mumps have been most effectively reduced by immunization of all school-aged children. School-aged children are at risk for problems such as exposure to viruses, respiratory infections, and parasitic infections (such as scabies or lice). Vaccination protects children from severe illness and complications of vaccine-preventable diseases, which can include amputation of an arm or leg, paralysis of limbs, hearing loss, convulsions, brain damage, and death.

Which action taken by the school nurse will have the most impact on the incidence of infectious disease in the school? A. Ensure that students are immunized according to national guidelines. B. Provide written information about infection control to all patients. C. Make soap and water readily available in the classrooms. D. Teach students how to cover their mouths when coughing.

A. Ensure that students are immunized according to national guidelines. The incidence of once-common infectious diseases such as measles, chickenpox, and mumps have been most effectively reduced by immunization of all school-aged children. School-aged children are at risk for exposure to viruses, respiratory infections, and parasitic infections (such as scabies or lice). Vaccination protects children from severe illness and complications of vaccine-preventable diseases, including amputation of an arm or leg, paralysis of limbs, hearing loss, convulsions, brain damage, and death.

The nurse is taking vital signs for a client who has a chest tube in place. While counting his respirations, she notes that the water in the water-seal-chamber is fluctuating. Which of the following actions are appropriate based on this finding? A. Finish counting the client's respirations B. Empty the water-seal chamber C. Assist the patient with incentive spirometry D. Notify the RN

A. Finish counting the client's respirations It is appropriate for the nurse to simply finish counting the client's respirations and continue to monitor them. Fluctuations of the water in the water-seal chamber with inspiration and expiration is a sign that the drainage system is patent. Normally, the water level will increase when the patient breathes in, and decrease when they breathe out. This is due to changes in intrathoracic pressures.

The nurse is taking vital signs for a client who has a chest tube in place. While counting his respirations, she notes that the water in the water-seal-chamber is fluctuating. Which of the following actions are appropriate based on this finding? A. Finish counting the client's respirations B. Empty the water-seal chamber C. Assist the patient with incentive spironmetry D. Notify the RN

A. Finish counting the client's respirations It is appropriate for the nurse to simply finish counting the client's respirations and continue to monitor them. Fluctuations of the water in the water-seal chamber with inspiration and expiration is a sign that the drainage system is patent. Normally, the water level will increase when the patient breathes in, and decrease when they breathe out. This is due to changes in intrathoracic pressures.

The nurse is caring for a client diagnosed with trichotillomania. The nurse anticipates a prescription for which medication from the primary healthcare provider (PHCP)? A. Fluoxetine B. Amphetamine C. Haloperidol D. Bupropion

A. Fluoxetine Trichotillomania is a syndrome that causes a client to engage in hair-pulling. This disorder is categorized as an obsessive-compulsive disorder. Common sites for hair pulling include the eyebrows, scalp hair, and chin. Selective serotonin reuptake inhibitors (SSRIs) combined with psychotherapy are effective treatments for this disorder. Medications that may be used include fluoxetine, citalopram, or paroxetine.

The nurse is caring for a client diagnosed with trichotillomania. The nurse anticipates a prescription for which medication from the primary healthcare provider (PHCP)? A. Fluoxetine B.Amphetamine C. Haloperidol D. Bupropion

A. Fluoxetine Trichotillomania is a syndrome that causes a client to engage in hair-pulling. This disorder is categorized as an obsessive-compulsive disorder. Common sites for hair pulling include the eyebrows, scalp hair, and chin. Selective serotonin reuptake inhibitors (SSRIs) combined with psychotherapy are effective treatments for this disorder. Medications that may be used include fluoxetine, citalopram, or paroxetine.

Which of these strategies would the nurse suggest to parents to add to their activities to promote tactile stimulation for an 11-month-old? A. Give the infant finger foods of different textures. B. Provide soft squeeze toys of various textures. C. Allow the infant to play nude on a soft, furry rug. D. Comb the infant's hair with a soft

A. Give the infant finger foods of different textures. At this age, finger foods are being introduced into the infant's diet. Providing a variety of foods with different textures provides a natural way to promote tactile stimulation.

The nurse plans care for a client with peritoneal dialysis (PD). Which of the following teaching points is essential for the nurse to reinforce with the client? A. Handwashing B. Daily weights C. Symptoms of constipation D. Daily dietary restrictions

A. Handwashing Peritoneal dialysis is an effective treatment for those with end- stage renal disease. This treatment allows the client to perform dialysis their home. The most serious complication associated with peritoneal dialysis is peritonitis. Handwashing is vital to review with the client as this is a significant way to reduce this complication. One of the earliest signs of peritonitis for a client receiving peritonitis is cloudy outflow.

The nurse is ambulating a client who is wearing a gait belt. The client begins to fall. The nurse should take which appropriate action to minimize injury? A. Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor. C. Grasp the gait belt, and instruct the client to fall gently down to the floor in a side-lying position. Correct Answer(s): A B. Let go of the gait belt, grab the client under each arm, and gently lower the client to the floor. D. Hold the gait belt, and lower the client to the floor by using a narrow base of support.

A. Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor. For a client who is ambulating, the nurse should always be slightly behind the client and positioned on the affected (weaker) side. If a client starts to fall, the nurse should hold the gait belt, try to extend one leg, let the client slide against the leg, and gently lower the client to the floor, protecting the head. The nurse can help prevent client injury by maintaining a wide base of support.

The nurse is monitoring a patient on a continuous telemetry monitor. She notes a flattened P wave, prolonged PR interval, widened QRS complex, and a tall t-wave. Which of the following electrolyte abnormalities does she suspect? A. Hypermagnesemia B. Hypomagnesemia C. Hyperphosphatemia D. Hypochloremia

A. Hypermagnesemia Hypermagnesemia is a dangerous electrolyte abnormality that can cause many EKG changes in severe cases. A flattened P wave, prolonged PR interval, widened QRS complex, and a tall t-wave are characteristic of hypermagnesemia.

The nurse is monitoring a patient on a continuous telemetry monitor. She notes a flattened P wave, prolonged PR interval, widened QRS complex, and a tall t-wave. Which of the following electrolyte abnormalities does she suspect? A. Hypermagnesemia B. Hypomagnesemia C. Hyperphosphatemia D. Hypochloremia

A. Hypermagnesemia Hypermagnesemia is a dangerous electrolyte abnormality that can cause many EKG changes in severe cases. A flattened P wave, prolonged PR interval, widened QRS complex, and a tall t-wave are characteristic of hypermagnesemia.

The nurse is caring for a 10-year-old patient with a tracheostomy tube. She notes that the patient has a large volume of secretions and prepares to suction him. Which of the following actions should she take first? A. Hyperoxygenate the patient B. Ask the patient to take a deep breath C. Place the patient supine D. Notify the RN

A. Hyperoxygenate the patient It is necessary to hyperoxygenate the patient prior to taking any of the other actions. This is one of the first steps in suctioning a tracheostomy. The nurse hyperoxygenates the patient to prepare them for the procedure and prevent desaturations. She then inserts the suction catheter without suctioning to the pre- measured depth, applies intermittent suction and rotates the suction catheter as she removes it from the tracheostomy.

While reviewing the morning labs of your client, you see the following results from their thyroid panel. What diagnosis does the nurse suspect? • TSH: 7 mU/L • T4: 1.0 mcg/dL • T3: 2.0 ng/dL A. Hypothyroidism B. Graves' disease C. Addison's Disease D. Cushing's disease

A. Hypothyroidism Hypothyroidism would be manifested with an increased thyroid- stimulating hormone level and decreased T4 and T3, as shown in these labs. Because of the increased TSH level, the thyroid gland is tricked into thinking that there is enough thyroid hormone already in the body and does not secrete more. The decreased T3 and T4 levels cause hypothyroidism symptoms, such as weight gain and fatigue.

While reviewing the morning labs of your client, you see the following results from their thyroid panel. What diagnosis does the nurse suspect? • TSH: 7 mU/L • T4: 1.0 mcg/dL • T3: 2.0 ng/dL A. Hypothyroidism B. Graves' disease C. Addison's Disease D. Cushing's disease

A. Hypothyroidism Hypothyroidism would be manifested with an increased thyroid- stimulating hormone level and decreased T4 and T3, as shown in these labs. Because of the increased TSH level, the thyroid gland is tricked into thinking that there is enough thyroid hormone already in the body and does not secrete more. The decreased T3 and T4 levels cause hypothyroidism symptoms, such as weight gain and fatigue.

A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to a nursing assistant who is assisting with the client's care? A. Implement contact precautions when handling the client. B. Educate the client and family members on ways to prevent transmission of VRE. C. Monitor the results of the laboratory culture and sensitivity test. D. Collaborate with other departments when the client is transported for an ordered test.

A. Implement contact precautions when handling the client. All hospital personnel who care for the client are responsible for the correct implementation of contact precautions.

The emergency room nurse is caring for a patient on 24-hour observation for signs of alcohol intoxication. While administering as-needed pain medication for headache, the nurse notes that the patient is diaphoretic and agitated, with shaking hands and eyes darting around the room. Which initial action would be most important for the nurse to take? A. Implement seizure precautions B. Ask patient to rate pain on a scale from 0-10 C. Call security to restrain the patient D. Assess the patient's neurological status

A. Implement seizure precautions This patient is presenting with signs of alcohol withdrawal: headache, tremors, visual hallucinations, diaphoresis, and agitation. Alcohol withdrawal puts this patient at risk for seizures. Of the options provided, the nurse's first priority would be to initiate seizure precautions immediately.

Which of the following clinical manifestations of the aging immune system should alert the nurse to increased susceptibility to illness in elderly clients? A. Increased autoimmune diseases. B. Increased production of T and B cells. C. Increased lymphoid tissue. D. Increased circulation of lymphocytes.

A. Increased autoimmune diseases. Elderly clients have an increased incidence of autoimmune disorders, immunological response to antigenic stimulus declines with age and puts them at increased risk for infections. This puts them at higher risk for experiencing diseases such as rheumatoid arthritis and other collagen-related diseases.

Which of the following clinical manifestations of the aging immune system should alert the nurse to increased susceptibility to illness in elderly clients? A. Increased autoimmune diseases. B. Increased production of T and B cells. C. Increased lymphoid tissue. D. Increased circulation of lymphocytes.

A. Increased autoimmune diseases. Elderly clients have an increased incidence of autoimmune disorders, immunological response to antigenic stimulus declines with age and puts them at increased risk for infections. This puts them at higher risk for experiencing diseases such as rheumatoid arthritis and other collagen-related diseases.

Which of the following clinical manifestations of the aging immune system should alert the nurse to increased susceptibility to illness in elderly clients? A. Increased autoimmune diseases. B. Increased production of T and B cells. C. Increased lymphoid tissue. D. Increased circulation of lymphocytes.

A. Increased autoimmune diseases. Elderly clients have an increased incidence of autoimmune disorders, immunological response to antigenic stimulus declines with age and puts them at increased risk for infections. This puts them at higher risk for experiencing diseases such as rheumatoid arthritis and other collagen-related diseases.

What intervention is appropriate for the nurse to teach her pregnant patient about relieving and/or preventing constipation? A. Increasing the consumption of fruits and vegetables. B. Taking a mild over-the-counter laxative. C. Lying flat on the back when sleeping. D. Reduce consumption of iron by half the amount.

A. Increasing the consumption of fruits and vegetables. Dietary roughage (or fiber) with sufficient fluids and exercise may help relieve constipation. Constipation in pregnant women is thought to occur due to hormones that relax the intestinal muscle and by the pressure of the expanding uterus on the intestines. Relaxation of the abdominal muscle causes food and waste to move slower through your system. Sometimes iron tablets may contribute to constipation.

The nurse is caring for a patient diagnosed with osteomyeloma. She reviews his lab values and notes a serum calcium level of 14 mg/dL(9-10.5 mg/dL). Which of the following actions should the nurse take? A. Inform the RN of the lab value B. Document the finding C. Continue to monitor the patient D. Remove the patient from the telemetry monitor

A. Inform the RN of the lab value This is the appropriate action for the nurse to take. The nurse has appreciated that the lab value is incorrect, and must escalate the finding to the registered nurse. The normal range for serum calcium is 8.4-10.2 mg/dL. This patient's serum calcium level is above 10.2 mg/dL, therefore they are experiencing hypercalcemia.

The nurse is caring for a patient diagnosed with osteomyeloma. She reviews his lab values and notes a serum calcium level of 14 mg/dL(9-10.5 mg/dL). Which of the following actions should the nurse take? A. Inform the RN of the lab value B. Document the finding C. Continue to monitor the patient D. Remove the patient from the telemetry monitor

A. Inform the RN of the lab value This is the appropriate action for the nurse to take. The nurse has appreciated that the lab value is incorrect, and must escalate the finding to the registered nurse. The normal range for serum calcium is 8.4-10.2 mg/dL. This patient's serum calcium level is above 10.2 mg/dL, therefore they are experiencing hypercalcemia.

X While caring for a 4-year-old child in the PICU, you develop a care plan to address his psychosocial development during his recovery. You know that he will be in which stage of development according to Erikson's stages of psychosocial development? A. Initiative vs. Guilt B.Autonomy vs. Shame and Doubt C. Industry vs. Inferiority D. Trust vs. Mistrust

A. Initiative vs. Guilt Initiative vs. Guilt is the typical development stage for preschool children, which are 3 to 5-year-olds, so this is correct for your 4-year-old patient. In Initiative vs. guilt, children start to assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval end up feeling guilty.

A gastrointestinal disease of childhood where a piece of bowel goes backward inside itself, forming an obstruction is called what? A. Intussusception B. Pyloric stenosis C. Hirschsprung's disease D. Omphalocele

A. Intussusception A gastrointestinal disease of childhood where a piece of bowel goes backward inside itself, forming an obstruction, is called intussusception. Choice B is incorrect. Pyloric stenosis is the enlargement and stiffening of the pylorus, the opening from the stomach into the duodenum. This prevents the passage of food into the duodenum and results in projectile vomiting.

The nurse is supervising a student nurse administer prescribed medications via a double-lumen nasogastric tube (NGT) with an air vent. Which action by the student requires follow-up? The student A. Irrigates the air vent before medication administration with water B. Contacts the pharmacy to obtain available medications in liquid form C. Flushes the NGT between medications with water D. Administers each medication separately through the NGT

A. Irrigates the air vent before medication administration with water The air vent should not be irrigated with water or used to administer medications. The purpose of the air vent is to permit free, continuous drainage of secretions when the NGT is connected to suction. This vent is found on a Salem sump tube and is often called a blue "pigtail."

The nurse is supervising a student nurse administer prescribed medications via a double-lumen nasogastric tube (NGT) with an air vent. Which action by the student requires follow-up? The student A. Irrigates the air vent before medication administration with water B. Contacts the pharmacy to obtain available medications in liquid form C. Flushes the NGT between medications with water D. Administers each medication separately through the NGT

A. Irrigates the air vent before medication administration with water The air vent should not be irrigated with water or used to administer medications. The purpose of the air vent is to permit free, continuous drainage of secretions when the NGT is connected to suction. This vent is found on a Salem sump tube and is often called a blue "pigtail."

The nurse is assessing a 4-year-old who was sent to the ED from urgent care. Assessment reveals tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling. Vital signs are: • Temp: 39 degrees C .HR: 188 • RR: 46 02: 82 % Which of the following is the priority nursing action at this time? A. Keep the child calm and call for emergency airway equipment. B. Obtain IV access. C. Assess the throat for a cherry red epiglottis. D. the child on a high flow nasal cannula at 100% FiO2.

A. Keep the child calm and call for emergency airway equipment. Based on the presenting symptoms, the nurse suspects that this child has epiglottitis. Any child presenting with excessive drooling, distress, and stridor is highly suspicious of this medical emergency. In addition, this patient is already showing signs of circulatory compromise including circumoral cyanosis and mottling. The priority nursing action in this emergency is keeping the child calm and calling for emergency airway equipment. The child is at risk of losing their airway, and the airway is always the priority.

The LPN is caring for a client scheduled for surgery who has a diet order of nothing by mouth (NPO). Which of the following prescriptions should the LPN clarify with the primary healthcare physician (PHCP)? A. Lispro insulin 5 units SubQ before meals TID B. Glargine insulin 15 units SubQ QHS C. Vitamin B12 100 mcg IM Daily D. Clonidine patch transdermal TTS-1 0.1 mg/24 hours q 7 days

A. Lispro insulin 5 units SubQ before meals TID A client who is NPO awaiting surgery should not receive rapid or short-acting insulin. This insulin is intended to be given before meals, and the client could develop life-threatening hypoglycemia if given this type of insulin with no meal.

The home health nurse is assessing a client with suspected carbon monoxide poisoning. The nurse should take which priority action? A. Move the client outdoors B. Notify the primary healthcare provider (PHCP) C. Auscultate the client's lung sounds D. Assess the client's pulse oximetry

A. Move the client outdoors Carbon monoxide poisoning is a serious emergency that is often fatal if not promptly treated. This medical emergency requires the client to be immediately relocated away from the carbon monoxide. Moving the client outside is effective because of the fresh air. Once this has been completed, the nurse should notify the PHCP or call emergency medical services (EMS) for further treatment. Another priority treatment is providing the client with 100% high-flow oxygen regardless of their pulse oximetry, lung sounds, or arterial blood gas results.

The nurse is caring for a client with an infected leg pressure ulcer. The initial priority for the nurse is to A. Obtain a wound culture B. Wrap the extremity with a sterile dressing C. Review the client's risk factors for skin breakdown D. Obtain a prescription for antibiotic ointment

A. Obtain a wound culture Obtaining wound culture before wrapping the extremity and applying a prescribed antibiotic ointment is essential. This will assist the primary healthcare provider (PHCP) in determining the most effective antibiotic to administer.

The nurse is caring for a client who sustained an electrical burn. The nurse plans to take which priority action? A. Obtain an electrocardiogram (ECG) B. Prepare for an arterial blood gas (ABG) collection C. Provide wound care D. Initiate supplemental oxygen

A. Obtain an electrocardiogram (ECG) Electrical burns are serious and require the client to undergo cardiac monitoring because of the risk of dysrhythmias. The nurse's priority action is to obtain telemetry monitoring or perform a 12-lead electrocardiogram.

The nurse is caring for a client who sustained an electrical burn. The nurse plans to take which priority action? A. Obtain an electrocardiogram (ECG) B. Prepare for an arterial blood gas (ABG) collection C. Provide wound care D. Initiate supplemental oxygen

A. Obtain an electrocardiogram (ECG) Electrical burns are serious and require the client to undergo cardiac monitoring because of the risk of dysrhythmias. The nurse's priority action is to obtain telemetry monitoring or perform a 12-lead electrocardiogram.

At 25 weeks gestation, a pregnant client presents with a uterine growth size less than expected, absence of fetal ballottement and an easily palpable fetus. What is this likely related to the development of? A. Oligohydramnios B. Macrosomia C. Hydramnios D. Amniotic fluid embolism

A. Oligohydramnios Oligohydramnios results from a severe reduction in the amount of amniotic fluid. It results in less than expected fetal growth. Also, because of the low amount of amniotic fluid, the fetus will be more easily outlined and palpated.

The emergency department (ED) nurse cares for a client with severe intrabdominal bleeding. The client has tachycardia, hypotension, and a thready pulse. The nurse anticipates the primary healthcare provider (PHCP) will prescribe which blood product? A. Packed red blood cells (PRBCs) B. Platelets C. Granulocytes D. Fresh frozen plasma (FFP) .

A. Packed red blood cells (PRBCs) The client is experiencing intraabdominal bleeding with manifestations confirming shock. The client will need to have the blood volume replaced with emergent surgery. Type-specific PRBCs would be preferred; however, if the client is critical, O-negative blood may be transfused.

When the nurse begins to irrigate a Salem Sump tube, she notices that the gastric drainage is dark brown. What is the first intervention the nurse should take? A. Perform a hemoccult test on the contents. B. Irrigate the tube and check the returns. C. Remove the tube from the suction. D. Check the pH of the gastric contents.

A. Perform a hemoccult test on the contents. The presence of dark brown drainage may indicate the presence of bleeding or blood in the GI tract. The first nursing intervention is to perform a hemoccult test to determine the presence of blood.

Your 78-year-old client, who has been receiving antibiotics for 10 days, tells you that he has frequent watery stools. Which action will you take first? A. Place the client on contact precautions. B. Instruct the client about correct handwashing techniques. C. Obtain stool specimens for culture. D. Notify the physician about the loose stools.

A. Place the client on contact precautions. The client's age, history of antibiotic therapy, and watery stools suggest that he may have Clostridium difficile infection. The initial action is to place him on contact precautions to prevent the spread of C. difficile to other clients. C. difficile is a spore-forming bacillus that infects the gastrointestinal (GI) tract treatment of other infections with antibiotics. It is one of the few hospital-acquired infections (HAIs) increasing in frequency. C. difficile spores are transferred to clients mainly via the hands of health care personnel who have touched a contaminated surface or item.

Your 78-year-old client, who has been receiving antibiotics for 10 days, tells you that he has frequent watery stools. Which action will you take first? A. Place the client on contact precautions. B. Instruct the client about correct handwashing techniques. C. Obtain stool specimens for culture. D. Notify the physician about the loose stools.

A. Place the client on contact precautions. The client's age, history of antibiotic therapy, and watery stools suggest that he may have Clostridium difficile infection. The initial action is to place him on contact precautions to prevent the spread of C. difficile to other clients. C. difficile is a spore-forming bacillus that infects the gastrointestinal (Gl) tract following treatment of other infections with antibiotics. It is one of the few hospital-acquired infections (HAIs) increasing in frequency. C. difficile spores are transferred to clients mainly via the hands of health care personnel who have touched a contaminated surface or item.

Which of the following client room assignments should the nurse question? A. Placement of an 89-year-old client with acute delirium at the end of the hallway. B. Placement of a 79-year-old client with C. difficile with a 26-year-old client with C. difficile. C. Placement of a 56-year-old client with HIV and bronchitis in a private room. D. Placement of a 39-year-old client with mild head trauma with a 40-year-old client with an arm fracture.

A. Placement of an 89-year-old client with acute delirium at the end of the hallway. Patients with delirium and those at high risk for safety events should be roomed close to the nurse's station to accommodate close monitoring. In addition to the delirium, this client's age poses a risk for injury related to falls.

The nurse is caring for a client prescribed enoxaparin. Which laboratory values should the nurse monitor? A. Platelet count B. Activated Partial Thromboplastin Time (aPTT) C. International Normalized Ratio (INR) D. Troponin

A. Platelet count Enoxaparin is a low molecular weight-based heparin, and the platelet count will need to be monitored if the client should develop heparin-induced thrombocytopenia (HIT). This condition is serious and results in a 50% decrease in the platelet count.

The nurse is caring for a client prescribed enoxaparin. Which laboratory values should the nurse monitor? A. Platelet count B. Activated Partial Thromboplastin Time (aPTT) C. International Normalized Ratio (INR) D. Troponin

A. Platelet count Enoxaparin is a low molecular weight-based heparin, and the platelet count will need to be monitored if the client should develop heparin-induced thrombocytopenia (HIT). This condition is serious and results in a 50% decrease in the platelet count.

The licensed practical/vocational nurse (LPN/VN) is assisting in caring for a client who had bariatric surgery. Which of the following should be included? A. Pneumatic compression devices B. Insertion of an indwelling urinary catheter C. Strict bed rest D. Fluid restrictions

A. Pneumatic compression devices Following bariatric surgery, the client faces an array of complications, including hemorrhage, wound disruption, pneumonia, and wound infection. Venous thromboembolism is a significant complication and may be mitigated using pneumatic compression devices and chemical prophylaxis.

While administering digoxin to an infant in heart failure, the nurse knows to monitor which of the following electrolytes? A. Potassium B. Calcium C. Sodium D. Phosphorus

A. Potassium It is important that the nurse knows to monitor potassium levels while her patient is taking digoxin. This is important because if the patient is hypokalemic, digoxin toxicity can be worsened. Whereas, if the patient is hyperkalemic, digoxin will not be as effective.

The nurse is precepting a newly hired nurse to administer an intramuscular injection to an adult. Which action by the newly hired nurse requires follow- up? A. Prepares to administer the medication in the dorsogluteal. B. Prepares to insert the needle at a 90-degree angle. C. Uses isopropyl alcohol to clean the area prior to injection. D. Washes their hands before and after the procedure.

A. Prepares to administer the medication in the dorsogluteal. This action requires follow-up as the dorsogluteal site is not recommended. The dorsogluteal site is not recommended because of potential damage to nearby nerves and blood vessels.

The nurse is demonstrating the appropriate use of a car seat to a client. The nurse is demonstrating which level of prevention? A. Primary B. Secondary C. Tertiary D. Quaternary

A. Primary Primary prevention is often referred to as the true level of prevention because it occurs before disease or illness. Demonstrating the appropriate use of a car seat is primary prevention because it happens before an automobile crash, a leading cause of death for those younger than 19.

The nurse is caring for a client involuntarily admitted to the behavioral health unit. The client has been mailed a package. The nurse should perform which action? A. Provide the client with the package B. Open the package to review its content C. Provide the package upon discharge D. Determine if the sender is the client's next of kin

A. Provide the client with the package. Under the patient bill of rights, the client has a right to confidentiality and privacy. The nurse should not open postal packages prior to giving them to the client. If the nurse is concerned that the client could be mailed something harmful, the nurse should request that they open the package up in front of them.

The nurse is caring for a child diagnosed with a coarctation of the aorta who is scheduled for a repair tomorrow morning. When she auscultates his lung sounds, she notes crackles and rales. The nurse knows this is a sign of which of the following? A. Pulmonary congestion B. Foreign body aspiration C. Pneumonia D. Systemic congestion

A. Pulmonary congestion Crackles and rales are indicative of pulmonary congestion. Since this child has coarctation of the aorta, there is too much blood backing up in the lungs. It is impossible for the left side of the heart to move sufficient blood forward working against the coarctation. This causes the back up of blood in the lungs, and therefore the crackles and rales indicative of pulmonary congestion.

The Maternal Serum Screen 4 (MMS4) of an obstetrics client shows decreased maternal serum alpha-fetoprotein and estriol along with increased hCG. What strategy should the nurse include in the plan of care? A. Refer to the physician. B. Tell the woman to increase her folic acid intake. C. Refer for amniocentesis. D. Order a plasma glucose level.

A. Refer to the physician. . The combination of results presented in this situation may be the result of a fetus with Down syndrome. The physician needs to be notified of thenresults, and the nurse would anticipate a referral for an amniocentesis. The Maternal Serum Screen 4 (MSS4) is a blood test performed during pregnancy to identify potential risks to the developing fetus. Its purpose is to screen for possible neural tube defects, Down syndrome, and trisomy 18 in the developing baby. Four substances in the blood are measured: Alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), estriol, and inhibin A. AFP is a substance made by the baby that enters the amniotic fluid and the mother's bloodstream. A small amount of AFP is usually found in amniotic fluid and the mother's blood. When the amount is high, it is a signal to the physician to look further for the possibility of a neural tube defect. Estriol, hCG, and inhibin A come from the developing baby as well as the placenta and are measured in the mother's blood. A woman carrying a baby with Down syndrome may have lower blood levels of AFP and estriol as well as higher blood levels of hCG and inhibin A than women with an unaffected baby. A woman carrying a baby with trisomy 18 may have lower blood levels of AFP, estriol, hCG, and inhibin A than women with unaffected babies. The MSS4 detects the same number of neural tube defects and trisomy 18 cases as other currently available maternal serum prenatal screens. When inhibin A is used with AFP, hCG, estriol, and the mother's age, approximately 10-15% more babies with Down syndrome can be detected before birth. Remember that not even the MSS4 can detect all babies with Down syndrome before they are born.

The nurse is performing a home visit for the parents of an infant. Which action by the parents while giving the infant a sponge bath requires follow-up by the nurse? A. Removes all of the infant's clothing for the bath B. Uses a mild soap for the bath C. Provides the bath in a warm room D. Washes and dries one part of the baby's body at a time

A. Removes all of the infant's clothing for the bath This action requires follow-up because it is incorrect. Only the area that is being washed should be uncovered to prevent the infant from getting cold during a sponge bath. Removing all the clothing articles would expose the infant, lowering their temperature.

What is the nurse's priority when a fire occurs in a client's room? A. Rescue the patient. B. Extinguish the fire. C. Sound the alarm. D. Run for help.

A. Rescue the patient. Patient safety is always the priority.

The nurse is caring for a client who sustained a cervical spinal cord injury. Which priority vital sign should the nurse obtain? A. Respiratory rate B. Blood Pressure C. Pulse D. Temperature

A. Respiratory rate Respiratory rate is essential to monitor when a cervical spinal cord injury is sustained. The upper cervical spinal nerves innervate the diaphragm to control breathing. Thus, specific injuries to the cervical spinal cord could be catastrophic.

The nurse is caring for a client who sustained a cervical spinal cord injury. Which priority vital sign should the nurse obtain? A. Respiratory rate B. Blood Pressure C. Pulse D. Temperature

A. Respiratory rate Respiratory rate is essential to monitor when a cervical spinal cord injury is sustained. The upper cervical spinal nerves innervate the diaphragm to control breathing. Thus, specific injuries to the cervical spinal cord could be catastrophic.

Which stage of cognitive development does the nurse expect her 6-month-old patient to be in? A. Sensorimotor B. Preoperational C. Concrete operational D. Formal operational

A. Sensorimotor The first stage of Piaget's Stages of Cognitive Development is the Sensorimotor stage. This stage occurs between 0 and 2 years old. During this stage, the child learns to coordinate their senses with motor responses. They are curious about the world and use their minds to explore. They start to form language and use it for demands. They also develop object permanence.

Which of the following is the most appropriate position for a patient getting thoracentesis? A. Sitting up, leaning over a bedside table and feet supported on the ground or stool. B. The head of the bed flat, with the patient lying on the unaffected side. C. Prone with both arms extended above the head. D. With the head of the bed elevated 45 degrees and the patient lying on the affected side.

A. Sitting up, leaning over a bedside table and feet supported on the ground or stool. The patient should be sitting up, leaning over a bedside table with arms rested, feet supported on the ground or stool so the needle can be inserted appropriately. Usually, only sufficient fluid to lubricate the pleura is present in the pleural cavity. However, excessive fluid can accumulate as a result of injury, infection, or other pathology. In such a case or with pneumothorax, a primary care provider may perform a thoracentesis to remove the excess fluid or air to ease breathing. Thoracentesis is also performed to introduce intrapleural chemotherapeutic drugs. The nurse assists the client to assume a position that allows easy access to the intercostal spaces. This is usually a sitting position with the arms above the head, which allows the ribs to spread and enlarges the intercostal spaces. Two positions that are commonly used include when the body is elevated then stretched forward, and when the client leans forward over a pillow. To ensure that the needle is inserted below the fluid level when fluid is to be removed (or above any liquid if the air is to be removed), the primary care provider will palpate and percuss the chest and select the specific site for insertion of the needle. A place on the lower posterior chest is often used to remove fluid, and a section on the upper anterior chest is used to remove air. A chest x-ray before the procedure will help pinpoint the best insertion site.

You are taking care of a 10-year-old with a gastrostomy jejunostomy (G-J) tube. Which electrolyte deficit is this patient at risk for? A. Sodium B. Potassium C. Chloride D. Calcium

A. Sodium There is a large amount of extracellular fluid in the peritoneal cavity, which contains a high sodium content. If this fluid is lost through the G-J tube, there will be a sodium deficit leading to hyponatremia.

The nurse is observing the surgical aseptic technique of a nursing student. Which observation by the nurse requires follow-up? A. Spills sterile water onto the sterile field B. Uses sterile gloves to handle objects on a sterile field C. Has sterile gauze placed into the sterile field D. Keeps the sterile field above their waist

A. Spills sterile water onto the sterile field When a sterile surface comes in contact with a liquid, the sterile object or field becomes contaminated. Even though the spilled water is sterile, it creates moisture and may disrupt the sterile protective barrier. The nurse should intervene because microorganisms travel to the sterile object if moisture leaks through the protective covering of a sterile package. This observation requires follow-up because the sterile field needs to be discarded and re-established.

The nurse in the emergency department (ED) is caring for a child with erythema infectiosum (Fifth disease). Which transmission-based precautions should the nurse implement? A. Standard B. Droplet C. Contact D. Airborne

A. Standard Standard precautions are used for a client with erythema infectiosum. Droplet precautions would only be necessary if the client is immunocompromised.

Chemotherapy induces vomiting by: A. Stimulating neuroreceptors in the medulla. B. Inhibiting the release of catecholamines. C. Autonomic instability. D. Irritating the gastric mucosa.

A. Stimulating neuroreceptors in the medulla. Vomiting (emesis) is initiated by a nucleus of cells located in the medulla called the vomiting center. This center coordinates a complex series of events involving pharyngeal, gastrointestinal, and abdominal wall contractions that lead to the expulsion of gastric contents.

Chemotherapy induces vomiting by: A. Stimulating neuroreceptors in the medulla. B. Inhibiting the release of catecholamines. C. Autonomic instability. D. Irritating the gastric mucosa.

A. Stimulating neuroreceptors in the medulla. Vomiting (emesis) is initiated by a nucleus of cells located in the medulla called the vomiting center. This center coordinates a complex series of events involving pharyngeal, gastrointestinal, and abdominal wall contractions that lead to the expulsion of gastric contents.

The patient with a history of right mastectomy is receiving maintenance IV fluids via a peripherally inserted intravenous line in the left cephalic vein. The patient complains of pain at the IV site. The nurse notes that the infusion has slowed and assesses swelling as well as erythema at the IV site. Which action should the nurse take first? A. Stop the infusion and remove the IV catheter. B. Insert a new IV in the left intermediate basilic vein. C. Prepare the patient for PICC line placement. D. Elevate the right arm to reduce swelling.

A. Stop the infusion and remove the IV catheter. This patient's IV site shows signs of phlebitis: redness, swelling, pain, and slowed infusion rate. The first priority action is to remove the current IV catheter to reduce the risk of further complications. Localized symptoms of phlebitis typically resolve after discontinuation of the catheter.

When a patient receiving oxygen at a flow rate of 6 L/min by nasal cannula complains of nasal passage discomfort, what intervention should the nurse suggest to improve the patient's comfort? A. Suggest adding humidification to the oxygen delivery system. B. Suggest that a simple face mask be used instead of a nasal cannula. C. Suggest that the patient be provided with an extra pillow. D. Suggest that the patient sit up in a chair at the bedside. .

A. Suggest adding humidification to the oxygen delivery system. When the flow rate of oxygen is higher than 4 L/min; the mucous membranes can become dry. The best treatment is to add humidification to the oxygen delivery system. The application of water-soluble jelly to the nares can also help decrease mucosal irritation

Which of the following statements correctly outlines the proper flow of blood through the heart? A. Superior and Inferior vena cavas → Right atrium → tricuspid valve → Right ventricle → pulmonary valve → pulmonary artery → lungs → pulmonary veins left atrium → mitral valve → left ventricle → aortic valve → aorta → systemic circulation. B. Superior and Inferior vena cavas → Right atrium → mitral valve → Right ventricle → pulmonary valve → pulmonary artery → lungs pulmonary veins → left atrium → tricuspid valve → left ventricle → aortic valve → aorta → systemic circulation. C. Superior and Inferior vena cavas → Right atrium → tricuspid valve → Right ventricle → pulmonary valve → pulmonary veins → lungs → pulmonary artery → left atrium → mitral valve → left ventricle → aortic valve → aorta → systemic circulation. D. Superior and Inferior vena cavas → Right atrium → tricuspid valve → Right ventricle aortic valve → pulmonary veins → lungs → pulmonary artery → left atrium → mitral valve → left ventricle → pulmonary valve aorta → systemic circulation

A. Superior and Inferior vena cavas → Right atrium → tricuspid valve → Right ventricle → pulmonary valve → pulmonary artery → lungs → pulmonary veins left atrium → mitral valve → left ventricle → aortic valve → aorta → systemic circulation. This is the proper flow of blood through a healthy heart with normal anatomy. The superior and inferior vena cavae are the large veins that bring back deoxygenated blood from the body to the heart's right atrium. The blood enters the right atrium, passes through the tricuspid valve into the right ventricle, and is then pumped into the lungs through the pulmonary artery. In pulmonary circulation, the deoxygenated blood drops off its carbon dioxide plus waste products and picks up fresh oxygen to deliver to the body. Blood is now oxygenated. The blood returns to the left atrium through the pulmonary veins that pass through the mitral valve to enter the left ventricle which is then pumped out to the body through the aorta. Oxygenated blood is now in the systemic circulation, where it can deliver oxygen to all the tissues of the body.

Diabetes insipidus is a potential complication of which of the following procedures? A. Surgical removal of the pituitary gland B. Reduction of mass on the thyroid gland C. Hysterectomy D. Dilation and curettage

A. Surgical removal of the pituitary gland Damage to the pituitary gland or hypothalamus from surgery increases the risk for diabetes insipidus. This is because the posterior pituitary is the gland that regulates the production, storage, and release of antidiuretic hormone (ADH). A decreased amount of ADH results in diabetes insipidus.

Which of the following nursing actions reflects effective time management? A. The nurse asks the patient what their priority is to accomplish each day. B. The nurse includes a "nice to do" for every "need to do" task on the list. C. The nurse "front-loads" the schedule with "must-do" priorities. D. The nurse avoids helping other nurses if scheduling does not permit it.

A. The nurse asks the patient what their priority is to accomplish each day. To manage time, the nurse should establish goals and priorities for each day and include the patient in prioritizing tasks.

Which nursing action is performed correctly when providing care for a newly placed gastrostomy tube of a postoperative patient? A. The nurse dips a cotton-tipped applicator into the sterile saline solution and gently cleans around the insertion site. B. The nurse wets a washcloth and washes the area around the tube with soap and water. C. The nurse adjusts the external disk every three hours to avoid crusting around the tube. D. The nurse tapes a gauze dressing over the site after cleansing it.

A. The nurse dips a cotton-tipped applicator into the sterile saline solution and gently cleans around the insertion site. When caring for a new gastrostomy tube, the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage.

A patient presents to the emergency department with a dissecting aortic aneurysm. The patient needs immediate surgery to save his life. He is unconscious and there is no family contact information on file. Which action is appropriate for obtaining informed consent for the surgery? A. There is no need for obtained consent. Send the client to surgery. B. Call the hospital lawyer. C. Search for people who may know the patient and can provide informed consent. D. Notify the on-call nursing supervisor and request her permission to waive informed consent.

A. There is no need for obtained consent. Send the client to surgery. When emergency surgery is needed, delaying the surgery to obtain informed consent may result in the patient's morbidity or death. In such urgent cases, informed consent is unnecessary. It is most appropriate to begin the surgery to save the patient's life.

A patient presents to the emergency department with a dissecting aortic aneurysm. The patient needs immediate surgery to save his life. He is unconscious and there is no family contact information on file. Which action is appropriate for obtaining informed consent for the surgery? A. There is no need for obtained consent. Send the client to surgery. B. Call the hospital lawyer. C. Search for people who may know the patient and can provide informed consent. D. Notify the on-call nursing supervisor and request her permission to waive informed consent.

A. There is no need for obtained consent. Send the client to surgery. When emergency surgery is needed, delaying the surgery to obtain informed consent may result in the patient's morbidity or death. In such urgent cases, informed consent is unnecessary. It is most appropriate to begin the surgery to save the patient's life.

Which of the following are clinical manifestations of the aging immune system that increase the susceptibility to illness? A. Increased lymph tissue. B. Increased autoimmune responses. C. Increased circulation of lymphocytes. D. Increased T and B cell production.

B. Increased autoimmune responses. The elderly experience increased autoimmune responses. This increases the risk of diseases such as rheumatoid arthritis and other collagen disorders.

The nurse is caring for a client who is receiving prescribed enoxaparin. Which of the following findings would indicate the client is having an adverse effect? A. Thrombocytopenia B. Leukocytosis C. Polycythemia D. Neutropenia

A. Thrombocytopenia Thrombocytopenia is an adverse effect associated with this medication. This effect is linked to Heparin-Induced Thrombocytopenia (HIT). This may occur within five to fourteen days of exposure to the drug and may be hastened by exposure to higher-than-normal doses.

The nurse is caring for a client who is receiving prescribed enoxaparin. Which of the following findings would indicate the client is having an adverse effect? A. Thrombocytopenia B. Leukocytosis C. Polycythemia D. Neutropenia

A. Thrombocytopenia Thrombocytopenia is an adverse effect associated with this medication. This effect is linked to Heparin-Induced Thrombocytopenia (HIT). This may occur within five to fourteen days of exposure to the drug and may be hastened by exposure to higher-than-normal doses.

The nurse is caring for assigned clients. The nurse should recognize that the client at greatest risk for postpartum hemorrhage (PPH) is the client who has which of the following? A. Uterine atony and delivered with the assistance of forceps B. Postpartum urinary incontinence and diuresis C. An active outbreak of genital herpes and had a cesarean section D. Gestational diabetes and has postpartum hyperglycemia

A. Uterine atony and delivered with the assistance of forceps Uterine atony is the most common cause of PPH. This is when the uterus fails to contract after delivery. Additionally, delivery with the use of instruments such as forceps raises the risk of PPH because of the trauma that may be caused by the instruments.

The nurse is caring for assigned clients. The nurse should recognize that the client at greatest risk for postpartum hemorrhage (PPH) is the client who has which of the following? A. Uterine atony and delivered with the assistance of forceps B. Postpartum urinary incontinence and diuresis C. An active outbreak of genital herpes and had a cesarean section D. Gestational diabetes and has postpartum hyperglycemia

A. Uterine atony and delivered with the assistance of forceps Uterine atony is the most common cause of PPH. This is when the uterus fails to contract after delivery. Additionally, delivery with the use of instruments such as forceps raises the risk of PPH because of the trauma that may be caused by the instruments.

The nurse is caring for a client who recently had a partial gastrectomy. Which of the following medications should the nurse anticipate that the primary health care provider (PHCP) will order? A. Vitamin B12 B. Metoclopramide C. Sucralfate D. Hydroxyzine

A. Vitamin B12 Procedures like a gastrectomy put the client at risk for pernicious anemia (B12 deficiency). It is quite common for a client to receive parenteral B12 replacement indefinitely.

Hospitalization may affect or delay the progression of which physical development in a 1-year-old patient? A. Walking B. Running C. Sitting D. Crawling

A. Walking At the age of 1 year, children should be starting to walk. Hospitalization during this age could delay this stage of development.

Which of the following medication orders for a client with pulmonary embolism is a priority to clarify with the physician before administration? A. Warfarin 1.0 mg PO B. Morphine Sulfate 2 to 4 mg IV C. Cephalexin 250 mg PO D. Heparin infusion at 900 units/hr

A. Warfarin 1.0 mg PO The trailing zero in this order could be misread/misinterpreted and result in an accidental overdose of medication. Trailing zeros appear on the Joint Commission on the Accreditation of Hospitals (JCAHO) "Do Not Use" list. The use of a zero after a decimal point may result in the administration of a drug at ten times its prescribed dose if the decimal point is illegible or not seen.

Which of the following medication orders for a client with pulmonary embolism is a priority to clarify with the physician before administration? A. Warfarin 1.0 mg PO B. Morphine Sulfate 2 to 4 mg IV C. Cephalexin 250 mg PO D. Heparin infusion at 900 units/hr

A. Warfarin 1.0 mg PO The trailing zero in this order could be misread/misinterpreted and result in an accidental overdose of medication. Trailing zeros appear on the Joint Commission on the Accreditation of Hospitals (JCAHO) "Do Not Use" list. The use of a zero after a decimal point may result in the administration of a drug at ten times its prescribed dose if the decimal point is illegible or not seen.

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

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

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

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

While working in the emergency department, you triage a 29-year-old female who states, "I am going to kill myself. They are coming for me!" Which of the below responses utilizes therapeutic communication? A. You are safe here; can you tell me more about what is happening? B. Please don't try to kill yourself; we will sedate you if we have to. C. Why would you kill yourself? D. Who is coming for you?

A. You are safe here; can you tell me more about what is happening? This statement uses therapeutic communication by helping the client feel safe and asking open-ended questions to gather more information.

The nurse is caring for a client who has influenza. Which of the following prescriptions may be prescribed by the primary healthcare provider (PHCP)? A. Valacyclovir B. Oseltamivir C.Azithromycin D. Omeprazole

B. Oseltamivir Oseltamivir is an antiviral agent approved for the treatment of influenza. This medication should be initiated within 48 hours of symptom onset.

The nurse is performing follow-up phone calls for clients recently discharged from the medical-surgical unit. Which client situation would require immediate follow-up? A client with A. a new prescription for risperidone reporting muscle stiffness. B. type Il diabetes mellitus reporting loose stools while taking their prescribed metformin. C. rheumatoid arthritis reporting an oral temperature of 99°F (37°C). D. chronic renal failure stating they have not had a bowel movement in two days.

A. a new prescription for risperidone reporting muscle stiffness. Risperidone is an atypical antipsychotic that may cause a client to develop neuroleptic malignant syndrome (NMS). If not recognized, this could be fatal. Classic manifestations of NMS include tachycardia, fever, muscle rigidity, and altered mental status.

The nurse is caring for a client experiencing septic shock. The client's blood pressure is unstable and requires multiple intravenous (IV) vasopressor support. To determine if the client is meeting the treatment goals, the nurse anticipates the primary healthcare provider (PHCP) will order A. an arterial line. B. a chest tube. C. mechanical ventilation. D. an indwelling urinary catheter.

A. an arterial line. An arterial line will likely be ordered for a client receiving multiple intravenous (IV) vasopressors. The PHCP will place this line to obtain continuous blood pressure, which will be more effective than intermittent blood pressure monitoring via an external cuff. An arterial line is also advantageous because arterial blood gas may be collected without requiring an arterial puncture.

The nurse is caring for the following assigned clients. Which client should the nurse assess first? A client A. being evaluated for chest pain and requests an antacid for indigestion. B. reporting nervousness following the administration of albuterol. C. requesting pain medication for their chronic knee and back pain. D. awaiting discharge teaching on their insulin pump and glucometer.

A. being evaluated for chest pain and requests an antacid for indigestion. Reports of indigestion could be a symptom associated with myocardial infarction. This atypical sign is concerning because the client is already being evaluated for chest pain. Thus, the nurse needs to follow up with this client.

The nurse is caring for a client requesting to leave against medical advice. The nurse barricades the client in their room because they feel that the client is not safe to go home. The nurse is demonstrating A. false imprisonment. B. malpractice. C. negligence. D. invasion of privacy.

A. false imprisonment. Refusing to let a client leave against medical advice (AMA) and physically obstructing the client from leaving is a form of false imprisonment.

✓ The nurse is caring for a client requesting to leave against medical advice. The nurse barricades the client in their room because they feel that the client is not safe to go home. The nurse is demonstrating A. false imprisonment. B. malpractice. C. negligence. D. invasion of privacy.

A. false imprisonment. Refusing to let a client leave against medical advice (AMA) and physically obstructing the client from leaving is a form of false imprisonment.

The nurse is caring for a client exhibiting signs of poor muscle coordination, stooped posture, and slow movements. Which medication is most likely to cause these symptoms? A. haloperidol B. nifedipine C. venlafaxine D. prazosin

A. haloperidol Haloperidol is a typical antipsychotic that may adversely cause extrapyramidal side effects (EPS). These effects include akathisia, dystonia, pseudo- parkinsonism, and/or tardive dyskinesia. Tardive dyskinesia is an adverse effect that occurs with antipsychotics and has an onset of months to years while on the medication.

The licensed practical/vocational nurse (LPN/VN) is reviewing client room assignments. Which room should the nurse assign to a client with hepatitis B? A client with A. heart failure receiving diuretics. B. bacterial meningitis receiving antibiotics. C. prostate cancer receiving brachytherapy. D. varicella prescribed antivirals.

A. heart failure receiving diuretics. Although hepatitis B needs to be reported to the public health department, a client with hepatitis B does not need to be isolated. An appropriate patient to room with would be an individual receiving intravenous diuretics for heart failure, as this client has no transmissible pathogens.

The nurse is caring for a group of children on the medical-surgical unit. The nurse should initially follow up on the child who A. is receiving treatment for Hirschsprung's disease and has a temperature of 101°F (38.3°C). B. has an indwelling urinary catheter and reports burning at the insertion site. C. has scant blood in their newly established ostomy pouch. D. has friends writing words on their fiberglass cast with different colored markers.

A. is receiving treatment for Hirschsprung's disease and has a temperature of 101°F (38.3°C). A major complication of Hirschsprung's disease is the development of enterocolitis manifested by fever, abdominal distention, vomiting, and increased abdominal pain. Emergent intervention is necessary because the child may develop sepsis leading to septic shock.

The nurse is caring for a client who is receiving prescribed pregabalin. The client is experiencing the intended effect when they report less A. neuropathic pain. B. cravings for cigarettes. C. binge eating. D. depressive symptoms.

A. neuropathic pain. Pregabalin is indicated in treating neuropathic pain, certain anxiety disorders, and focal seizures. This controlled substance is five times more potent compared to gabapentin.

The nurse is caring for a client who is receiving prescribed pregabalin. The client is experiencing the intended effect when they report less A. neuropathic pain. B. cravings for cigarettes. C. binge eating. D. depressive symptoms.

A. neuropathic pain. Pregabalin is indicated in treating neuropathic pain, certain anxiety disorders, and focal seizures. This controlled. substance is five times more potent compared to gabapentin.

The nurse is caring for a client who intentionally overdosed on amitriptyline. What action should the nurse prioritize? A. obtain a 12-lead electrocardiogram B. request a prescription to consult psychiatry C. determine the reasoning for the overdose D. establish a therapeutic relationship

A. obtain a 12-lead electrocardiogram Amitriptyline is a tricyclic antidepressant (TCA) and, when taken in excess, may cause cardiac dysrhythmias. The essential action is addressing the client's physiological needs by assessing if the patient has catastrophic dysrhythmias.

The nurse observes a client go up the stairs with a cane. It would indicate effective teaching if the client grabs the handrail and A. places the stronger leg up a step, then simultaneously moves up the weaker leg and cane. B. holds the cane in one hand and hops up each stair using the stronger leg. C. places the cane up a step, then simultaneously moves up the stronger and weaker legs. D. places the weaker leg up a step, then simultaneously moves up the stronger leg and cane.

A. places the stronger leg up a step, then simultaneously moves up the weaker leg and cane. When a client is ambulating upstairs using a cane, the client will face the stairs and place the cane on the side opposite the handrail. Then, the client will advance the unaffected (stronger) leg up to the next step, then the cane and the affected (weaker) leg simultaneously. This reflects adequate understanding. Remember that the weaker side and the cane share the load and should always move together.

The nurse is caring for assigned clients. The nurse should initially follow-up with the client who A. receiving mechanical ventilation and low-pressure alarm sounds. B. has a new colostomy and refuses to participate in care. C. has acute glomerulonephritis and has periorbital edema. D. has atrial fibrillation and an irregular pulse.

A. receiving mechanical ventilation and low-pressure alarm sounds. A client receiving mechanical ventilation requires multiple assessments. The low-pressure alarm is concerning for ventilator disconnection or low cuff pressure. The high-pressure alarm is concerned with obstruction, such as secretions. This client should be assessed first under the priority model of "ABCs" = airway, breathing, circulation.

The nurse receives a prescription for sevelamer. The nurse plans on administering this medication A. with the client's meals. B. immediately before hemodialysis. C. with a prescribed proton pump inhibitor (PPI). D. right before the client goes to bed. .

A. with the client's meals. Sevelamer is a phosphate binder indicated in the treatment of hyperphosphatemia associated with chronic kidney disease. This medication is purported to decrease serum phosphorus levels by binding to food. Thus, this medication is given with meals. Combined with a low phosphorus diet, the goal of this medication is to decrease serum phosphate levels.

The nurse is caring for a client who is prescribed enoxaparin. Which of the following findings in the medical history would require follow-up with the primary healthcare physician (PHCP)? A.Recent spinal surgery B. Diabetes mellitus C. Osteoarthritis D. Venous thromboembolism

A.Recent spinal surgery Recent spinal surgery requires follow-up with the prescription of enoxaparin. This medication may cause a hematoma, which may consequently cause severe neurological impairment.

A patient with a crush injury to her left arm calls the nurse's station and requests pain medication. An hour after administration, the patient is still complaining of intense pain. What is the next nursing action? A. Ask the patient to describe the pain in quality and intensity. B. Offer the patient a distraction, such as a book or television. C. Tell the patient she can have more medication in three hours. D. Tell the patient crush injury victims should expect intense pain.

Ask the patient to describe the pain in quality and intensity. A crush wound is a wound caused by a force that leads to compression or disruption of tissues. It is often associated with fractures. Usually, there is minimal to no break in the skin. While other external symptoms, such as bruising or edema, may be visible, nurses should also rely on subjective symptoms reported by the patient. Choice A is correct. Unrelieved pain is an indication of a complication. Patients who experience a crush injury are at risk for developing compartment syndrome. Therefore, asking the patient to be specific about the quality and intensity of pain is vital in re-evaluating the patient's status.

You are the nurse performing education for a patient with AIDS at the community clinic. Which of the following statements is an example of appropriate teaching? A. "Do not wash your dishes with your roommate's dishes." B. "Clean all utensils and dishes before reusing them." C. "Do not use the same shower or toilet as your roommate." D. "Hand sanitizer is not necessary unless you plan on touching someone else."

B. "Clean all utensils and dishes before reusing them." Stagnant water and food particles can be a breeding ground for pathogenic microorganisms. A patient with an AIDS diagnosis is susceptible to contracting illness/infections more quickly due to the deficiency in his/her immune system. The focus of education should include measures to protect the patient from contracting illnesses from others.

You are the nurse performing education for a patient with AIDS at the community clinic. Which of the following statements is an example of appropriate teaching? A. "Do not wash your dishes with your roommate's dishes." B. "Clean all utensils and dishes before reusing them." C. "Do not use the same shower or toilet as your roommate." D. "Hand sanitizer is not necessary unless you plan on touching someone else."

B. "Clean all utensils and dishes before reusing them." Stagnant water and food particles can be a breeding ground for pathogenic microorganisms. A patient with an AIDS diagnosis is susceptible to contracting illness/infections more quickly due to the deficiency in his/her immune system. The focus of education should include measures to protect the patient from contracting illnesses from others.

The patient with COPD reports to the nurse that she has trouble sleeping at night. Which question is most important for the nurse to ask next? A. "What do you eat before you go to bed?" B. "How many pillows do you sleep on at night?" C. "Have you always been a light sleeper?" D. "Is your partner snoring and keeping you awake?"

B. "How many pillows do you sleep on at night?" Orthopnea is shortness of breath that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair. Asking the patient how many pillows she uses to sleep on is a way to assess if the patient has been educated about preventing orthopnea. COPD causes blocked or narrowed airways that make breathing more difficult. Patients may experience symptoms like wheezing, coughing, mucus production, and tightness in the chest. Smoking or exposure to harmful chemicals can cause COPD. Orthopnea is a common symptom of COPD patients.

The nurse is monitoring a 10-year-old patient status post-tonsillectomy. Which of the following observations should be immediately reported to the healthcare provider? A. Drooling B. Frequent swallowing C. Sneezing D. Moaning

B. Frequent swallowing Swallowing is a sign of hemorrhage and should be immediately reported to a healthcare provider. If the patient has a hemorrhage at the surgical site in the back of their throat there will be blood running down the back of their throat causing them to constantly swallow. The nurse must monitor closely for this complication.

A parent is sobbing loudly at the bedside of their infant, who was just born with an omphalocele. They wail saying, "I cannot believe my baby was born this way! He will surely die!" Which of the following statements by the nurse is most appropriate? A. "Oh, hush. This is not so bad." B. "I am so sorry. This is certainly serious, but there is a treatment that can repair the omphalocele. We will take excellent care of your baby." C. "Your baby will not die; this can be fixed!" D. "I understand that you are upset. Would you like to hold yourbaby while he is still here?"

B. "I am so sorry. This is certainly serious, but there is a treatment that can repair the omphalocele. We will take excellent care of your baby." This statement is a correct example of therapeutic communication. It validates the fear and emotions that the parent is experiencing and provides education about the infant's treatment and prognosis. This opens up the conversation for dialogue and further information about what the parent can expect.

The nurse is reinforcing education to parents of a child who plans on riding their bicycle. Which statements, if made by the parents, indicate effective understanding? A. "I should tell my child should ride against the traffic pattern." B. "I should instruct my child to walk their bike through busy intersections." C. "Wearing a helmet is only necessary when my child is riding near a busy intersection." D. "My child can ride their bike barefoot as long as it's short distances."

B. "I should instruct my child to walk their bike through busy intersections." A child should walk their bike through busy intersections to reduce their risk of being hit by an automobile.

The nurse reinforces discharge education to a client about using a cane while going upstairs. Which statement by the client would indicate a correct understanding of the teaching? A. "I should move my cane up, then my weaker leg, then my stronger leg." B. "I should move my stronger leg up, then my cane and the weaker leg simultaneously." C. "I should move my stronger leg up, then my cane, followed by my weaker leg." D. "I should move my cane up, then my stronger leg, then my weaker leg."

B. "I should move my stronger leg up, then my cane and the weaker leg simultaneously." When a client is ambulating upstairs using a cane, the client will advance the unaffected (stronger) leg up to the next step, then the cane and the affected (weaker) leg simultaneously. This reflects adequate understanding. Remember that the weaker side and the cane share the load and should always move together.

The nurse is caring for a client who was recently prescribed antihypertensive medications. Which statement, if made by the client, requires follow-up? A. "My pulse decreases after taking my metoprolol." B. "I started taking my furosemide right before I went to sleep." C. "I am seasoning my foods without salt while on lisinopril." D. "I wear my clonidine patch for seven days."

B. "I started taking my furosemide right before I went to sleep." Furosemide is a loop diuretic that should be dosed early in the day. This prevents the client from experiencing nocturia. This also reduces the risk of falls by the client as they will not have to wake up at night when there is reduced lighting.

The licensed practical/vocational nurse (LPN/VN) reinforces medication instructions to a client prescribed phenytoin. Which statements, if made by the client, indicate effective understanding? A. "If my gums get irritated and large, I can stop this medication." B. "I will need laboratory work to monitor the medication level." C. "It is okay for me to increase this medication if I have a seizure." D. "I should take this medication with low protein foods

B. "I will need laboratory work to monitor the medication level." Phenytoin is an anticonvulsant and is indicated for epilepsy. Therapeutic levels must be maintained to ensure the effectiveness of the drug. The therapeutic drug levels of phenytoin are 10-20 mcg/ml.

The nurse is caring for a client newly diagnosed with Cushing's disease. Which of the following client statements requires follow-up? A. "I will need to eat more potassium-rich foods." B. "I will need more steroids during periods of stress." C. "I will be at a higher risk for an infection." D. "I should do weight-bearing exercises."

B. "I will need more steroids during periods of stress." A client with Cushing's disease has an excess of androgens, cortisol, and aldosterone and will have manifestations such as central obesity, weight gain, hypokalemia, hypernatremia, and hypertension. The client will not need more steroids during periods of stress as this is necessary for a client with Addison's disease to prevent a crisis.

The nurse is reinforcing teaching regarding prescribed risperidone. Which statement, if made by the client, requires follow-up? A. "I should report any abnormal movements that I develop." B. "I will need to have weekly tests to monitor my white blood cells." C. "If I get muscle stiffness, I should notify my physician." D. "I will need to chew sugarless gum if I develop a dry mouth."

B. "I will need to have weekly tests to monitor my white blood cells." Risperidone is a second-generation antipsychotic used in delirium, schizophrenia, and some childhood disorders. Weekly white blood cell tests are not required with risperidone as this is appropriate teaching for an individual receiving clozapine. Clozapine may cause neutropenia.

The nurse reinforces discharge instructions to a client with chronic diabetes insipidus (DI). Which of the following client statements would indicate a correct understanding of the discharge instructions? A. "I will need to drink no more than 800 ml per day." B. "I will need to weigh myself at the same time every day." C. "I should increase salty snacks in my diet." D. "I need to log my daily fluid intake."

B. "I will need to weigh myself at the same time every day." A client with chronic diabetes insipidus (DI) must weigh themselves daily. This weight should be taken with the same scale and obtained after the first-morning void. Weight is the most accurate assessment relevant to fluid volume status.

The nurse reinforces discharge instructions to a client with chronic diabetes insipidus (DI). Which of the following client statements would indicate a correct understanding of the discharge instructions? A. "I will need to drink no more than 800 ml per day." B. "I will need to weigh myself at the same time every day." C. "I should increase salty snacks in my diet." D. "I need to log my daily fluid intake."

B. "I will need to weigh myself at the same time every day." A client with chronic diabetes insipidus (DI) must weigh themselves daily. This weight should be taken with the same scale and obtained after the first-morning void. Weight is the most accurate assessment relevant to fluid volume status.

The nurse has taught a client about a scheduled intravenous (IV) urography (pyelogram). Which of the following statements by the client would indicate a correct understanding of the teaching? A. "I should expect a temporary urinary catheter inserted during the procedure." B. "I will take a laxative the night before to clear my bowels." C. "I must fill my bladder with water immediately before the procedure." D. "I may experience blood in my urine for a few days after this procedure."

B. "I will take a laxative the night before to clear my bowels." An IV urography (pyelogram) is a diagnostic test used to gather urinary tract imaging that views the collecting ducts and renal pelvis and outlines the ureters, bladder, and urethra. The client must perform a bowel cleansing the night before to ensure adequate visualization of the urinary tract. During this procedure, the client will empty their bladder, and then an intravenous injection of contrast medium is given, and a series of x-ray films and fluoroscopy is used to observe the passage of urine from the renal pelvis to the bladder. The use of this test has decreased because of computed tomography scans of the urinary tract.

The LPN is taking vital signs on a baby diagnosed with TAPVR when the mother starts crying. Which of the below statements by the nurse is most therapeutic? A. "Don't cry, your baby will be fine!" B. "I'm so sorry you are going through this, would you like to talk?" C. "I'm sure this is hard, but your baby is doing so well!" D. "You think this is bad, you should see some of the other babies here."

B. "I'm so sorry you are going through this, would you like to talk?" This is a good example of therapeutic communication. The nurse has validated the mother's feelings and encouraged further dialogue to understand what the mother is upset about.

The nurse is caring for a client receiving buspirone. Which of the following client statements would indicate a therapeutic response? A. "I am less depressed and able to spend time with my friends." B. "My anxiety has lessened, and I have started going out more." C. "I noticed an improvement in my concentration." D. "I have been able to fall asleep without any problem."

B. "My anxiety has lessened, and I have started going out more." Buspirone is a serotonergic medication indicated for individuals with generalized anxiety disorder. The client reporting decreased anxiety would indicate a therapeutic effect.

The licensed practical/vocational nurse (LPN/VN) is reinforcing teaching for a client newly diagnosed with multiple sclerosis. Which of the following statements by the client would indicate a correct understanding of the teaching? A. "If I experience double-vision, I should put an eye patch on both eyes for a few hours." B. "Planning my activities should help manage the fatigue." C. "I should plan to take a hot bath if my muscles spasm." D. "This disease may cause me to have an increased sensitivity to pain."

B. "Planning my activities should help manage the fatigue." Fatigue is a significant clinical feature associated with MS. Strategies to mitigate fatigue and maximize functioning include spacing activities out, planning them in a planner or whiteboard, and taking frequent breaks. Fatigue is often worsened during elevations in temperature. Thus, activities may be best performed early morning or late evening when temperatures are not as high.

Which of these would be the most appropriate way to document a patient's refusal of medication? A. "The patient refused the heparin injection when I tried to administer it. She yelled at me, saying 'I do not want that injection right now,' and told me to leave the room. I explained the risks of not taking the medication. She seemed very annoyed that I tried to give it at that time. I will attempt again later in my shift." B. "Subcutaneous Heparin injection was attempted to be given to the patient per the physician's order. The patient refused, stating, "I do not want that injection.' Potential risks for refusing the medication were reviewed with the patient, and the patient verbalized understanding." C. "Pt stated she did not want the SQ heparin injection at this time. Risks of not taking this med were reviewed with the pt, and pt verbalized understanding." D. "Heparin refused during the shift, risks reviewed."

B. "Subcutaneous Heparin injection was attempted to be given to the patient per the physician's order. The patient refused, stating, "I do not want that injection.' Potential risks for refusing the medication were reviewed with the patient, and the patient verbalized understanding." Documentation in healthcare should be objective, thorough, but direct. It should be articulate, with correct grammar and spelling. The health record will be scrutinized by legal experts if a dispute about a client's care arises. In court, the health record is legal evidence of the care given to a client and is used to judge whether the interventions were timely and appropriate. Expert reviewers look for documentation of the client's baseline status, changes in status, interpretation of the changes, interventions implemented, and the client's responses to those interventions. The patient has the right to refuse a medication regardless of her reasons and regardless of the consequences, except under certain circumstances (e.g. incompetency). It is up to the nurse to document thoroughly and accurately any patient's refusal.

A client is diagnosed with a spontaneous pneumothorax, which results in the need to insert a chest tube. What is the BEST explanation for the nurse to provide this client? A. "The tube will prevent you from having chest pains." B. "The tube will remove excess air from your chest." C. "The tube controls the amount of air that enters your chest." D. "The tube will seal the hole in your lung."

B. "The tube will remove excess air from your chest." The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.

The nurse arrives to assist victims following an earthquake. Which victim would the nurse recognize as the highest priority for immediate treatment? A. 74-year-old with several heavily bleeding wounds who is lethargic [34%] and pale. B. 37-year-old who appears anxious and is using neck muscles to breathe. C. 16-year-old who is confused, holding her head, and complaining of nausea. D. 65-year-old who rates his pain at 10/10 and is guarding his right leg.

B. 37-year-old who appears anxious and is using neck muscles to breathe. In the setting of a mass casualty or disaster, triage systems are essential to prioritize patients. Triage deals with the appropriate allocation of limited resources during a disaster. In a disaster, the highest priority is given to the person with life-threatening injuries who has a high chance of survival if stabilized. The client in option B presents with symptoms highly suspicious of traumatic pneumothorax, using accessory muscles for breathing, and anxiety (due to difficulty getting enough air). The use of accessory muscles indicates severe respiratory distress. This patient would be the nurse's highest priority and requires rapid chest decompression to allow lung expansion. A needle thoracostomy and subsequent tube thoracostomy could be life-saving in this situation.

The nurse arrives to assist victims following an earthquake. Which victim would the nurse recognize as the highest priority for immediate treatment? A. 74-year-old with several heavily bleeding wounds who is lethargic and pale. B. 37-year-old who appears anxious and is using neck muscles to breathe. C. 16-year-old who is confused, holding her head, and complaining of nausea. D. 65-year-old who rates his pain at 10/10 and is guarding his right leg.

B. 37-year-old who appears anxious and is using neck muscles to breathe. In the setting of a mass casualty or disaster, triage systems are essential to prioritize patients. Triage deals with the appropriate allocation of limited resources during a disaster. In a disaster, the highest priority is given to the person with life-threatening injuries who has a high chance of survival if stabilized. The client in option B presents with symptoms highly suspicious of traumatic pneumothorax, using accessory muscles for breathing, and anxiety (due to difficulty getting enough air). The use of accessory muscles indicates severe respiratory distress. This patient would be the nurse's highest priority and requires rapid chest decompression to allow lung expansion. A needle thoracostomy and subsequent tube thoracostomy could be life-saving in this situation.

Which of these would be an appropriate assignment for the LPN/LVN? A. A 17-year-old patient with a femur fracture that is just returning to the floor from the recovery unit. B. A 21-year-old client with cystic fibrosis that needs an early morning sputum sample collection. C. An 82-year-old patient 2 days post-op after knee replacement surgery who needs help ambulating. D. A 31-year-old patient who is suffering from an acute asthma attack.

B. A 21-year-old client with cystic fibrosis that needs an early morning sputum sample collection. Collecting sputum samples on stable patients are within the scope of practice for an LPN/LVN. While an LPN/LVN may feel comfortable providing care for patients with varying degrees of illness, that does not mean that all attention should be delegated to an LPN/LVN. As an LPN/LVN, it is your responsibility to know which patients you should and should not care for and why. This is important because if an LPN/LVN accepts an assignment that is not within their scope of practice/competency, it could result in legal ramifications.

Which of the following clients should the nurse assess first when preparing to do initial rounds? A. The patient with diabetes that is being discharged today. B. A 32-year-old female with a tracheostomy that is experiencing copious secretions. C. A 16-year-old patient that is scheduled for physical therapy this morning. D. An 80-year-old male with a decubitus ulcer that needs a dressing change.

B. A 32-year-old female with a tracheostomy that is experiencing copious secretions. The patient with airway compromise should always be given the highest priority. Remember "ABCs" (Airway, Breathing, Circulation).

Which of the following clients should the LPN/LVN attend to first? A. A client who is newly diagnosed with Hepatitis A that is reporting [2%] stomach pain and itchy skin. B. A patient in an arm cast that is 2 days post-op and reports feeling numbness and tingling in his affected arm. C. A post-op prostatectomy patient complaining of bladder spasms and blood in his foley bag. D. A patient with a newly placed NG tube complaining of pain around the face and a "plugged" nose.

B. A patient in an arm cast that is 2 days post-op and reports feeling numbness and tingling in his affected arm. Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a doctor right away.

A nurse who primarily works on an adult-only unit has been pulled to work on a floor that provides care to patients of all ages. What would be an appropriate action of this nurse? A. Accept the assignment, but ask to be paired with a more experienced LPN. B. Accept the assignment, but explain the situation to the charge nurse and ask for a quick orientation before starting. C. Take the assignment but tell the charge nurse she will only care for adult patients. D. Refuse to take the assignment, as caring for the infant and child population is not within her practice scope.

B. Accept the assignment, but explain the situation to the charge nurse and ask for a quick orientation before starting. The nurse should take the assignment, but explain the situation to the charge nurse and ask for a quick orientation before starting. While the LPN may specialize in a specific type of nursing or feel more comfortable caring for a particular patient population, she should be able to use her skillset to safely and independently care for other people as well. However, the LPN should let the charge nurse know her background before beginning her shift to familiarize herself with new equipment, ask questions, and identify resources.

The parent of an 11-year-old receiving chemotherapy for leukemia is concerned because the client's sibling has chickenpox. Which of these actions will you anticipate taking next? A. Teach the parents regarding contact and airborne precautions. B. Administer varicella-zoster immune globulin to the client. C. Prepare the client for admission to a private room in the hospital. D. Educate the parent about the correct use of acyclovir (Zovirax). E. Administer the Varicella vaccine.

B. Administer varicella-zoster immune globulin to the client. Varicella-zoster immune globulin (VZIG) administration can prevent the development of chickenpox in high-risk clients and will typically be prescribed. Varicella-zoster immunoglobulin is not a live vaccine. VZIG is a readymade passive immunity (a specific antibody) against the varicella-zoster virus. Since the client is concerned about recent exposure to chickenpox, the only way to quickly protect this immunocompromised client is with a readymade antibody against the varicella-zoster virus (VZIG).

The nurse manager reviews client assignments. Which client assignment would be inappropriate for a licensed practical/vocational (LPN/VN) nurse? A. Obtaining an occult blood sample from a 15-year-old client with ulcerative colitis. B. Assessing a 35-year-old client newly admitted for chest pain. C. Reinforcing education to a 25-year-old first-time mother on how to properly care for her new baby. D. Providing pin care and data collecting on neurovascular status for a client in cervical traction.

B. Assessing a 35-year-old client newly admitted for chest pain. LPN/VNs should be assigned the most stable client with a predictable outcome. A client newly admitted for chest pain would not be stable or predictable and, thus, require intervention.

The nurse in the emergency department (ED) is anticipating the arrival of a client with severe hypothermia. Which of the following would be an expected finding? A. Tachycardia B. Hypotension C Tachypnea D. Hypertension

B. Hypotension Severe hypothermia is a medical emergency defined as a core temperature of less than 82.4°F (28°C). This state causes massive vasodilation that causes the client to experience hypotension, bradycardia, bradypnea, and neuromuscular weakness.

The nurse is reinforcing teaching to a client about newly prescribed carbamazepine. Which of the following information should the nurse include? A. This medication will require weekly dosage adjustments B. Avoid taking this medication with grapefruit C. This medication may make your emotions more intense D. Take this medication if you feel like you are going to have a seizure

B. Avoid taking this medication with grapefruit Carbamazepine is an antiepileptic drug, and mood stabilizer. This medication is indicated in the management of epilepsy and bipolar disorder. This medication should not be taken with grapefruit products because cytochrome P- 450 3A4 (liver enzyme) is inhibited by the ingredients in grapefruit, leading to increased serum concentrations of carbamazepine.

Which advice is most appropriate for a patient on neutropenic precautions who wants to learn ways to prevent infection? A. Only brush your teeth once a day or every other day. B. Avoid the use of tampons for menstrual periods. C. Do not let visitors within 10 feet. D. Wash hands after handling pets.

B. Avoid the use of tampons for menstrual periods. Tampons may cause tears in the vagina that could lead to infection. Therefore patients with neutropenic precautions should avoid using them.

The nurse is caring for a client receiving nifedipine. Which of the following findings would indicate a therapeutic response? A. Sinus rhythm on the electrocardiogram B. Blood pressure 128/77 mm Hg C. Total cholesterol 180 mg/dl D. Weight loss of 2 kilograms

B. Blood pressure 128/77 mm Hg Nifedipine is a calcium channel blocker and is indicated for hypertension. A therapeutic effect of this medication would be normal blood pressure. This medication does not lower heart rate compared to other calcium channel blockers (verapamil and diltiazem).

The nurse is caring for a client receiving nifedipine. Which of the following findings would indicate a therapeutic response? A. Sinus rhythm on the electrocardiogram B. Blood pressure 128/77 mm Hg C. Total cholesterol 180 mg/dl D. Weight loss of 2 kilograms'

B. Blood pressure 128/77 mm Hg Nifedipine is a calcium channel blocker and is indicated for hypertension. A therapeutic effect of this medication would be normal blood pressure. This medication does not lower heart rate compared to other calcium channel blockers (verapamil and diltiazem).

The patient with testicular cancer is receiving IV cisplatin. What should the nurse assess for? A. Irreversible heart failure B. Bone marrow suppression C. Cardiac toxicity D. Peripheral neuropathy

B. Bone marrow suppression Bone marrow suppression is the most significant adverse reaction of this particular class of drugs. Cisplatin is an alkylating agent. Blood cells are susceptible to alkylating agents and bone marrow suppression is the most important adverse effect of this class. Within days after administration, the numbers of red blood cells, white blood cells, and platelets begin to decline.

The patient with testicular cancer is receiving IV cisplatin. What should the nurse assess for? A. Irreversible heart failure B. Bone marrow suppression C. Cardiac toxicity D. Peripheral neuropathy

B. Bone marrow suppression Bone marrow suppression is the most significant adverse reaction of this particular class of drugs. Cisplatin is an alkylating agent. Blood cells are susceptible to alkylating agents and bone marrow suppression is the most important adverse effect of this class. Within days after administration, the numbers of red blood cells, white blood cells, and platelets begin to decline.

25-year-old female reports intermittent abdominal pain, bloating, and flatulence that has lasted for several months. Which of the following would the nurse tell the patient to avoid? A. Fiber B. Broccoli C. Yogurt D. Simple carbohydrates

B. Broccoli Broccoli forms gas in the stomach and should be avoided for this patient.

How should the nurse assess for the presence of thrombophlebitis in a patient who reports having pain in the left lower leg? A. By palpating the skin over the tibia and fibula. B. By documenting daily calf circumference measurements. C. By recording vital signs obtained four times a day. D. By noting difficulty with ambulation.

B. By documenting daily calf circumference measurements. Inflammation from thrombophlebitis increases the size of the affected extremity and can be assessed regularly by measuring calf circumference. Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative patients. Manifestations of thrombophlebitis are pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the affected area, elevated temperature, and an increase in the involved extremity's diameter. Each shift, nurses should assess the legs for swelling and tenderness, measure bilateral calf or thigh circumference, and determine if they experience any chest pain or dyspnea. The patient should be instructed not to massage the legs.

Which of the following is the likely contributing factor of an elevated red blood cell count in a patient with a history of chronic bronchitis? A. Hypercapnia B. Chronic hypoxia C. Insensible water loss D. Decreased fluid intake

B. Chronic hypoxia Chronic hypoxia, from reduced air exchange, leads to low body oxygen levels. The kidneys respond to chronic hypoxia by releasing erythropoietin (EPO), which stimulates red blood cell production. The red blood cell count is elevated to compensate for hypoxia or low oxygen levels. More cells are available to carry and deliver the maximum amount of oxygen. Polycythemia is a condition in which there is an increased number of red blood cells in the blood. There are two types of polycythemia: 1) primary polycythemia and 2) secondary polycythemia. The two main conditions of primary polycythemia are polycythemia vera (PV) and primary familial and congenital polycythemia (PFCP). Causes of secondary polycythemia include conditions resulting from chronic hypoxial such as COPD, emphysema, chronic bronchitis, pulmonary hypertension, congestive heart failure, obstructive sleep apnea, and certain cancers. Examples of polycythemia symptoms include easy bruising or bleeding, blood clot formation, headache, itching, and fatigue. Treatment for polycythemia depends on the cause. Untreated polycythemia generally has a poor outcome for the patient.

Which of the following are clinical manifestations of the aging immune system that increase the susceptibility to illness? A. Increased lymph tissue. B. Increased autoimmune responses. C. Increased circulation of lymphocytes. D. Increased T and B cell production.

B. Increased autoimmune responses. The elderly experience increased autoimmune responses. This increases the risk of diseases such as rheumatoid arthritis and other collagen disorders.

Which of the following is the likely contributing factor of an elevated red blood cell count in a patient with a history of chronic bronchitis? A. Hypercapnia B. Chronic hypoxia C. Insensible water loss D. Decreased fluid intake .

B. Chronic hypoxia Chronic hypoxia, from reduced air exchange, leads to low body oxygen levels. The kidneys respond to chronic hypoxia by releasing erythropoietin (EPO), which stimulates red blood cell production. The red blood cell count is elevated to compensate for hypoxia or low oxygen levels. More cells are available to carry and deliver the maximum amount of oxygen. Polycythemia is a condition in which there is an increased number of red blood cells in the blood. There are two types of polycythemia: 1) primary polycythemia and 2) secondary polycythemia. The two main conditions of primary polycythemia are polycythemia vera (PV) and primary familial and congenital polycythemia (PFCP). Causes of secondary polycythemia include conditions resulting from chronic hypoxia such as COPD, emphysema, chronic bronchitis, pulmonary hypertension, congestive heart failure, obstructive sleep apnea, and certain cancers. Examples of polycythemia symptoms include easy bruising or bleeding, blood clot formation, headache, itching, and fatigue. Treatment for polycythemia depends on the cause. Untreated polycythemia generally has a poor outcome for the patient.

The nurse is caring for a client who has just been diagnosed with peritonitis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe? A. Pantoprazole B. Ciprofloxacin C. Lactulose D. Loperamide

B. Ciprofloxacin Peritonitis is an intra-abdominal severe infection that has a significant mortality rate. Peritonitis may originate from perforation (appendix, intestine, etc.), which causes a significant amount of fluid and bacteria to shift into the peritoneum. The priority treatment in peritonitis is administering prescribed antibiotics such as ciprofloxacin, metronidazole, or ceftriaxone.

The nurse is caring for a child in the emergency department (ED) who sustained a bite by a rabid animal. The nurse should take which initial action? A. Assess the wound's length and width B. Cleanse the wound with soap and water C. Obtain a prescription for an antibiotic D. Report the bite to animal control

B. Cleanse the wound with soap and water Cleansing the wound inflicted by a rabid animal with soap and water is essential to prevent a rabies infection. Aggressive wound cleaning minimizes the exposure to this infection which can be fatal without the appropriate cleaning and post-exposure prophylaxis.

Which of the following would the nurse expect to be administered to a newborn with respiratory distress syndrome (RDS)? A. Theophylline B. Colfosceril C. Dexamethasone D. Albuterol

B. Colfosceril RDS (Respiratory Distress Syndrome) is a type of neonatal respiratory disease most often caused by a lack of surfactant in the lungs. The fetal lungs start making surfactant during the third trimester of pregnancy, or around 26 weeks gestation through labor and delivery. Surfactant coats the alveoli's insides, reducing the surface tension of fluid in the lungs and making the alveoli more stable. This keeps the lungs from collapsing when the newborn exhales. Choice B is correct. Colfosceril palmitate (Exosurf) is a pulmonary surfactant drug. An infant with RDS may be given two to four doses of it during the first 24-48 hours after birth. It improves respiratory status, and research has shown a significant decrease in pneumothorax incidence when administered.

When assessing the new stoma of a client diagnosed with Crohn's disease, which will alert the healthcare provider that the stoma has retracted? A. Narrowed and flattened B. Concave and bowl-shaped C. Dry and reddish-purple D. Pinkish-red and moist

B. Concave and bowl-shaped A stoma that has retracted will appear concave and bowl- shaped. A colostomy is created when the bowel is pulled through an opening in the abdominal wall, creating a stoma through which intestinal contents will pass. Monitoring for signs of proper healing and educating the client/caregivers on signs of complicated healing is notable. Complications that could arise from retracted stoma include difficulty maintaining appliance placement, leading to leakage and irritated skin.

When assessing the new stoma of a client diagnosed with Crohn's disease, which will alert the healthcare provider that the stoma has retracted? A. Narrowed and flattened B. Concave and bowl-shaped C. Dry and reddish-purple D. Pinkish-red and moist

B. Concave and bowl-shaped A stoma that has retracted will appear concave and bowl- shaped. A colostomy is created when the bowel is pulled through an opening in the abdominal wall, creating a stoma through which intestinal contents will pass. Monitoring for signs of proper healing and educating the client/caregivers on signs of complicated healing is notable. Complications that could arise from retracted stoma include difficulty maintaining appliance placement, leading to leakage and irritated skin.

The nurse is in an elevator and observes two staff members discussing a client's condition. The nurse understands that this conversation may potentially violate which ethical principle? A. Beneficence B. Confidentiality C. Autonomy D. Veracity

B. Confidentiality This conversation being observed by the nurse may violate the client's confidentiality. Conversations about a client's personal medical information (PMI) should be kept private and involve only those involved in the client's care. This is considered the right to know, which mandates that information be safeguarded and limited in how it is shared.

The LPN is asked to check the client's respirations. Which of the following should the LPN perform? A. Place one hand over the patient's chest and count for 30 seconds. B. Count the respirations for one minute while simultaneously checking the client's pulse. C. Observe and count respirations for 30 seconds, then multiply by two without mentioning to the client that the respirations are being counted. D. If respirations are irregular, ask the patient to rest for 10 minutes, then reassess the respiratory rate.

B. Count the respirations for one minute while simultaneously checking the client's pulse. The best way to assess respiratory rate is to count the respirations for a full minute ( 60 seconds). One breath is equal to one rise ( inspiration) and one fall (expiration) of the chest wall. While assessing respiration, the pattern (regular/ irregular) and the effort ( labored/ unlabored) are also assessed in addition to the rate. A full minute length will provide accurate assessment of the respiratory rate and the pattern. If the clients know their respiration is being observed, they may alter their breathing. To prevent this, the nurse should attempt to count respirations simultaneously while checking the pulse rate or a pulse oximetry reading.

The LPN is asked to check the client's respirations. Which of the following should the LPN perform? A. Place one hand over the patient's chest and count for 30 seconds. B. Count the respirations for one minute while simultaneously checking the client's pulse. C. Observe and count respirations for 30 seconds, then multiply by two without mentioning to the client that the respirations are being counted. D. If respirations are irregular, ask the patient to rest for 10 minutes, then reassess the respiratory rate.

B. Count the respirations for one minute while simultaneously checking the client's pulse. The best way to assess respiratory rate is to count the respirations for a full minute ( 60 seconds). One breath is equal to one rise ( inspiration) and one fall (expiration) of the chest wall. While assessing respiration, the pattern (regular/ irregular) and the effort (labored/ unlabored) are also assessed in addition to the rate. A full minute length will provide accurate assessment of the respiratory rate and the pattern. If the clients know their respiration is being observed, they may alter their breathing. To prevent this, the nurse should attempt to count respirations simultaneously while checking the pulse rate or a pulse oximetry reading.

The nurse is caring for a client who has sickle cell disease (SCD). Which of the following laboratory findings would require follow-up? A. Hemoglobin 11.2 mg/dL B. Creatinine 2.5 mg/dL C. BUN 19 mg/dL D. Platelet count 150,000 mm3

B. Creatinine 2.5 mg/dL One of the many complications associated with sickle cell disease is renal injury. The significantly elevated creatinine requires follow-up because this is evidence of significant renal insufficiency.

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

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

The nurse is caring for a client who is receiving prescribed methylergonovine. Which of the following findings would indicate a therapeutic response? A. Increased blood pressure B. Decreased post-partum bleeding C. Decreased uterine tone D. Increased urinary output

B. Decreased post-partum bleeding Methylergonovine is an alkaloid medication used to manage postpartum hemorrhage (PPH). This medication causes vasoconstriction, therefore, decreasing postpartum bleeding.

Which of the following sexual complications is a patient with chronic renal failure at risk of developing? A. Retrograde ejaculation B. Decreased testosterone C. Hypertrophy of the testicles D. Feelings of euphoria

B. Decreased testosterone Chronic renal failure causes decreased testosterone levels. Sexuality has physical and emotional components, both of which can be affected by chronic kidney disease. Kidney disease can cause chemical changes in the body, affecting circulation, nerve function, hormones, and energy levels. Any underlying health conditions that contribute to CKD, like hypertension or diabetes, can affect male sexuality. Fatigue is one of the most common symptoms of men with kidney disease experience. Since kidney disease affects the endocrine system, changes in hormone levels may result in decreased sex drive. An estimated 20 to 30 million men in the U.S. have problems with impotence. ED can happen when blood vessels and nerves to the penis become damaged. Without proper blood flow, the penis cannot maintain an erection. Diabetes and high blood pressure affect blood flow and weaken blood vessels. Feeling sexual or attractive becomes more complicated when the body undergoes unexpected changes. This can affect how people interact with others and their ability to develop intimate relationships. Men may feel worried, anxious, and depressed when faced with CKD. This is normal, but these emotions may cause a loss of energy and lower interest in activities, including sex.

Which of the following sexual complications is a patient with chronic renal failure at risk of developing? A. Retrograde ejaculation B. Decreased testosterone C. Hypertrophy of the testicles D. Feelings of euphoria

B. Decreased testosterone Chronic renal failure causes decreased testosterone levels. Sexuality has physical and emotional components, both of which can be affected by chronic kidney disease. Kidney disease can cause chemical changes in the body, affecting circulation, nerve function, hormones, and energy levels. Any underlying health conditions that contribute to CKD, like hypertension or diabetes, can affect male sexuality. Fatigue is one of the most common symptoms of men with kidney disease experience. Since kidney disease affects the endocrine system, changes in hormone levels may result in decreased sex drive. An estimated 20 to 30 million men in the U.S. have problems with impotence. ED can happen when blood vessels and nerves to the penis become damaged. Without proper blood flow, the penis cannot maintain an erection. Diabetes and high blood pressure affect blood flow and weaken blood vessels. Feeling sexual or attractive becomes more complicated when the body undergoes unexpected changes. This can affect how people interact with others and their ability to develop intimate relationships. Men may feel worried, anxious, and depressed when faced with CKD. This is normal, but these emotions may cause a loss of energy and lower interest in activities, including sex.

Which of the following steps is the final step used during the physical assessment of the abdomen? A. Inspection B. Deep palpation C. Percussion D. None of the above

B. Deep palpation Deep palpation is cautiously done after light palpation when necessary because the client's responses to deep palpation may include tightening of the abdominal muscles. When this occurs, it could make light palpation less effective, particularly if an area of pain or tenderness has been palpated. A complete health assessment may be conducted starting at the head and proceeding systematically downward (head-to-toe evaluation). However, the procedure can vary according to the individual's age, the severity of the illness, the preferences of the nurse, the location of the examination, and the hospital's priorities and procedures.

The LPN is preparing to distribute teaching handouts about developmental milestones to the parents of a 6-month-old male. He was born at 28 weeks gestation. Which of the following handouts are appropriate for their son's development? A. Developmental milestones for 6-month-olds B. Developmental milestones for 3-month-olds C. Developmental milestones for 4-month-olds D. Developmental milestones for 1-month-olds

B. Developmental milestones for 3-month-olds Developmental milestones for 3-month-olds will be appropriate for this patient. Although he is 6 months old, he was born at 28 weeks gestation. Premature infants should always be evaluated based on their corrected gestational age. In this case, born at 28 weeks is 12 weeks (or 3 months) early, so the LPN needs to subtract 3 months for his appropriate developmental age. Therefore a handout with 3-month-old milestones is the appropriate developmental milestone to review with the parents.

This nurse is caring for a client who is receiving prescribed sitagliptin. The nurse understands that this medication is intended to treat which condition? A. Hyperlipidemia B. Diabetes mellitus C. Hypothyroidism D. Hypertension

B. Diabetes mellitus Sitagliptin is a DPP-4 Inhibitor used in managing diabetes mellitus type II. This medication reduces blood glucose levels by delaying gastric emptying and slowing the rate of nutrient absorption into the blood.

This nurse is caring for a client who is receiving prescribed sitagliptin. The nurse understands that this medication is intended to treat which condition? A. Hyperlipidemia B. Diabetes mellitus C. Hypothyroidism D. Hypertension

B. Diabetes mellitus Sitagliptin is a DPP-4 Inhibitor used in managing diabetes mellitus type II. This medication reduces blood glucose levels by delaying gastric emptying and slowing the rate of nutrient absorption into the blood.

The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. This specimen is then : A. Placed in a separate container and later added to the collection. B. Discarded, then the collection process begins. C. Tested, then discarded. D. Saved as part of the 24-hour collection.

B. Discarded, then the collection process begins. A 24-hour urine collection may be prescribed to evaluate some renal disorders by showing kidney function at different times of the day and night. The nurse is responsible for providing the collection container and educating the patient on how to collect the specimen. • The correct answer is B. The patient should collect the first specimen, which is considered "old urine" or urine in the bladder before the test began. After the first discarded specimen, urine is collected for 24 hours.

The nurse is caring for a client who is experiencing early decelerations. Which of the following actions should the nurse take? A. Reposition the patient on her side B. Document the findings C. Discontinue oxytocin infusion D. Prepare for an amnioinfusion

B. Document the findings Early decelerations are a reassuring finding and are caused by head compression, which is a normal part of labor.

The LPN is working with a child who has a learning disability. The child is ten years old and has trouble reading and interpreting words, letters, and symbols. This disorder is described as which of the following? A. Phonologic processing deficit B. Dyslexia C. Tourette's syndrome D. Apraxia

B. Dyslexia Dyslexia is defined as a disorder that involves trouble reading and interpreting words, letters, and symbols. It does not affect general intelligence, but children may need special assistance at school when learning to read. They may not understand at their appropriate grade level, depending on the severity of the disorder.

What is the first nursing action for a client experiencing dyspnea? A. Remove pillows from under the client's head. B. Elevate the head of the bed. C. Elevate the foot of the bed. D. Take the client's blood pressure.

B. Elevate the head of the bed. Elevating, the head of the bed, allows the abdominal organs to descend, giving the diaphragm more room for expansion and facilitating lung expansion. Dyspnea is difficult or labored breathing. A dyspneic client usually has rapid, shallow respirations and appears anxious. Dyspneic people can often breathe more quickly in an upright position, a condition known as orthopnea. While sitting or standing, gravity lowers organs in the abdominal cavity away from the diaphragm. This gives the lungs more room for expansion within the chest and allows more air intake with each breath.

What is the first nursing action for a client experiencing dyspnea? A. Remove pillows from under the client's head. B. Elevate the head of the bed. C. Elevate the foot of the bed. D. Take the client's blood pressure.

B. Elevate the head of the bed. Elevating, the head of the bed, allows the abdominal organs to descend, giving the diaphragm more room for expansion and facilitating lung expansion. Dyspnea is difficult or labored breathing. A dyspneic client usually has rapid, shallow respirations and appears anxious. Dyspneic people can often breathe more quickly in an upright position, a condition known as orthopnea. While sitting or standing, gravity lowers organs in the abdominal cavity away from the diaphragm. This gives the lungs more room for expansion within the chest and allows more air intake with each breath.

Which of the following medications may be prescribed to control hypertension associated with nephroblastoma? A. Propranolol B. Enalapril C. Nitroprusside D. Digoxin

B. Enalapril Enalapril is an ACE inhibitor used to lower blood pressure. Since patients with nephroblastoma are hypertensive due to increased renin levels, this medication is commonly prescribed to decrease their blood pressure. ACE inhibitors reduce blood pressure by inhibiting angiotensin II formation in the RAAS system, so they are an excellent choice for treating hypertension caused by nephroblastoma.

After reporting to her usual adult medical-surgical floor, the LPN is told she must float to the mother-baby unit. The LPN has never cared for this patient population before. Which of the following actions is most appropriate? A. Refuse the assignment. B. Float to the mother-baby unit and identify tasks within her training that she can safely perform. C. Call the nurse manager. D. Float to the mother-baby unit and ensure no one knows her inexperience.

B. Float to the mother-baby unit and identify tasks within her training that she can safely perform. Floating to the mother-baby unit and identifying tasks within her training that she can safely perform is the correct action. This promotes patient safety and benefits both the nurse and the unit.

The nurse is caring for a client receiving prescribed lactulose. Which of the following finding would indicate a therapeutic response? A. Increased liver enzymes B. Increased level of consciousness C. Decreased urinary calcium D. Increased gastric pH

B. Increased level of consciousness Lactulose is indicated for clients with hyperammonemia secondary to cirrhosis of the liver. Increased ammonia levels cause a patient to develop altered mental status (hepatic encephalopathy). A client receiving this medication will have increased bowel movements as that is the primary way of excreting the excess ammonia.

The nurse is caring for a client receiving prescribed lactulose. Which of the following finding would indicate a therapeutic response? A. Increased liver enzymes B. Increased level of consciousness C. Decreased urinary calcium D. Increased gastric pH

B. Increased level of consciousness Lactulose is indicated for clients with hyperammonemia secondary to cirrhosis of the liver. Increased ammonia levels cause a patient to develop altered mental status (hepatic encephalopathy). A client receiving this medication will have increased bowel movements as that is the primary way of excreting the excess ammonia.

Among Erickson's Stages of Development, which of the following development stages would the nurse expect for her 4-year-old patient to be in? A. Trust vs. Mistrust B. Initiative vs. Guilt C. Identity vs. Role Confusion D. Industry vs. Inferiority

B. Initiative vs. Guilt initiative vs. Guilt is the typical development stage for preschool children, who are 3 to 5-year-olds, so this is correct for your 4-year-old patient. In initiative vs. guilt, children start to assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval end up feeling guilty.

The nurse plans to use a mechanical lift to transfer a client from a stretcher to a wheelchair. Which appropriate action should the nurse take? A. Keep the stretcher's side rails raised during the transfer B. Instruct the client to fold their arms over their chest C. Apply gloves and gown for this procedure D. Unlock the wheels on the stretcher and wheelchair

B. Instruct the client to fold their arms over their chest During any mechanical lift transfer, the nurse should instruct the client to fold their arms over the chest, preventing injuries to the client's arms during the transfer.

The nurse is collecting data on a child with bilateral lower extremity chemical burns. The nurse suspects that the child may have been abused. The nurse should take which initial action? A. Cover the affected area with sterile dressing B. Irrigate the affected area with saline C. Report the suspected abuse D. Document the findings

B. Irrigate the affected area with saline A common mnemonic to remember is "the solution to pollution is dilution." When a client has a chemical burn, the highest priority is to copiously irrigate it (dilute it) with saline or water. Prompt irrigation of the area exposed to caustic substances (acid, alkali) dilutes the chemical, attempts to neutralize the pH change in the skin, and decreases the extent of the dermal injury. Additionally, dilution lessens the risk of the caregiver getting burned by the chemical.

The nurse reviews a client's medication record who takes prescribed sildenafil. Which medication should the nurse clarify with the primary healthcare provider (PHCP)? A. Lisinopril B. Isosorbide C. Atorvastatin D. Losartan .

B. Isosorbide Isosorbide is a nitrate medication and should not be taken concurrently with phosphodiesterase inhibitors such as sildenafil. The combination of the two may result in profound hypotension.

When instructing a patient on deep breathing and coughing, why should the patient be sitting for these activities? A. It is physically more comfortable for the patient. B. It helps the patient to support their positioning with a pillow. C. It loosens respiratory secretions. D. It allows the patient to observe their room and relax.

B. It helps the patient to support their positioning with a pillow. The patient should be sitting when deep breathing and coughing. This position allows the patient to use a pillow, providing abdominal support when coughing. It also allows the lungs to expand more fully and the diaphragm to drop. Coughing and deep breathing exercises are essential to enhance lung expansion and mobilize secretions, thereby preventing atelectasis (collapse of the alveoli) and pneumonia. Instructions on deep breathing exercises should include: 1. Place your palms down on the border of your rib cage, and inhale slowly and evenly through the nose until entire chest expansion is achieved. 2. Hold your breath for 2 to 3 seconds. 3. Then exhale slowly through the mouth. 4. Continue exhalation until maximum chest contraction has been achieved.

When instructing a patient on deep breathing and coughing, why should the patient be sitting for these activities? A. It is physically more comfortable for the patient. B. It helps the patient to support their positioning with a pillow. C. It loosens respiratory secretions. D. It allows the patient to observe their room and relax.

B. It helps the patient to support their positioning with a pillow. The patient should be sitting when deep breathing and coughing. This position allows the patient to use a pillow, providing abdominal support when coughing. It also allows the lungs to expand more fully and the diaphragm to drop. Coughing and deep breathing exercises are essential to enhance lung expansion and mobilize secretions, thereby preventing atelectasis (collapse of the alveoli) and pneumonia. Instructions on deep breathing exercises should include: 1. Place your palms down on the border of your rib cage, and inhale slowly and evenly through the nose until entire chest expansion is achieved. 2. Hold your breath for 2 to 3 seconds. 3. Then exhale slowly through the mouth. 4. Continue exhalation until maximum chest contraction has been achieved.

Which of the following terms describe the soft down hairs present on the shoulders, back, and forehead of newborns? A. Milia B. Lanugo C. Vernix D. Mongolian spot

B. Lanugo Lanugo is the soft hairs present on the shoulders, back, and forehead of newborns.

The LPN is reinforcing education to a client about modifiable risk factors and risk factors that are not. Which of the following is most likely able to be corrected? A. Genetic predisposition B. Lifestyle choices C. Depression D. All of the above

B. Lifestyle choices Lifestyle choices are the risk factors that are most likely able to be corrected. Poor lifestyle choices place a person at risk and they are often considered risky behaviors.

Which of the following formulas would the LPN correctly choose for an infant diagnosed with phenylketonuria? A. Alfamino B. Lofenalac C. Enfamil D. Gentlease

B. Lofenalac Lofenalac is a formula that is very low in the amino acid phenylalanine. In phenylketonuria (PKU), there is impaired metabolism of this essential amino acid. When patients eat foods that contain this amino acid, they cannot break it down, and levels of this amino acid can then become toxic to the patient. Therefore, the formula Lofenalac is the appropriate choice for patients with PKU.

A 90-year-old female has been bedridden for two weeks. Which of the following complications, observed by the nurse, is not expected? A. A decrease in bone density B. Loss of short term memory C. Atelectasis D. Loss of appetite

B. Loss of short term memory Loss of short-term memory is not expected as a complication of bed rest and would therefore need further assessment. Risk factors related to mobility can affect every body system. The musculoskeletal system can experience contractures, joint ankylosis, and the depletion of necessary minerals. Pneumonia is a significant risk factor associated with the respiratory system. Immobile people are also more prone to orthostatic hypotension, slowed metabolism, skin breakdown, and decreased peristalsis, which affects the gastrointestinal and genitourinary systems.

A 90-year-old female has been bedridden for two weeks. Which of the following complications, observed by the nurse, is not expected? A. A decrease in bone density B. Loss of short term memory C. Atelectasis D. Loss of appetite

B. Loss of short term memory Loss of short-term memory is not expected as a complication of bed rest and would therefore need further assessment. Risk factors related to mobility can affect every body system. The musculoskeletal system can experience contractures, joint ankylosis, and the depletion of necessary minerals. Pneumonia is a significant risk factor associated with the respiratory system. Immobile people are also more prone to orthostatic hypotension, slowed metabolism, skin breakdown, and decreased peristalsis, which affects the gastrointestinal and genitourinary systems.

Which of the following terms refers to the first stool passed by a newborn infant? A. Melena B. Meconium C. Diarrhea D. Hematemesis

B. Meconium Meconium is defined as the first stool passed by a newborn infant. It is typically a dark black/green sticky stool.

Your client is experiencing severe, acute anxiety before a scheduled endoscopy procedure. Which of the following medications is most likely to be ordered by the physician? A. Oxycodone B. Midazolam C. Clonazepam D. Haloperidol

B. Midazolam Midazolam (Versed) is a benzodiazepine used for acute anxiety attacks. Midazolam is preferred in this setting because of its rapid onset (2 to 5 minutes after IV administration) and short duration of action (3 to 8 hours). It can be administered intravenously or orally. Given these benefits, midazolam would be the most useful for the patient experiencing an acute anxiety attack prior to/during endoscopic procedures or prior to surgery. Additional benefits of midazolam during procedures are sedation and amnesia. Midazolam as a continuous IV infusion is also used in sedating mechanically ventilated patients in critical care settings. The nurse should keep flumazenil as an antidote ready in case severe respiratory depression occurs with benzodiazepines.

The nurse is caring for a patient with a history of hyperparathyroidism who is complaining of nausea. Upon assessment, the nurse notes the patient is tachycardic, with a QT interval of 0.3 seconds, and slight abdominal distention. What action should the nurse take first? A. Encourage intake of vitamin D-rich foods B. Notify the primary health care provider (PHCP) C. Hold the patient's scheduled furosemide D. Assess for Chvostek's sign .

B. Notify the primary health care provider (PHCP) Hyperparathyroidism can result in elevated calcium levels due to the overproduction of parathyroid hormone, increased intestinal absorption, and bone resorption. This patient shows signs of hypercalcemia: nausea, abdominal distention, bradycardia, ventricular tachycardia, and shortened QT interval. The nurse has assessed the patient's presentation as well as cardiovascular status and should immediately notify the physician of the change in status.

The LPN is caring for an infant who will be going to the operating room the next day for surgical repair of his total anomalous pulmonary venous return. She has finished signing the consent paperwork for the operation. The mother states "I'm not so sure about this. What if my baby dies?!" What is the appropriate action for the LPN? A. Explain the procedure to the mother. B. Notify the surgical team and have them come back to speak with the mother. C. Reassure the mother that everything will go as planned. D. Tell the mother that because she has already signed the consent paperwork she cannot change her mind now.

B. Notify the surgical team and have them come back to speak with the mother. The LPN has identified that the mother has concerns about the surgery, so it is her responsibility to notify the surgical team and have them come back to speak with the mother.

The nurse is visiting the home of a client with Clostridium difficile. Which infection control measure should the nurse include? A. Ask the client to wear a surgical mask during the visit. B. Obtain vital signs with a disposable blood pressure cuff. C. Interview the client while maintaining 3 feet distance. D. Use sterile gloves when performing venipuncture.

B. Obtain vital signs with a disposable blood pressure cuff. C. diff is a spore-producing bacterium that allows it to be transmitted between clients, environmental surfaces, and contaminated hands. Obtaining vital signs with disposable equipment is recommended to prevent the transmission of this pathogen.

At the 24-week visit, a pregnant woman demonstrates less than expected growth in uterine size, an easily palpable fetus that can be outlined by the nurse, and the absence of fetal ballottement. Which of the following is this most likely related to the development of? A. Hydramnios B. Oligohydramnios C. Amniotic fluid embolism D. Macrosomia

B. Oligohydramnios Oligohydramnios occurs when the amount of amniotic fluid is severely reduced. This would result in less than expected growth in the uterus, a fetus surrounded so little amniotic fluid is easily palpated and outlined. The fetus will not be palpable when the examiner does a vaginal exam and pushes against the cervix (ballottement).

The nurse is caring for a client who has influenza. Which of the following prescriptions may be prescribed by the primary healthcare provider (PHCP)? A. Valacyclovir B. Oseltamivir C. Azithromycin D. Omeprazole

B. Oseltamivir Oseltamivir is an antiviral agent approved for the treatment of influenza. This medication should be initiated within 48 hours of symptom onset.

A patient who is 2-days postoperative from right femoral popliteal bypass surgery complains of worsening right leg pain. Upon assessment, the nurse notes swelling and ecchymosis at the incision sites. Which action would be the nurse's initial priority? A. Apply pressure to sites with a sandbag B. Palpate pedal pulses C. Assess for signs of claudication D. Apply a warm compress to the incision sites

B. Palpate pedal pulses The most significant complications that this patient is at risk for after the revascularization procedure are thrombus, hemorrhage, infection, and arrhythmias. Mild to moderate swelling, bruising, and pain at the surgical site are expected and typically resolve over time as the leaked blood is reabsorbed. The most important action would be to assess the patient's pedal pulses (distal to incisions). If pulses are intact, the nurse would then address the patient's complaint of worsening pain.

A patient who is 2-days postoperative from right femoral popliteal bypass surgery complains of worsening right leg pain. Upon assessment, the nurse notes swelling and ecchymosis at the incision sites. Which action would be the nurse's initial priority? A. Apply pressure to sites with a sandbag B. Palpate pedal pulses C. Assess for signs of claudication D. Apply a warm compress to the incision sites

B. Palpate pedal pulses The most significant complications that this patient is at risk for after the revascularization procedure are thrombus, hemorrhage, infection, and arrhythmias. Mild to moderate swelling, bruising, and pain at the surgical site are expected and typically resolve over time as the leaked blood is reabsorbed. The most important action would be to assess the patient's pedal pulses (distal to incisions). If pulses are intact, the nurse would then address the patient's complaint of worsening pain.

The nurse is monitoring a patient with a chest tube for crepitus. Which of the following actions is appropriate for this? A. Press down on the patient's abdomen, releasing, and assessing for pain. B. Palpate the skin around the chest tube and observe for a crackling sensation. C. Auscultate the bowel sounds in each quadrant. D. Inspect the patient's chest for even rise and fall.

B. Palpate the skin around the chest tube and observe for a crackling sensation. The nurse may assess for crepitus by palpating the skin around the chest tube and observing for a crackling sensation. Crepitus is defined as infiltration of air in the subcutaneous layer of skin, also known as subcutaneous emphysema. It is caused by air leaking into the subcutaneous space and can be assessed by palpating the skin and noting a crackling sensation.

While caring for a client who requires a mechanical ventilator for breathing, the high-pressure alarm goes off on the ventilator. What is the FIRST action the nurse should perform? A. Disconnect the client from the ventilator and use a manual resuscitation bag. B. Perform a quick assessment of the client's condition. C. Call the respiratory therapist for help. D. Press the alarm reset button on the ventilator.

B. Perform a quick assessment of the client's condition. Several things can trigger pressure alarms on mechanical ventilators. Some of the most common causes of high-pressure alarm triggers include water in the ventilator circuit, increased or thick mucus or other secretions blocking the airway (caused by not enough humidity), bronchospasm, coughing, gagging, or "fighting" the ventilator breath. Regardless of the cause of the triggered alarm, nurses' priority is to evaluate the patient's status FIRST. • The correct answer is B. Several situations can cause the high-pressure alarm to sound. An assessment of the client will tell the nurse whether the alert was triggered by something simple, such as the patient coughing or a more difficult situation that might require using a manual resuscitation bag and calling the respiratory therapist.

While caring for a client who requires a mechanical ventilator for breathing, the high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A. Disconnect the client from the ventilator and use a manual resuscitation bag. B. Perform a quick assessment of the client's condition. C. Call the respiratory therapist for help. D. Press the alarm reset button on the ventilator.

B. Perform a quick assessment of the client's condition. Several situations can cause the high-pressure alarm to sound. An assessment of the client will tell the nurse whether the alert was triggered by something simple, such as the patient coughing or a more difficult situation that might require using a manual resuscitation bag and calling the respiratory therapist. Several things can trigger pressure alarms on mechanical ventilators. Some of the most common causes of high-pressure alarm triggers include water in the ventilator circuit, increased or thicker mucus or other secretions blocking the airway (caused by not enough humidity), bronchospasm, coughing, gagging, or "fighting" the ventilator breath. Regardless of the cause of the triggered alarm, the priority for nurses is to evaluate the patient's status FIRST

While caring for a client who requires a mechanical ventilator for breathing, the high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A. Disconnect the client from the ventilator and use a manual resuscitation bag. B. Perform a quick assessment of the client's condition. C. Call the respiratory therapist for help. D. Press the alarm reset button on the ventilator

B. Perform a quick assessment of the client's condition. Several situations can cause the high-pressure alarm to sound. An assessment of the client will tell the nurse whether the alert was triggered by something simple, such as the patient coughing or a more difficult situation that might require using a manual resuscitation bag and calling the respiratory therapist. Several things can trigger pressure alarms on mechanical ventilators. Some of the most common causes of high-pressure alarm triggers include water in the ventilator circuit, increased or thicker mucus or other secretions blocking the airway (caused by not enough humidity), bronchospasm, coughing, gagging, or "fighting" the ventilator breath. Regardless of the cause of the triggered alarm, the priority for nurses is to evaluate the patient's status FIRST.

The nurse is obtaining vital signs for a client who has acquired immune deficiency syndrome (AIDS). Prior to entering the room, the nurse should do which of the following? A. Wear gloves and a gown. B. Perform hand hygiene. C. Review the client's viral load. D. Obtain a disposable stethoscope.

B. Perform hand hygiene. When caring for a client who has AIDS, the nurse should maintain standard precautions. Applying PPE such as a gown, pair of gloves, and mask would be inappropriate. Standard precautions require appropriate hand hygiene and other PPE as needed.

A patient is being discharged from the hospital after being diagnosed with lupus erythematosus. The patient is advised to follow up with what to monitor his condition? A. HgbA1C B. Daily blood pressure checks C. Monthly urine specimens D. Monthly CBC

C. Monthly urine specimens A patient with systemic lupus erythematosus (SLE) needs monthly urine specimens to check for proteinuria to monitor for any kidney damage.

An altered physical condition caused by the nervous system adapting to repeated drug use is: A. Addiction B. Physical dependence C. Psychological dependence D. Withdrawal

B. Physical dependence Some drugs are frequently abused or have a high potential for addiction. Drugs that cause dependency are restricted to use in situations of medical necessity if they are allowed at all. According to the law, drugs that have a significant potential for abuse are placed into categories called schedules.

George, age 8, is admitted with rheumatic fever. Which clinical finding indicates to the nurse that George needs to continue taking the salicylates he had received at home? A. Chorea B. Polyarthritis C. Subcutaneous nodules D. Erythema marginatum

B. Polyarthritis Polyarthritis is characterized by swollen, painful, hot joints that respond to salicylates. Rheumatic fever is an inflammatory disease that can develop when strep throat or scarlet fever, caused by streptococcus bacteria, isn't adequately treated. It most often affects children between 5 and 15 years old, though it can develop in younger children and adults. Although strep throat is frequent, rheumatic fever is rare in the United States and other developed countries. However, rheumatic fever remains common in many developing nations. Rheumatic fever can cause permanent damage to the heart, including damaged heart valves and heart failure. Treatments can reduce inflammation, lessen pain and other symptoms, and prevent the recurrence of rheumatic fever.

The pathological process causing esophageal varices is: A. Systemic hypertension B. Portal hypertension C. Ascites and edema D. Dilated veins and varicosities

B. Portal hypertension Esophageal varices are enlarged veins in the esophagus. They're often due to obstructed blood flow through the portal vein, which carries blood from the intestine, pancreas, and spleen to the liver. Pathology refers to the science of the cause and effects of the disease. Among the answer choices, more than once refers to a symptom that is seen with esophageal varices. However, the cause of the varices is what we are looking for. It's essential to look for clue words in NCLEX questions, such as pathology or symptom.

X After failing a final anatomy exam, a student is angry with the instructor and talks negatively about her. What defense mechanism is this an example of? A. Acting out B. Projection C. Compensation D. Reaction-formation

B. Projection The client is placing blame on others and not taking responsibility for her behavior. This is known as projection.

The nurse is caring for a client who is receiving prescribed doxorubicin. Which of the following findings would indicate the client is having an adverse effect? A. Urine discoloration B. Pulmonary congestion C. Hirsutism D. Pruritus

B. Pulmonary congestion Doxorubicin is an antineoplastic that is indicated for a variety of cancers. Doxorubicin is highly cardiotoxic, which may cause cardiomyopathy. The cardiotoxicity may cause a decrease in left ventricular ejection fraction, therefore, causing pulmonary congestion and, at worse life-threatening pulmonary edema. The client may present with leg edema, cough, and worsening shortness of breath.

The nurse is caring for a client who is receiving prescribed doxorubicin. Which of the following findings would indicate the client is having an adverse effect? A. Urine discoloration B. Pulmonary congestion C. Hirsutism D. Pruritus

B. Pulmonary congestion Doxorubicin is an antineoplastic that is indicated for a variety of cancers. Doxorubicin is highly cardiotoxic, which may cause cardiomyopathy. The cardiotoxicity may cause a decrease in left ventricular ejection fraction, therefore, causing pulmonary congestion and, at worse life-threatening pulmonary edema. The client may present with leg edema, cough, and worsening shortness of breath.

The nurse is assisting a client using a fracture bedpan. Which action should the nurse take? A. Position the client prone while applying the bed pan B. Raise the head-of-bed to 30 degrees C. Place the open rim of the bedpan facing toward the head of the bed D. Lower all of the side rails

B. Raise the head-of-bed to 30 degrees Placing the head-of-bed at 30 to 60 degrees will facilitate comfort by preventing strain on the lumbar spinal column.

The nurse has received a telephone prescription from the primary healthcare provider (PHCP) for citalopram 10 mg PO daily. Which action is the nurse's priority after taking the telephone order? A. Verify that the medication is in stock B. Read back the prescription to the PHCP C. Inform the client of the new prescription D. Transmit the prescription to the pharmacy

B. Read back the prescription to the PHCP It is essential that the nurse read back the order to the PHCP to ensure that the prescription telephone order is accurate. Any verbal or telephone order from a PHCP requires the nurse back the order to verify that the order was accurate. Telephone and verbal orders may result in medication errors because of accents, background noise, etc., that may distort communication.

Which of the following is the most accurate education for injury prevention in the home of elderly clients? A. Use the handrail when going up and down the stairs, ensure robes or pants are held up if flowy, and wear comfortable slippers. B. Remove all throw rugs, remove furniture from all pathways, and wear comfortable non-skid footwear. C. Use solid chairs without armrests, keep walkways clear, use cordless phones. D. Install raised toilet seats, ensure that all sinks have throw rugs to prevent slipping on water, and use grab bars in the shower/bathroom.

B. Remove all throw rugs, remove furniture from all pathways, and wear comfortable non-skid footwear. Throw rugs, furniture in walkways, and slippery footwear are fall risks for patients.

The licensed practical/vocational nurse (LPN/VN) cares for a client with pulmonary tuberculosis (TB). Which infection control measure should the LPN implement? A. Restrict visitors who are pregnant B. Remove any portable fans in the room C. Wear a dosimeter badge during client care D. Place the patient further away from the nursing station

B. Remove any portable fans in the room Fans should be removed from a room for a client with droplet or airborne precautions. Fans may propel the transmission of a pathogen. A client with pulmonary tuberculosis should be isolated using airborne precautions. The door should be kept closed and the room should have monitored negative air pressure.

The nurse is caring for a client with a pulmonary embolism (PE). Which of the following findings requires immediate follow-up? A. Pleuritic chest pain B. Restlessness C. Cough D. Exertional dyspnea

B. Restlessness Restlessness is an ominous sign suggestive of hypoxia. Hypoxia is indicative of a pulmonary embolism (PE) that is advancing, and the client is becoming unstable. The nurse should immediately follow up on this finding.

The nurse is caring for a client with a pulmonary embolism (PE). Which of the following findings requires immediate follow-up? A. Pleuritic chest pain B. Restlessness C. Cough D. Exertional dyspnea

B. Restlessness Restlessness is an ominous sign suggestive of hypoxia. Hypoxia is indicative of a pulmonary embolism (PE) that is advancing, and the client is becoming unstable. The nurse should immediately follow up on this finding.

The sense of hearing is assessed using which standardized test? A. Taylor test B. Rinne test C. Babinski test D. APGAR test

B. Rinne test Hearing is assessed using the Rinne test and the Weber test, with a tuning fork.

The nurse is data collecting on a client with congestive heart failure. Which physical finding should the nurse expect? A. Intermittent claudication B. S3 gallop C. Venous stasis ulcers D. Widened pulse pressure

B. S3 gallop An S3 gallop is an expected finding in heart failure. This is often an early manifestation of heart failure; it and this sound are best auscultated at the apex of the heart.

The nurse is caring for a client who was newly prescribed warfarin. Which medication on the client's medication list requires follow-up with the primary healthcare provider (PHCP)? A. Loratidine B. Saw Palmetto C. Furosemide D. Pantoprazole

B. Saw Palmetto Saw Palmetto is an over-the-counter supplement purported to decrease symptoms of benign prostatic hyperplasia. This medication should be used with caution if it is administered with warfarin. Warfarin is an anticoagulant; if the client takes both concurrently, it may potentiate the anticoagulant effect. The primary healthcare provider (PHCP) must be made aware of this interaction.

The nurse is caring for a client who was newly prescribed warfarin. Which medication on the client's medication list requires follow-up with the primary healthcare provider (PHCP)? A. Loratidine B. Saw Palmetto C. Furosemide D. Pantoprazole

B. Saw Palmetto Saw Palmetto is an over-the-counter supplement purported to decrease symptoms of benign prostatic hyperplasia. This medication should be used with caution if it is administered with warfarin. Warfarin is an anticoagulant; if the client takes both concurrently, it may potentiate the anticoagulant effect. The primary healthcare provider (PHCP) must be made aware of this interaction.

The nurse is caring for a patient with a Sengstaken-Blakemore tube. She performs her safety checks at the beginning of the shift and ensures which one of the following priority items is readily available at the bedside? A. Trach kit B. Scissors C. Obturator D. Yaunker

B. Scissors Scissors must be kept at the bedside of any patient with a Sengstaken-Blakemore tube. The nurse should check for this essential item at the beginning of her shift to ensure the safety of the patient. Scissors are necessary for this patient because if the Sengstaken-Blakemore tube were to rupture the tube would move upward and could obstruct the airway. This is an emergency, and the nurse would need to immediately notify the RN so that the balloon can be cut.

The nurse is caring for a client with acute renal failure. Which of the following laboratory results should be reported to the primary healthcare provider (PHCP)? A. Blood urea nitrogen 20 mg/dL B. Serum potassium 6 mEq/L C. Venous blood pH 7.30 D. Hemoglobin of 10.3 mg/dL

B. Serum potassium 6 mEq/L Acute renal failure can cause a significant imbalance in lab values. Although all of the lab results listed are abnormal, the elevated potassium level is a life-threatening finding. • Although all of these findings are abnormal, elevated potassium is a life- threatening finding and must be reported immediately. The normal potassium is 3.5-5.0 mEq/l • The BUN level should be 10 to 20 mg/dL. • Venous blood pH should be 7.31 to 7.41. • Normal hemoglobin levels differ based on age, sex, and general health. The normal range for hemoglobin is 14 to 17.5 grams per deciliter for men. For women, 12.0 to 16 grams per deciliter. i Additional Info Acute renal failure may occur for a variety of reasons, including severe hypotension, exposure to a nephrotoxic substance, or cardiac arrest. Elevations in potassium are essential to report because of the life-threatening dysrhythmias that may occur. Sodium - 135-145 mEq/L Potassium- 3.5-5.0 mEq/L Calcium-9.0-10.5 mg/dL BUN-10-20 mg/dL Creatinine-0.6-1.2 mg/dL

The nurse is assessing a 6-year-old client with asthma. Which of the following findings is of highest concern? A. Expiratory wheezing B. Silent chest C. Cough D. Head bobbing

B. Silent chest Silent chest is the assessment finding of most concern. This refers to the inability to auscultate any lung sounds. There is complete obstruction of the patient's airway, and therefore the inability to move air. When complete obstruction occurs, this is a medical emergency. This assessment finding is of most concern because the patient has lost their airway.

The nurse is collecting data on a client receiving prescribed lamotrigine. Which client finding requires immediate follow-up? A. Abnormal dreams B. Skin blistering C. Dyspepsia D. Xerostomia

B. Skin blistering Skin blistering associated with lamotrigine therapy is a critical finding to report. This is a feature of Steven-Johnson syndrome (SJS). Lamotrigine has been implicated as causing this adverse finding.

The nurse is assessing a patient being treated for hypertension that has poor gait and impaired balance. What should the nurse do next? A. Do nothing as this has nothing to do with why the patient was hospitalized. B. Speak with the attending physician about his concerns and request a referral to physical therapy. C. Speak with the attending physician about his concerns and request a referral for the patient to go to the hospital gym. D. Add this issue to the nursing care plan and have daily gait/balance training as an intervention.

B. Speak with the attending physician about his concerns and request a referral to physical therapy. Nurses need to be aware of the patient's needs even if they do not pertain to the reason for hospitalization and treatment. Observation is a crucial nursing skill. The nurse should always be alert for any changes in a patient's condition, regardless of the patient's initial diagnosis. Being aware of the patient's status will equip the nurse to advocate for patients and request referrals when concerns or issues arise during care.

Which of the following interventions helps reduce the effects of GERD? A. Lie down after eating. B. Wear a girdle. C. Elevate the head of the bed on 4-6 inch blocks. D. Increase fluid intake just before bedtime.

C. Elevate the head of the bed on 4-6 inch blocks. Patients should be encouraged to elevate the head of the bed to allow food to move out of the stomach before lying flat. GERD occurs when stomach acid slips into the esophagus. Any position that hinders or slows the movement of food from the stomach should be avoided.

The risk manager reviews an incident report completed by a nurse regarding a client's fall. Which finding in the report demonstrates inappropriate documentation? A. The client's explanation of the event. B. Subjective factors preceding the fall. C. Any injuries sustained as a result of the fall. D. The names of all witnesses present.

B. Subjective factors preceding the fall. The purpose of an incident report is to provide an objective account of an incident/occurrence, in order to identify issues with current practices, improve policies, and potentially investigate situations of negligence/malpractice. Subjectivity should be excluded from a report because subjectivity allows for opinions on details that may not be true (example, stating I believe the client fell because he did not follow instruction) would be inappropriate.

The nurse is planning a staff developmental conference about confidentiality. Which of the following scenarios should the nurse include as a violation of client confidentiality? A. Informing a visitor of the room number of a client admitted with pneumonial B. Telling a police officer who brought a client into the emergency department (ED) the urine drug screen results C. Notifying the pharmacist that a client is HIV positive and may have a potential drug interaction D. Informing local authorities that a client is suspected of being a victim of domestic violence

B. Telling a police officer who brought a client into the emergency department (ED) the urine drug screen results The results of a UDS are confidential, and that confidentiality should not be pierced because an individual is a police officer. If the police officer requests the results, they should obtain a legal court order and present it to risk management to obtain the necessary records.

The nurse is precepting a student nurse on the medical-surgical unit. The student collects a blood sample from a patient with TPN infusing. Which action by the student nurse would require immediate intervention by the nurse? A. The student flushes the port with saline prior to collecting blood. B. The student accesses the non-infusing port to obtain the blood sample. C. The student draws up 10 mL of blood, clamps the line, and discards the syringe. D. The student uses an alcohol swab to clean the port.

B. The student accesses the non-infusing port to obtain the blood sample. TPN solutions are administered via a central line in order to reduce the risk of phlebitis and allow for rapid dilution. Even if a second port is available, the student nurse should stop the infusion for at least one minute prior to obtaining a blood sample to avoid aspirating fluids such as glucose and electrolytes which will give inaccurate results if the sample is drawn while TPN is running.

The nurse is precepting a student nurse on the medical-surgical unit. The student collects a blood sample from a patient with TPN infusing. Which action by the student nurse would require immediate intervention by the nurse? A. The student flushes the port with saline prior to collecting blood. B. The student accesses the non-infusing port to obtain the blood sample. C. The student draws up 10 mL of blood, clamps the line, and discards the syringe. D. The student uses an alcohol swab to clean the port.

B. The student accesses the non-infusing port to obtain the blood sample. TPN solutions are administered via a central line in order to reduce the risk of phlebitis and allow for rapid dilution. Even if a second port is available, the student nurse should stop the infusion for at least one minute prior to obtaining a blood sample to avoid aspirating fluids such as glucose and electrolytes which will give inaccurate results if the sample is drawn while TPN is running.

Which of the following is the reason a patient receives nitrous oxide in addition to thiopental sodium? A. To provide the additional anesthesia to put him in a sleep-like state. B. To increase the effectiveness of each drug at a lower dosage. C. Thiopental sodium is not effective when used alone. D. Nitrous oxide is not effective when used alone.

B. To increase the effectiveness of each drug at a lower dosage. Nitrous oxide may be used for dental procedures or brief obstetrical or surgical procedures. It may also be used together with other general anesthetics, making it possible to decrease its dosage with greater effectiveness. There are two primary methods of causing general anesthesia. IV agents are usually administered first because they act within a few seconds. After the patient loses consciousness, inhaled agents are used to maintain the anesthesia.

Which of the following lipid levels is out of range and should be reported to the physician? A.Triglycerides 75 mg/dL B. Total cholesterol 212 mg/dL C. High-density lipoprotein (HDL) 60 mg/dL D. Low-density lipoprotein (LDL) 95 mg/dL

B. Total cholesterol 212 mg/dL The goal is to keep the total cholesterol less than 200 mg/dL for both sexes. This value is high and warrants follow-up by the nurse.

The nurse is assessing a child for physical abuse. Which finding would require follow-up? A. Unexplained weight loss B. Unexplained bruising C. Poor hygiene D. Brittle hair and nails

B. Unexplained bruising The most common physical sign of child abuse is unexplained (or implausible) bruising. The physical maltreatment of a child can manifest in many ways, but bruising is the most commonly recognized that may start an investigation. It is important to note that all nurses are mandatory reporters of abuse.

A client with a history of falls is admitted to the medical-surgical unit. The nurse should plan to implement which intervention to reduce this client's risk of falling? A. Encouraging the client to ambulate independently to improve muscle strength. B. Verify that the bed alarm is enabled during client rounding. C. Administering sedatives to promote rest and reduce anxiety. D. Implementing a restrictive mobility policy to minimize the potential of falls.

B. Verify that the bed alarm is enabled during client rounding. Ensuring the bed alarm is on will help notify staff if the client is trying to get up unassisted and allow the staff to intervene and reduce their risk of falling. This client has a history of falls, and it is appropriate to provide this measure.

The nurse is taking care of a client with encopresis. Which of the following statements correctly describe encopresis? A. Infrequent and hard to pass stools lasting greater than two weeks. B. Voluntary or involuntary fecal incontinence in children over the age of 4 who were previously toilet trained. C. Involuntary fecal incontinence in children over the age of 4 who were previously toilet trained. D. Inability to pass stool due to fecal impaction

B. Voluntary or involuntary fecal incontinence in children over the age of 4 who were previously toilet trained. Voluntary or involuntary fecal incontinence in children over the age of 4 who were previously toilet trained is the correct definition of encopresis.

Which of the following is a priority for assessing a patient who is taking digoxin and lasix? A. Night sweats and headache. B. Vomiting and halos around lights. C. Stomach upset and headache. D. Low blood pressure and dark urine.

B. Vomiting and halos around lights. Lasix causes the patient to lose potassium. If taken with a low potassium level, Digoxin can become toxic and show signs/symptoms of nausea, vomiting, and halos around lights. Furosemide and digoxin are often used together but may require more frequent evaluation of digoxin, potassium, and magnesium levels. Patients are encouraged to notify their healthcare provider if they experience any symptoms such as weakness, tiredness, muscle pains or cramps, nausea, decreased appetite, visual problems, or irregular heartbeats.

Which of the following is a priority for assessing a patient who is taking digoxin and lasix? A. Night sweats and headache. B. Vomiting and halos around lights. C. Stomach upset and headache. D. Low blood pressure and dark urine.

B. Vomiting and halos around lights. Lasix causes the patient to lose potassium. If taken with a low potassium level, Digoxin can become toxic and show signs/symptoms of nausea, vomiting, and halos around lights. Furosemide and digoxin are often used together but may require more frequent evaluation of digoxin, potassium, and magnesium levels. Patients are encouraged to notify their healthcare provider if they experience any symptoms such as weakness, tiredness, muscle pains or cramps, nausea, decreased appetite, visual problems, or irregular heartbeats.

The nurse is performing data collection on a client experiencing psychosis. The client states, "I am convinced my wife and brother-in-law want to kill me." The nurse interprets this statement as a A. delusion of reference. B. delusion of persecution. C. delusion of grandeur. D. delusion of erotomania.

B. delusion of persecution. Delusion of persecution is when an individual is falsely convinced someone is out to get them or intends to cause them harm. This is a serious delusion because the client may react with violence.

The nurse is educating a client about the newly prescribed oxymetazoline nasal spray. It would be appropriate for the nurse to instruct the client to A. sit upright for thirty minutes after taking this medication. B. do not use this medication for more than three days. C. change positions slowly while taking this medication. D. rinse your mouth out after taking this medication.

B. do not use this medication for more than three days. Oxymetazoline is a nasal spray used to decrease congestion. This medication is administered intranasally and constricts blood vessels in the nasal passage. This medication should not be used for more than three days to prevent rebound congestion.

The nurse is caring for assigned clients. The nurse should immediately follow up with the client who A. has influenza and their most recent temperature was 102°F (39°C). B. is recovering from a thoracentesis and reports a nagging cough. C. reports reddish-brown sputum immediately following a bronchoscopy. D. has pulmonary tuberculosis and is wearing a surgical mask while ambulating to radiology.

B. is recovering from a thoracentesis and reports a nagging cough. Following a thoracentesis, the nurse must assess the client for the most common complication of pneumothorax. Manifestations of a pneumothorax that are concerning include a nagging persistent cough, increased heart and respiratory rate, dyspnea, and potentially a feeling of air hunger. The nurse must act quickly because the client's condition may deteriorate. Depending on the size of the pneumothorax, a chest tube may be needed.

The nurse is caring for assigned clients. The nurse should immediately follow up with the client who A. has influenza and their most recent temperature was 102°F (39°C). B. is recovering from a thoracentesis and reports a nagging cough. C. reports reddish-brown sputum immediately following a bronchoscopy. D. has pulmonary tuberculosis and is wearing a surgical mask while ambulating to radiology.

B. is recovering from a thoracentesis and reports a nagging cough. Following a thoracentesis, the nurse must assess the client for the most common complication of pneumothorax. Manifestations of a pneumothorax that are concerning include a nagging persistent cough, increased heart and respiratory rate, dyspnea, and potentially a feeling of air hunger. The nurse must act quickly because the client's condition may deteriorate. Depending on the size of the pneumothorax, a chest tube may be needed.

The nurse has just inserted an indwelling urinary catheter for a male client. The nurse plans on securing the catheter to the client's A. inner thigh. B. lower abdomen. C. outer thigh. D. medial thigh.

B. lower abdomen. When securing an indwelling urinary catheter for a male, it is appropriate to anchor it to the lower abdomen or upper thigh. The catheter tubing should be secured to the lower abdomen or the upper thigh to prevent urethral injury.

The nurse is performing follow-up phone calls for clients recently discharged from the medical-surgical unit. Which client situation would require immediate follow-up? A client with A. cystitis reporting a localized rash since starting the prescribed sulfamethoxazole-trimethoprim. B. neutropenia reporting an oral temperature of 100°F (37.8°C). C. anemia reporting increased energy since starting epoetin alfa injections. D. congestive heart failure reporting increased urination since starting prescribed bumetanide.

B. neutropenia reporting an oral temperature of 100°F (37.8°C). Clients discharged with neutropenia must take their temperature daily and report a temperature of 100°F (37.8°C) or greater the primary healthcare provider. The client who is neutropenic is most susceptible to bacterial, viral, and fungal infections, and any sign (or symptom) of infection should be reported promptly.

The licensed practical/vocational nurses (LPN/VN) nurse reviews assigned clients' arterial blood gas (ABG) results. Which ABG requires immediate follow-up? A. pH = 7.46; PaO2 = 90 mm Hg; PaCO2 = 33 mm Hg; HCO3- = 22 mEq/L; SaO2 = 94% B. pH = 7.27; PaO2 = 73 mm Hg; PaCO2 = 50 mm Hg; HCO3- = 25 mEq/L; SaO2 = 85% C. pH = 7.45; PaO2 = 95 mm Hg; PaCO2 = 38 mm Hg; HCO3- = 26 mEq/L; SaO2 = 96% D. pH = 7.32; PaO2 = 93 mm Hg; PaCO2 = 42 mm Hg; HCO3- = 20 mEq/L; SaO2 = 94%

B. pH = 7.27; PaO2 = 73 mm Hg; PaCO2 = 50 mm Hg; HCO3- = 25 mEq/L; SaO2 = 85% This ABG depicts respiratory acidosis (low pH; high PaCO₂) and is concerning because the patient is hypoxic (PaO₂ 73; SaO2 85% ). This patient requires immediate intervention because of hypoxia.

The nurse is caring for a client diagnosed with attention deficit hyperactivity disorder (ADHD). The nurse should anticipate a prescription for which of the following? A. Citalopram B. Risperidone C. Methylphenidate D. Carbamazepine

C. Methylphenidate ADHD may be treated by psychostimulants such as amphetamines or methylphenidate. These medications work by projecting the dopamine and norepinephrine in the front of the brain to ameliorate the symptoms of inattention, impulsivity, and hyperactivity.

The nurse reviews prescriptions for packed red blood cell (PRBC) transfusions. Which PRBC transfusion should the nurse question with the primary healthcare provider (PHCP)? A. with a febrile illness. B. with pulmonary edema. C. receiving mechanical ventilation. D. with a chest tube for a hemothorax

B. with pulmonary edema. A unit of PRBCs will add fluid volume, and if the client has pulmonary edema, the unit of blood should be questioned with the PHCP until the edema has resolved. Giving a unit of PRBCs may worsen pulmonary edema. Clients at risk for transfusion-associated circulatory overload (TACO) will need to receive their unit of PRBCs slower and may require diuretics after the blood has been administered.

The nurse is caring for a client who has just been diagnosed with peritonitis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe? A. Pantoprazole B.Ciprofloxacin C. Lactulose D. Loperamide .

B.Ciprofloxacin Peritonitis is an intra-abdominal severe infection that has a significant mortality rate. Peritonitis may originate from perforation (appendix, intestine, etc.), which causes a significant amount of fluid and bacteria to shift into the peritoneum. The priority treatment in peritonitis is administering prescribed antibiotics such as ciprofloxacin, metronidazole, or ceftriaxone.

The practical nurse assists the registered nurse conduct a prenatal class. Which of the following statements regarding antepartum testing should be included? A. "Chorionic Villous Sampling (CVS) may detect neural tube defects." B. "Maternal serum alpha-fetal protein (MSAFP) may determine gender." C. "Amniocentesis may be used to assess for chromosomal abnormalities." D."A biophysical profile (BPP) assesses six variables such as fetal glucose."

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

The practical nurse assists the registered nurse conduct a prenatal class. Which of the following statements regarding antepartum testing should be included? A. "Chorionic Villous Sampling (CVS) may detect neural tube defects." B. "Maternal serum alpha-fetal protein (MSAFP) may determine gender." C. "Amniocentesis may be used to assess for chromosomal abnormalities." D. "A biophysical profile (BPP) assesses six variables such as fetal glucose."

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

The licensed practical/vocational nurse (LPN/VN) reinforces teaching to a client prescribed tamsulosin. Which of the following statements should the nurse include? A. "This medication may turn your urine reddish/orange." B. "You will urinate more often with this medication." C. "Change positions slowly while you take this medication." D. "Avoid calcium-containing foods while on this medication."

C. "Change positions slowly while you take this medication." Tamsulosin is an alpha-1 antagonist medication indicated in the treatment of benign prostatic hypertrophy. This medication causes vasodilation, and orthostatic hypotension is the most significant side effect. The nurse should educate the client to change positions slowly while taking this medication to reduce the risk of orthostasis.

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

C. "He has lost his short-term memory but can still remember events from long ago." Family members can become frustrated when clients with Alzheimer's disease lose short-term memory. The nurse should explain to the family member that it is the "short-term memory" that is declining and encourage the client to talk about things that he/she can remember.

The nurse is caring for a client who is receiving prescribed acamprosate. Which of the following statements, if made by the client, would indicate a therapeutic response? A. "I no longer hear voices." B. "I have more motivation during the day." C. "I am not drinking alcohol anymore." D. "My anxiety has lessened in public."

C. "I am not drinking alcohol anymore." Acamprosate is a medication intended to treat alcohol use disorder. This medication may be combined with naltrexone to increase the chance of sobriety.

The nurse reinforces discharge teaching to the parents of a 17-year-old male diagnosed with a moderate concussion. Which of the following statements by the parents would indicate effective understanding? A. "I should wake my child up every two hours to check how he is feeling." B. "I should put extra padding underneath his football helmet for tomorrow's practice." C. "I will drive him to school until his follow-up appointment." D. "He should stay active during the day and not take any naps."

C. "I will drive him to school until his follow-up appointment." Strenuous activity, sports, and intense cognitive tasks should be delayed until the client has approval from the physician. Concussions vary in severity, but what they all have in common is that rest is necessary for the first two to three days. This includes taking it easy with restful sleep and taking naps as necessary. Intense physical and cognitive activities (contact sports, taking an exam, driving, excessive screen time) should be avoided for two to three days or until the physician has provided medical clearance.

The nurse is teaching a client about peptic ulcer disease. Which of the following statements should the nurse include? A. "You should take aspirin if you have mild aches or pains." B. "You will need to consume liquids one hour after each meal." C. "It will be important to reduce the stress in your life." D. "Take your prescribed omeprazole with food."

C. "It will be important to reduce the stress in your life." A client with peptic ulcer disease will need to reduce the amount of stress in their life to mitigate some of the symptoms. Ulcers can be caused by excessive use of non-steroidal anti-inflammatory drugs, alcoholism, and stress.

The LPN is caring for a family who just found out that their newborn has tetralogy of Fallot. They state, "we can't believe our baby is going to die!" Which of the following statements by the LPN is most appropriate? A. "Yes, that is so sad. What can I do to help you?" B. "Your baby will be fine! This is not so serious." C. "Tetralogy of Fallot can be surgically repaired. Let's talk more about what you can expect." D. "Well, at least you get to spend time with your baby now. Some people don't even get that."

C. "Tetralogy of Fallot can be surgically repaired. Let's talk more about what you can expect." This statement does not support that the baby will die, but provides factual information about the treatment plan for the defect and leads into a more detailed conversation about what the parents can expect. It is clear that they do not fully understand tetralogy of Fallot (TOF) and the treatment options, so education is very important for these parents.

The LPN is caring for a family who just found out that their newborn has tetralogy of Fallot. They state, "we can't believe our baby is going to die!" Which of the following statements by the LPN is most appropriate? A. "Yes, that is so sad. What can I do to help you?" B. "Your baby will be fine! This is not so serious." C. "Tetralogy of Fallot can be surgically repaired. Let's talk more about what you can expect." D. "Well, at least you get to spend time with your baby now. Some people don't even get that."

C. "Tetralogy of Fallot can be surgically repaired. Let's talk more about what you can expect." This statement does not support that the baby will die, but provides factual information about the treatment plan for the defect and leads into a more detailed conversation about what the parents can expect. It is clear that they do not fully understand tetralogy of Fallot (TOF) and the treatment options, so education is very important for these parents.

Which of the following statements should the nurse use to best describe a very low-calorie diet? A. "This is a long-term treatment measure that assists obese people [30%] who can't lose weight." B. "A VLCD contains very little protein." C. "This diet can be used only when there is close medical supervision." D. "This diet consists of solid food that is pureed to facilitate digestion and absorption."

C. "This diet can be used only when there is close medical supervision." Very Low-Calorie Diets (VLCD) are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality proteins, and has a minimum of carbohydrates to spare protein and prevent ketosis. Very low-calorie diets, generally providing fewer than 800 kcal per day, became widely available for outpatient use in treating adult obesity in the 1980s. These diets, sometimes called protein-sparing modified fasts, were associated with significant medical risks (electrolyte abnormalities, arrhythmias, and sudden death). They became widely marketed as part of many commercial weight loss programs. Despite their overall success in supporting rapid weight loss, most patients experienced subsequent weight regain once the very low-calorie diet was discontinued. These extremely hypocaloric diets have been used on a limited basis in the pediatric population, generally in an inpatient setting, with close medical supervision. Given the deficient daily caloric intake associated with the VLCD, this diet requires almost a full liquid approach. Patients are often on 3-5 shakes daily, with multivitamin and mineral supplementation. Side effects include fatigue, hair loss, dizziness, constipation, and risk for cholelithiasis secondary to rapid weight loss. The VLCD usually results in >20% weight loss within the first 3-4 months. Although rapid weight loss is seen, it is not regularly well maintained, with many patients gaining up to 50% of that weight back within the subsequent 12 months; and gaining all of it back in less than five years. LCDs are not as extreme, and with almost twice as many calories allowed (1200-1500 kcal/day), the weight loss is modest.

Which of the following statements should the nurse use to best describe a very low-calorie diet? A. "This is a long-term treatment measure that assists obese people who can't lose weight." B. "A VLCD contains very little protein." C. "This diet can be used only when there is close medical supervision." D. "This diet consists of solid food that is pureed to facilitate digestion and absorption."

C. "This diet can be used only when there is close medical supervision." Very Low-Calorie Diets (VLCD) are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality proteins, and has a minimum of carbohydrates to spare protein and prevent ketosis. Very low-calorie diets, generally providing fewer than 800 kcal per day, became widely available for outpatient use in treating adult obesity in the 1980s. These diets, sometimes called protein-sparing modified fasts, were associated with significant medical risks (electrolyte abnormalities, arrhythmias, and sudden death). They became widely marketed as part of many commercial weight loss programs. Despite their overall success in supporting rapid weight loss, most patients experienced subsequent weight regain once the very low-calorie diet was discontinued. These extremely hypocaloric diets have been used on a limited basis in the pediatric population, generally in an inpatient setting, with close medical supervision. Given the deficient daily caloric intake associated with the VLCD, this diet requires almost a full liquid approach. Patients are often on 3-5 shakes daily, with multivitamin and mineral supplementation. Side effects include fatigue, hair loss, dizziness, constipation, and risk for cholelithiasis secondary to rapid weight loss. The VLCD usually results in >20% weight loss within the first 3-4 months. Although rapid weight loss is seen, it is not regularly well maintained, with many patients gaining up to 50% of that weight back within the subsequent 12 months; and gaining all of it back in less than five years. LCDs are not as extreme, and with almost twice as many calories allowed (1200-1500 kcal/day), the weight loss is modest.

The licensed practical/vocational (LPN/VN) assists a registered nurse (RN) in planning a community health course about preventing Lyme disease. Which of the following information should be included? A. "You should try limiting your outdoor activities between 10 a.m. and 4 p.m." B. "Wear sunglasses that wrap around and block UVA and UVB rays." C. "Wear long-sleeved clothing when in heavily wooded areas." D. "Apply sunscreen with at least an SPF of 30."

C. "Wear long-sleeved clothing when in heavily wooded areas." Lyme disease is spread by a deer tick commonly found in heavily wooded areas. Wearing long-sleeved clothing, applying tick repellent. and showering after hikes in the woods is an effective strategy in preventing being bitten by a tick and further infected with the bacteria.

An LPN is working in a group home for adolescents who are recovering from substance abuse. She is assigned to work with a 16-year-old girl who is trying to quit smoking marijuana. While talking with the girl, she uses motivational interviewing to help her work towards her goals. Which of the following statements by the LPN would be best? A. "Would it be alright if we talk about your pot use now?" B. "What good things do you have going for you in your life?" C. "What changes can you make in your marijuana use this week?" D. "Who can help you quit marijuana?"

C. "What changes can you make in your marijuana use this week?" This is a direct, open-ended question that addresses the patient's substance abuse. Motivational interviewing maintains direct communication with an open-ended question. By using motivational interviewing, the patient should be empowered and encouraged to make positive changes. The nurse will help the patient see the need to change, but the patient is actually making their own decision to change.

A patient is scheduled for an IV pyelogram. He asks the nurse what he needs to do to prepare for the test. Which of the following is the correct response? A. "You need to have a full bladder for the test to be successful." B. "You need to alert the technician if you feel any burning after the dye is injected." C. "You will receive a bowel preparation before the test can be performed." D. "You must lie on your back for four hours after the test is performed."

C. "You will receive a bowel preparation before the test can be performed." Bowel prep is necessary to make sure the x-rays are clear and that urinary structures are not obstructed by bowel contents. An IV pyelogram is an x-ray that is used to view the urinary structures.

What is the normal level of creatinine in a healthy adult male? A. 0.4 to 0.8 mg/dL B. 0.1-0.4 mg/dL C. 0.6-1.2 mg/dL D. 1.5-2.0 mg/dL

C. 0.6-1.2 mg/dL The normal creatinine range is 0.6 to 1.2 mg/dL in a healthy adult male. Creatinine values reflect both the amount of muscle a person has and their amount of kidney function. Hence, the levels are slightly lower in women due lesser muscle mass. Most men with normal kidney function have 0.6 to 1.2 milligrams/deciliters (mg/dL) of creatinine. Most women with normal kidney function have between 0.5 to 1.1 mg/dL of creatinine.

What is the normal level of creatinine in a healthy adult male? A. 0.4 to 0.8 mg/dL B. 0.1-0.4 mg/dL C. 0.6-1.2 mg/dL D. 1.5-2.0 mg/dL

C. 0.6-1.2 mg/dL The normal creatinine range is 0.6 to 1.2 mg/dL in a healthy adult male. Creatinine values reflect both the amount of muscle a person has and their amount of kidney function. Hence, the levels are slightly lower in women due to lesser muscle mass. Most men with normal kidney function have 0.6 to 1.2 milligrams/deciliters (mg/dL) of creatinine. Most women with normal kidney function have between 0.5 to 1.1 mg/dL of creatinine.

When doing presurgical assessments of patients in an ambulatory care center, which scenario would be deemed necessary by the nurse to report to the surgeon as soon as possible, which may require surgery to be postponed? A. A 20-year-old patient who is a vegan. B. An elderly client who intakes daily nutritional drinks. C. A 40-year-old patient who takes ginkgo biloba and aspirin daily. D. An infant who is breastfeeding.

C. A 40-year-old patient who takes ginkgo biloba and aspirin daily. Ginkgo biloba (herbal), aspirin, and vitamin E all have anticoagulant properties. It is vital to notify the surgeon about these medications to decrease the patient's risk of excessive bleeding.

Among the patients in a long term care facility, which client is at the greatest risk for developing a decubitus ulcer? A. An incontinent client who had 3 diarrhea stools. B. An 80-year-old ambulatory diabetic client. C. A 79-year-old malnourished client on bed rest. D. An obese client who uses a wheelchair.

C. A 79-year-old malnourished client on bed rest. Prolonged inadequate nutrition causes weight loss, muscle atrophy, and the loss of subcutaneous tissue. These three conditions reduce the amount of padding between the skin and bones, thus increasing the risk of pressure ulcer development. More specifically, inadequate protein intake, carbohydrates, fluids, zinc, and vitamin C contribute to pressure ulcer formation. Several factors contribute to the formation of pressure ulcers: friction and shearing, immobility, inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age, and the presence of certain chronic conditions.

Among the patients in a long term care facility, which client is at the greatest risk for developing a decubitus ulcer? A. An incontinent client who had 3 diarrhea stools. B. An 80-year-old ambulatory diabetic client. C. A 79-year-old malnourished client on bed rest. D. An obese client who uses a wheelchair.

C. A 79-year-old malnourished client on bed rest. Prolonged inadequate nutrition causes weight loss, muscle atrophy, and the loss of subcutaneous tissue. These three conditions reduce the amount of padding between the skin and bones, thus increasing the risk of pressure ulcer development. More specifically, inadequate protein intake, carbohydrates, fluids, zinc, and vitamin C contribute to pressure ulcer formation. Several factors contribute to the formation of pressure ulcers: friction and shearing, immobility, inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age, and the presence of certain chronic conditions.

While working in the emergency department, the nurse sees the following clients, and recognizes which of them is at highest risk for elder abuse? A. A 70-year-old female with orthostatic hypotension B. An 86-year-old female with glaucoma C. A 92-year-old male with late-stage Alzheimer's disease D. A 75-year-old male with leukemia

C. A 92-year-old male with late-stage Alzheimer's disease A 92-year-old male with late-stage Alzheimer's disease is at very high risk for elder abuse. This can include both physical and psychological abuse. Elders with late-stage Alzheimer's disease are at very high risk because of the memory loss and confusion that occurs with this disease.

Which of these patients should the LPN/LVN see first? A. A patient with a newly placed NG tube who is complaining of pain around the face and a plugged nose. B. A post-op prostatectomy patient complains of bladder spasms and blood in his foley bag. C. A patient in an arm cast that is 2 days post-op and reports feelings of numbness and tingling in her affected arm. D. A patient newly diagnosed with hepatitis A reports stomach pain and itchy skin.

C. A patient in an arm cast that is 2 days post-op and reports feelings of numbness and tingling in her affected arm. Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a doctor right away. Learning to prioritize the care of patients is an essential nursing skill. When daily patient assignments are given, the nurse should consider the report provided by the previous shift, any immediate complaints/requests by the patient, as well as any existing orders and determine the order in which assessments will be done. Using "problem urgency" will help determine which patient should be seen first. According to problem urgency criteria, the patient complaints/problems would be ranked based on the degree of threat they pose to the patient's life or how immediate the need for care is. High priority problems are considered entity- threatening or could have destructive long-term effects on the patient; i.e. ineffective airway clearance or substance abuse. Medium priority problems do not pose a direct threat to life, but that may cause destructive physical or emotional changes; i.e. ineffective denial, unilateral neglect. Low priority problems require minimal supportive nursing intervention; i.e. mild anxiety, interrupted breastfeeding.

Which of these patients should the LPN/LVN see first? A. A patient with a newly placed NG tube who is complaining of pain around the face and a plugged nose. B. A post-op prostatectomy patient complains of bladder spasms and blood in his foley bag. C. A patient in an arm cast that is 2 days post-op and reports feelings of numbness and tingling in her affected arm. D. A patient newly diagnosed with hepatitis A reports stomach pain and itchy skin.

C. A patient in an arm cast that is 2 days post-op and reports feelings of numbness and tingling in her affected arm. Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a doctor right away. Learning to prioritize the care of patients is an essential nursing skill. When daily patient assignments are given, the nurse should consider the report provided by the previous shift, any immediate complaints/requests by the patient, as well as any existing orders and determine the order in which assessments will be done. Using "problem urgency" will help determine which patient should be seen first. According to problem urgency criteria, the patient complaints/problems would be ranked based on the degree of threat they pose to the patient's life or how immediate the need for care is. High priority problems are considered entity- threatening or could have destructive long-term effects on the patient; i.e. ineffective airway clearance or substance abuse. Medium priority problems do not pose a direct threat to life, but that may cause destructive physical or emotional changes; i.e. ineffective denial, unilateral neglect. Low priority problems require minimal supportive nursing intervention; i.e. mild anxiety, interrupted breastfeeding.

What consideration should the nurse keep in mind regarding the use of side rails for a confused patient?

C. A person of small stature is at increased risk for injury from entrapment. Studies of restraint-related deaths have shown that people of small stature are more likely to slip through or between the side rails.

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

C. A pregnant woman with a blister-like rash on the face that is possibly having varicella. The triage nurse's primary responsibility is to perform an initial nursing assessment and determine which patients require immediate care or isolation. The triage nurse should be able to identify patients who pose a potential risk to others by being familiar with commonly occurring illnesses/infections. Chickenpox (Varicella) is transmitted airborne, and that can be easily transferred to the other clients in the emergency unit. The pregnant woman with the rash should be isolated right away from other clients through placement in a negative-pressure room.

Which of the following healthcare team members is paired with the primary function related to their role? A. An occupational therapist assisting with gait exercises. B. A physical therapist offering the provision of assistive devices to be used with activities of daily living. C. A speech or language therapist addressing swallow disorders. D. An RN case manager ordering therapies and medications.

C. A speech or language therapist addressing swallow disorders. Speech/language therapists assess and treat patients with swallowing disorders, and with communication and speech problems that occur following a stroke. Understanding the role of each member of the healthcare team is essential. It helps foster accountability within the organization and also helps to ensure that each person acts within his/her role.

When caring for a client on total parenteral nutrition (TPN), what is the nurse's most important action? A. Record the number of stools per day. B. Maintain strict intake and output records. C. A sterile technique for dressing change at the IV site. D. Monitor for cardiac arrhythmias.

C. A sterile technique for dressing change at the IV site. Clients receiving TPN are very susceptible to infection. The concentrated glucose solutions are an excellent medium for bacterial growth. Strict sterile technique is crucial in preventing disease at the IV infusion site.

The nurse is assessing a patient diagnosed with stage IV nephroblastoma. Which of the following actions is contraindicated in this patient? A. Checking capillary refill B. Auscultating heart sounds C. Abdominal palpation D. Assessing urine color

C. Abdominal palpation Abdominal palpation is contraindicated in the patient with a nephroblastoma. This is because the tumor is located in their abdominal cavity, and by palpating it, you can disturb the tissue and cause cells from the tumor to break loose and spread to other parts of the body. The nurse should not perform abdominal palpation on a patient with a nephroblastoma.

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

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

The nurse prepares a client for a computed tomography (CT) scan of their abdomen and pelvis with intravenous (IV) contrast. The nurse should take which action prior to the client's exam? A. Remove any medicated patches before the exam B. Instruct the client to empty their bladder right before the test C. Advise the client that they may experience a flushing sensation during the exam D. Assess the client for an implantable pacemaker

C. Advise the client that they may experience a flushing sensation during the exam Flushing of the face is a response to the intravenous administration of contrast dye commonly seen in clients. Often, clients experience a warm sensation throughout the body once the intravenous contrast dye begins infusing. Usually, if the client does experience this warm sensation, clients will typically report the sensation occurring initially in the face and neck region. Shortly after, clients will often state they feel the warmth in their pelvic area.

The nurse prepares a client for a computed tomography (CT) scan of their abdomen and pelvis with intravenous (IV) contrast. The nurse should take which action prior to the client's exam? A. Remove any medicated patches before the exam B. Instruct the client to empty their bladder right before the test C. Advise the client that they may experience a flushing sensation during the exam D. Assess the client for an implantable pacemaker

C. Advise the client that they may experience a flushing sensation during the exam Flushing of the face is a response to the intravenous administration of contrast dye commonly seen in clients. Often, clients experience a warm sensation throughout the body once the intravenous contrast dye begins infusing. Usually, if the client does experience this warm sensation, clients will typically report the sensation occurring initially in the face and neck region. Shortly after, clients will often state they feel the warmth in their pelvic area.

The nurse is assisting in the placement of an indwelling foley catheter in a male patient. She knows to inflate the balloon on the catheter at which of the following points in the procedure? A. Upon meeting resistance B. As soon as urine is observed in the tubing C. After advancing to the point of bifurcation D. After fully advancing the length of the catheter

C. After advancing to the point of bifurcation The nurse should inflate the balloon on the catheter once she reaches the point of bifurcation. This is achieved by slowly advancing the catheter, observing the tubing for urine to appear, and then continuing to advance to the point of bifurcation after urine is observed. This will ensure the balloon is in the bladder before the nurse inflates it.

The nurse is assisting in the placement of an indwelling foley catheter in a male patient. She knows to inflate the balloon on the catheter at which of the following points in the procedure? A. Upon meeting resistance B. As soon as urine is observed in the tubing C. After advancing to the point of bifurcation D. After fully advancing the length of the catheter

C. After advancing to the point of bifurcation The nurse should inflate the balloon on the catheter once she reaches the point of bifurcation. This is achieved by slowly advancing the catheter, observing the tubing for urine to appear, and then continuing to advance to the point of bifurcation after urine is observed. This will ensure the balloon is in the bladder before the nurse inflates it.

The nurse is caring for a client with the following clinical data. Which medication would the nurse clarify with the primary healthcare provider (PHCP) before administration based on the vital signs? -Medication Administration Record (MAR) Metoprolol 50 mg PO Daily Lisinopril 40 mg PO Daily Albuterol 2.5 mg via nebulizer Daily Diltiazem XR 120 mg PO Daily -Vital Signs (VS) Pulse (P) Respirations (R) Blood pressure (BP) Temperature (T) Oxygen saturation A. Metoprolol 50 mg PO Daily B. Lisinopril 40 mg PO Daily C. Albuterol 2.5 mg via nebulizer Daily D. Diltiazem XR 120 mg PO Daily

C. Albuterol 2.5 mg via nebulizer Daily The vital signs (VS) are all within normal limits except the pulse, which is 123 bpm, and the blood pressure is slightly elevated. This should cause the nurse to clarify the prescription of albuterol with the PHCP as this medication increases heart rate. This would foreseeably worsen the tachycardia that the client is already experiencing.

Which of the following healthcare providers are responsible for documenting care provided to a patient? A. The LPNs should document the care they provided and the care given by unlicensed assistive staff. B. The registered nurse must document all of the care that is provided by the nursing assistants because they are accountable for all care. C. All staff members should document all of the care that they have provided. D. All staff should document all of the care that they have provided, but the registered nurse is the only independent practitioner that signs it.

C. All staff members should document all of the care that they have provided. All staff members, including unlicensed assistive staff like nursing assistants, document and sign all of the care that they have personally provided. For example, the nursing assistants will document the vital signs that they have taken, the licensed practical nurses will document all of the treatments and medications that they have given to the patient, and the registered nurse will document nursing diagnoses and assessments that they have completed. There is an old saying among healthcare professionals that have been passed on to new generations. The saying is, "I don't care what you did; if you didn't document it, you didn't do it." Documentation is an essential part of patient care. A patient's complete medical record is a legal document. Proper documentation means 1. The person who provided care should document what care/treatment/medication was given and how the patient responded. 2. If responsibility is delegated to another person, it should be noted to whom the care was assigned, and proper documentation and follow-up should be done.

The nurse is re-assessing a client who with irritable bowel syndrome (IBS). Which of the following findings is consistent with this diagnosis? A.Unexplained weight loss B. Epigastric pain and nausea. C. Alternating constipation and diarrhea D. Low-grade fever and fatigue

C. Alternating constipation and diarrhea Alternating constipation and diarrhea are the hallmark manifestations associated with irritable bowel syndrome (IBS).

What is the leading cause of cognitive impairment in old age? A. Stroke B. Malnutrition C. Alzheimer's disease D. Loss of cardiac reserve

C. Alzheimer's disease Alzheimer's disease is the most common degenerative neurological illness and the most common cause of cognitive impairment. It is irreversible, progressing from deficits in memory and thinking skills to an inability to perform even the simplest of tasks.

What is the leading cause of cognitive impairment in old age? A. Stroke B. Malnutrition C. Alzheimer's disease D. Loss of cardiac reserve

C. Alzheimer's disease Alzheimer's disease is the most common degenerative neurological illness and the most common cause of cognitive impairment. It is irreversible, progressing from deficits in memory and thinking skills to an inability to perform even the simplest of tasks.

The nurse is caring for a patient with suspected meningitis. Which action would the nurse recognize as the highest priority immediately following a lumbar puncture procedure? A. Test for gag reflex return B. Elevate the head of the bed to 30 degrees C. Encourage oral fluid intake D. Assess the patient for Brudzinski sign

C. Encourage oral fluid intake A lumbar puncture (or spinal tap) procedure is used to obtain cerebrospinal fluid (CSF) to diagnose meningitis and identify the cause. The nurse would encourage oral fluid intake following this procedure to replace CSF volume and reduce the risk of spinal headaches.

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

C. Anticholinergics Anticholinergic medications can increase the IOP and worsen patients' condition with glaucoma. Anticholinergic agents also can produce central side effects, such as confusion, unsteady gait, or drowsiness in adults. Children may become restless or spastic. Glaucoma is one of the leading causes of blindness in the United States. In some cases, it is genetic. In others, it may occur due to eye injury or disease. Some medications may contribute to glaucoma development, such as long- term use of topical glucocorticoids, some antihypertensives, antihistamines, and antidepressants. The primary risk factor associated with glaucoma includes high blood pressure.

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

C. Anticholinergics Anticholinergic medications can increase the IOP and worsen patients' condition with glaucoma. Anticholinergic agents also can produce central side effects, such as confusion, unsteady gait, or drowsiness in adults. Children may become restless or spastic. Glaucoma is one of the leading causes of blindness in the United States. In some cases, it is genetic. In others, it may occur due to eye injury or disease. Some medications may contribute to glaucoma development, such as long- term use of topical glucocorticoids, some antihypertensives, antihistamines, and antidepressants. The primary risk factor associated with glaucoma includes high blood pressure.

Chronic pain is most effectively relieved when analgesics are administered in what manner? A. On a PRN basis B. Conservatively C. Around the clock. D. Intramuscularly

C. Around the clock. Around-the-clock doses of analgesics are more useful for managing chronic pain.

A primigravida patient begins labor and is visibly upset that her family is unavailable. Which is the most appropriate approach for the nurse to take to help meet the client's needs at this time? A. Assure her that the nursing triage team will stay with her at all times. B. Encourage the client regarding her own abilities to cope and maintain a sense of control. C. Ask the client if there is someone else who wants to be her support person. D. Tell the client she will try to locate her family. .

C. Ask the client if there is someone else who wants to be her support person. Allow the client to select another individual to give support. This allows her to have someone with her until her family can be with her. Women and families have different expectations during childbearing. These expectations are shaped by their experiences, knowledge, belief systems, social, and family backgrounds. In most cases, a childbirth companion (or social support during birth) has improved the whole birth experience. Research shows that women who receive excellent social support during labor and childbirth tend, on average to have shorter labor, control their pain better, and often have less need for medical intervention. With these things in mind, the nurse should put forth an effort to help find a support person for the laboring mother. Keep in mind, while nursing staff and non-medical staff can offer support, this is a very emotional time for the mother. Asking the mother's preference regarding an alternate support person will give her the ability to feel like she still has some control over the situation and may prevent worsening stress.

The school nurse is performing the corneal light reflex test on a child she suspects has strabismus. Which of the following does she know is a sign of this condition? A. Symmetrical pin-point light on each pupil B. Red reflex in both eyes C. Asymmetrical pin-point lights on the pupils D. Sun setting sign

C. Asymmetrical pin-point lights on the pupils Asymmetrical pin-point lights on the pupils are a sign of strabismus. If the nurse suspects that the child has strabismus and conducts a corneal light reflex test, this may confirm her suspicions. This child should have a full eye exam performed to confirm the diagnosis and receive proper treatment.

During a physical assessment, the nurse inspects the patient's abdomen. What assessment technique would the nurse perform next? A. Percussion B. Palpation C. Auscultation D. Whichever is most comfortable for the patient

C. Auscultation Auscultation. When performing a physical assessment, the most often used sequence is: 1. Inspection 2. Palpation 3. Percussion 4. Auscultation However, palpation and percussion can alter bowel sounds. Therefore, for abdominal assessments, the steps should be: 1. Inspection 2. Auscultation 3. Percussion 4. Palpation

During a physical assessment, the nurse inspects the client's abdomen. What assessment technique would the nurse perform next? A. Percussion B. Palpation C. Auscultation D. Whichever is most comfortable for the patient

C. Auscultation Palpation and percussion can alter bowel sounds. Therefore, for abdominal assessments, the steps should be: 1. Inspection 2. Auscultation 3. Percussion 4. Palpation

Which of the following parenting styles is highly controlling, expecting always to be obeyed, and inflexible with the rules? A. Authentic B. Permissive C. Authoritarian D. Indifferent

C. Authoritarian The parenting style described is authoritarian. This parent is often described as the rigid disciplinarian. They are highly controlling, expect to always be obeyed, and are inflexible with the rules. Though these parents may have their child's best interests at heart, they do not support their growing autonomy. Instead, they expect to be obeyed without reason.

A 25-year-old is found unconscious with fever and a noticeable rash. Which of the following tests will most likely be a priority order? A. Blood sugar check B. CT scan C. Blood cultures D. Arterial blood gases

C. Blood cultures Blood cultures would be ordered to investigate the source of fever and rash.

The nurse is working in the normal newborn nursery. Which of the following signs would make the nurse suspect cystic fibrosis and notify the healthcare provider for further testing? A. Steatorrhea B. Hyperhidrosis C. Meconium ileus D. Barrel chest

C. Meconium ileus Meconium ileus is very frequently the first sign of cystic fibrosis in a newborn. It is a bowel obstruction that occurs when the infant's first stool is thicker and stickier than usual, causing a blockage in the ileum.

The LPN is reinforcing teaching to a client who is taking phenytoin. To make sure phenytoin does not fail, which over the counter (OTC) medication should the nurse advise the patient not to take at the same time? A. Acetaminophen B. Ibuprofen C. Calcium carbonate D. Ranitidine Choice A is incorrect. Choice D is incorrect. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies

C. Calcium carbonate Calcium carbonate (Tums) should not be taken simultaneously as phenytoin because taking them together can decrease the effects of phenytoin. Antacids containing calcium carbonate reduce the bioavailability of phenytoin by reducing both the rate of absorption and the amount of intake. Phenytoin is an anticonvulsant, therefore not getting a therapeutic dose may result in the client having a recurrent seizure. Clients should be cautioned against the concomitant use of antacids containing calcium carbonate and phenytoin. If the client needs calcium carbonate, he should be instructed to separate the intake of calcium carbonate and phenytoin by at least two to three hours.

The LPN is reinforcing teaching to a client who is taking phenytoin. To make sure phenytoin does not fail, which over the counter (OTC) medication should the nurse advise the patient not to take at the same time? A. Acetaminophen B. Ibuprofen C. Calcium carbonate D. Ranitidine

C. Calcium carbonate Calcium carbonate (Tums) should not be taken simultaneously as phenytoin because taking them together can decrease the effects of phenytoin. Antacids containing calcium carbonate reduce the bioavailability of phenytoin by reducing both the rate of absorption and the amount of intake. Phenytoin is an anticonvulsant, therefore not getting a therapeutic dose may result in the client having a recurrent seizure. Clients should be cautioned against the concomitant use of antacids containing calcium carbonate and phenytoin. If the client needs calcium carbonate, he should be instructed to separate the intake of calcium carbonate and phenytoin by at least two to three hours.

The nurse reviews clinical data for a client 24 hours postpartum following a vaginal delivery. Which of the following findings would require follow-up by the nurse? A. White blood cell count 14,000 mm3 B. BUN 18 mg/dL C. Capillary blood glucose 258 mg/dL D. Urinary output 60 mL/hr

C. Capillary blood glucose 258 mg/dL This blood glucose is greater than 250 mg/dL and is clinical hyperglycemia. Regardless if the client has a history of diabetes mellitus, this CBG requires follow-up because it is the only abnormal clinical data.

The nurse is anticipating a client arriving at the emergency department (ED) exposed to inhalation anthrax. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which medication? A. Acyclovir B. Zidovudine C. Ciprofloxacin D. Oseltamivir

C. Ciprofloxacin Anthrax is a bacterial infection treated with antibiotics such as penicillin, doxycycline, and ciprofloxacin. Inhaled anthrax is most effectively treated with a combination of ciprofloxacin and another antibiotic (i.e. penicillin, clindamycin, chloramphenicol). Antibiotics are usually given for 60 days because it takes that long for spores to germinate. Acyclovir is an antiviral used to treat herpes. Antiviral medications do not affect anthrax, which is a bacterial infection. Zidovudine is an anti-retroviral medication that is used for the treatment of HIV. Antiviral drugs do not affect anthrax, which is a bacterial infection. Oseltamivir is an antiviral drug used to treat influenza. Antiviral medications do not affect anthrax, which is a bacterial infection. i Additional Info ✓ Anthrax is a bioterrorism agent and must be taken seriously because it has a high mortality rate. ✓ Anthrax may be cutaneous or inhaled and is caused by exposure to the gram-positive bacterium. ✓ Standard precautions are used for a client with inhalation anthrax. ✓ Nursing care is aimed at stabilizing the client's breathing and promptly initiating treatment: antibiotics (levofloxacin) and/or antitoxins such as raxibacumab.

The nurse administered prescribed six units of regular insulin. Which data collection finding requires follow-up? A. Rapid, labored breathing B. Increase appetite C. Cold sweats D. Increased urination

C. Cold sweats Regular insulin may be given subcutaneously and peaks within two to four hours after administration. The peak effects of the medication raise the client's risk for hypoglycemia. Cold sweats are a clinical feature of hypoglycemia.

You are taking care of a 5-year-old girl on a pediatrics floor at the hospital. While engaging her in conversation, you note that she uses 4-5 words in complete sentences. She can tell you what color her stuffed animals are, and she tells you stories about what the stuffed animals have done today. Knowing the appropriate language development milestones, the nurse should do which of the following? A. Consult the speech-language pathologist for evaluation. B. Notify the health care provider. C. Continue with the assessment. D. Engage the child's mother with questions about how the child communicates at home. .

C. Continue with the assessment. The nurse should continue with her assessment. The nurse has observed several milestones of language development that are normal for a 5-year- old. She should take note of this and continue to assess the child. Other language development milestones that she would expect include: a vocabulary of about 2,100 words, correctly naming objects and people, and knowing their own name and address.

Which focus is the nurse most likely to teach a client with a flaccid bladder? A. Habit training: Attempt voiding at specific time periods. B. Bladder training: Delay voiding according to a pre-scheduled timetable. C. Credé's maneuver: Apply gentle manual pressure to the lower abdomen. D. Kegel exercises: Contract the pelvic muscles.

C. Credé's maneuver: Apply gentle manual pressure to the lower abdomen. Since bladder muscles will not contract to increase intrabladder pressure and promote urination, the process is initiated manually. Overflow incontinence is "continuous involuntary leakage or dribbling of urine that occurs with incomplete bladder emptying." It can be seen in men with an enlarged prostate and clients with a neurologic disorder (e.g. Parkinson's disease, spinal cord injury). An impaired neurologic function can interfere with the standard mechanisms of urine elimination, resulting in a neurogenic bladder. A client with a neurogenic bladder does not perceive bladder fullness and is unable to control the urinary sphincters. The bladder may become flaccid and distended or spastic, with frequent involuntary urination.

The nurse is caring for a client diagnosed with attention deficit hyperactivity disorder (ADHD). The nurse should anticipate a prescription for which of the following? A. Citalopram B. Risperidone C. Methylphenidate D. Carbamazepine

C. Methylphenidate ADHD may be treated by psychostimulants such as amphetamines or methylphenidate. These medications work by projecting the dopamine and norepinephrine in the front of the brain to ameliorate the symptoms of inattention, impulsivity, and hyperactivity.

Which of the following infection control activities should be delegated to an experienced nursing assistant? A. Asking clients about the duration of antibiotic therapy. B. Demonstrating correct handwashing techniques to the client and family. C. Disinfecting blood pressure cuffs after clients are discharged. D. Screening clients for upper respiratory tract symptoms.

C. Disinfecting blood pressure cuffs after clients are discharged. Nursing assistants can follow agency protocol to disinfect items that come in contact with intact skin by cleaning with chemicals such as alcohol. Nurses must know their own scope of practice and the scope of practice of the UAP, which may vary depending on a facility's policies and procedures. Thus, the nurse must know the employer's policies and procedures for delegation, the UAP's job description, and the UAP's skill level. The NCSBN has provided "five rights of delegation" to help nurses make delegation decisions. It is important to remember that the nurse may delegate a task to a UAP; however, the responsibility for action or inaction on the nurse or UAP remains with the nurse.

Which of the following infection control activities should be delegated to an experienced nursing assistant? A. Asking clients about the duration of antibiotic therapy. B. Demonstrating correct handwashing techniques to clients and their families. C. Disinfecting blood pressure cuffs after clients are discharged. D. Screening clients for upper respiratory tract symptoms.

C. Disinfecting blood pressure cuffs after clients are discharged. Nursing assistants can follow agency protocol to disinfect items that come in contact with intact skin by cleaning with chemicals such as alcohol. In nursing, delegation refers to indirect care. The intended outcome is achieved through the work of someone supervised by the nurse. It involves defining the task, determining who can perform the job, describing the expectation, seeking agreement, monitoring performance, and providing feedback to the delegate regarding performance. While some nursing assistants may be proficient in tasks or be familiar with symptoms of diseases or disorders, clinical tasks such as assessments and education should always be assigned to a licensed nurse.

Which of the following would be an appropriate question for the LPN to ask when taking a patient's menstrual history? A. How many sexual partners have you had? B. Do you have a history of any type of cancer in your family? C. Do you ever skip periods? D. Do you use condoms during intercourse?

C. Do you ever skip periods? When obtaining a menstrual history, the nurse should ask for information only related to the menstrual function. This includes information about the last menstrual period (LMP, date of the first day of bleeding), cycle length, and frequency (e.g. 4/28, 4 days of bleeding every 28 days), the heaviness of bleeding (number of tampons used per day), history of intermenstrual bleeding, history of postcoital bleeding (PCB), age of menarche/menopause, and presence or absence of postmenopausal bleeding.

Which of the following would be an appropriate question for the LPN to ask when taking a patient's menstrual history? A. How many sexual partners have you had? B. Do you have a history of any type of cancer in your family? C. Do you ever skip periods? D. Do you use condoms during intercourse?

C. Do you ever skip periods? When obtaining a menstrual history, the nurse should ask for information only related to the menstrual function. This includes information about the last menstrual period (LMP, date of the first day of bleeding), cycle length, and frequency (e.g. 4/28, 4 days of bleeding every 28 days), the heaviness of bleeding (number of tampons used per day), history of intermenstrual bleeding, history of postcoital bleeding (PCB), age of menarche/menopause, and presence or absence of postmenopausal bleeding.

A diabetic patient receives ten units of Regular insulin and 20 units of NPH insulin each day after breakfast. After following the usual preparation steps for administering insulin, what should the nurse do next? A. Draw up NPH insulin first because it is clear. B. Either insulin can be drawn first as long as 30 units are given. C. Draw up Regular insulin first because it is clear. D. Administer each type of insulin separately for accuracy.

C. Draw up Regular insulin first because it is clear. Regular (short-acting) insulin is clear. NPH (intermediate-acting) is cloudy. Giving one injection is more efficient and comfortable for the patient. REMEMBER: ALWAYS CLEAR BEFORE CLOUDY or remember the mnemonic: RN = Regular to NPH. The correct procedure for administering short and long-acting insulins together is: 1. Verify orders for insulin types and doses. 2. Wash hands and put on gloves. 3. Roll NPH (cloudy vial) insulin between palms to mix contents of the bottle. Do NOT shake! 4. Clean the tops of vials with alcohol prep for 5-10 seconds. 5. Inject 20 units of air into the NPH vial and remove the syringe (air equal to the volume that will be withdrawn from the bottle). 6. Inject ten units of air into the Regular (clear vial) vial and withdraw ten units (air equal to the volume that will be withdrawn from the bottle). Remove the syringe. 7. Insert the syringe into NPH (cloudy vial) vial and withdraw 20 units. 8. Administer immediately. Within 5-10 minutes, combined insulins may be affected.

While assessing a laboring mother during a contraction. The LPN notes a decrease in fetal heart rate from 150 to 120 bpm. The heart rate slows for about 10 seconds and increases back to 150 bpm as the contraction ends. Which of the following correctly classifies this observation? A. Late deceleration B. Moderate variability C. Early deceleration D. Marked variability

C. Early deceleration Early decelerations occur when the fetal heart rate decreases at the same time as a contraction. In this question, the nurse noted a decrease from 150 to 120 bpm with the diminution, and then a return to baseline. This occurs due to the pressure of the head of the fetus on the pelvis or soft tissue, and no intervention is required by the nurse after an early deceleration.

The most effective way to perform hand hygiene is which of the following? A. Washing hands after gloves are removed and following any patient care. B. Using hand sanitizer and rubbing hands together for at least 30 seconds. C. Either wash hands for 30 seconds in warm, soapy water or use hand sanitizer if hands are not visibly soiled. D. Holding hands down after washing to prevent water from rolling down your arm while drying.

C. Either wash hands for 30 seconds in warm, soapy water or use hand sanitizer if hands are not visibly soiled. Both techniques are an evidence-based practice of hand hygiene and have proven to kill more germs than other methods.

Which of the following interventions helps reduce the effects of GERD? A. Lie down after eating. B. Wear a girdle. C. Elevate the head of the bed on 4-6 inch blocks. D. Increase fluid intake just before bedtime.

C. Elevate the head of the bed on 4-6 inch blocks. Patients should be encouraged to elevate the head of the bed to allow food to move out of the stomach before lying flat. GERD occurs when stomach acid slips into the esophagus. Any position that hinders or slows the movement of food from the stomach should be avoided.

Which of the following actions is most effective at reducing the incidence of health-care-associated infections? A. Screen all newly admitted clients for colonization or infection with MRSA B. Develop policies that automatically start antibiotic therapy for clients colonized by multi-drug resistant organisms. C. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital. D. Require nursing staff to don gowns to change wound dressings for all client

C. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital. Since healthcare workers' hands are the most common means of transmission of infection from one client to another, the most effective method of preventing disease spread is to make supplies for hand hygiene readily available for staff to use. Reducing the risk of healthcare-associated infections is the responsibility of every healthcare worker. Following standard precautions for all patients is the easiest and most effective way of preventing disease spread.

The nurse is collecting data on a client with acute cholecystitis. Which of the following manifestations would be expected? A. Stools that contain blood and mucus B. Pain with urination C. Episodic upper abdominal pain D. Hypoactive bowel sounds .

C. Episodic upper abdominal pain Episodic abdominal pain originating in the right upper quadrant or epigastric area is commonly associated with cholecystitis. The pain often refers to the client's right shoulder blade. The pain may be induced by a meal high in fat. Other manifestations associated with acute cholecystitis include nausea, vomiting, elevation in temperature, anorexia, and dyspepsia.

A patient is prescribed a calcium channel blocker to treat primary hypertension. When teaching the patient about the medication, which of these foods will the healthcare provider advise the patient to avoid? A. Eggs B. Milk C. Grapefruit D. Bananas

C. Grapefruit Grapefruit and its juice contain furanocoumarins, which block the enzymes involved in metabolizing many drugs, including calcium channel blockers. Grapefruit can interfere with other drugs too, including statins (atorvastatin, lovastatin, simvastatin), some antibiotics, and some cancer drugs. Medication blood levels can increase, resulting in toxicity. The calcium channel blockers' levels are increased when grapefruit or grapefruit juice is consumed, potentially causing hypotension.

The nurse is caring for a client who is newly prescribed cimetidine. The nurse understands that this medication is prescribed to treat which condition? A. Cystic fibrosis B. Clostridium difficile C. H. pylori D. Crohn's disease

C. H. pylori Cimetidine is a H2 receptor antagonist indicated in treating peptic ulcer disease, gastric esophageal reflux disease, or H. pylori infections. This older medication has widely been replaced with newer H2 receptor antagonists because this medication is known to cause significant drowsiness.

A client has a pressure ulcer with a shallow, partial skin thickness eroded area but no necrotic areas. The nurse would treat the area with which dressing? A. Alginate B. Dry gauze C. Hydrocolloid D. No dressing is indicated

C. Hydrocolloid Hydrocolloid dressings protect shallow ulcers and promote an appropriate healing environment. Several factors contribute to the formation of pressure ulcers: friction and shearing, immobility, inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age, and the presence of certain chronic conditions. The stage of breakdown will determine treatment. Nurses should review standing orders from their facility and any additional physician's orders for pressure ulcer care.

The nurse is caring for a client who is postoperative ordered incentive spirometry. The nurse understands that this device will help prevent which complication? A. Venous thromboembolism B. Obstructive sleep apnea C. Hypostatic pneumonia D. Aspiration pneumonia

C. Hypostatic pneumonia Hypostatic pneumonia after surgery is best prevented through incentive spirometry and early mobilization. The purpose of incentive spirometry (IS) is to promote deep breathing to prevent or treat atelectasis in the postoperative client. Hypostatic pneumonia is caused by pulmonary congestion in the dorsal region of the lungs. This type of pneumonia is common for those who are bedridden or have restricted mobility. Hypostatic pneumonia can be prevented through early postoperative ambulation and incentive spirometry.

Which is an intrinsic risk factor that increases the risk of patients developing pressure ulcers? A. Shearing B. Friction C. Impaired tissue perfusion D. Pressure

C. Impaired tissue perfusion Intrinsic refers to anything essential or belonging naturally. Impaired tissue perfusion is an internal risk factor. Other intrinsic risk factors associated with skin breakdown include: • Poor nutritional status • Incontinence . Alterations in fluid balance • Altered neurological status

While working in a pediatric cardiac unit, the LPN knows that which of the following interventions is a priority when caring for an infant diagnosed with transposition of the great arteries? A. Administer digoxin B. Chest x-ray C. Initiate alprostadil infusion D. Make the infant NPO

C. Initiate alprostadil infusion Initiation of alprostadil is the priority for an infant diagnosed with transposition of the great arteries. Alprostadil will keep the ductus arteriosus in the fetal circulation patent, allowing shunting of blood from left to right so that some oxygenated blood can exit the transposed aorta and be distributed to the body. Without alprostadil administration, the ductus arteriosus will begin to close, and if the infant does not have an ASD or VSD they will become profoundly hypoxic due to the lack of oxygenated blood in the systemic circulation.

The nurse is removing a nasogastric tube (NGT). The nurse should take which action? A. Deflate the balloon B. Irrigate the tube with 200 mL of water C. Instruct the client to take a deep breath and hold it. D. Assess the gag reflex

C. Instruct the client to take a deep breath and hold it. Prior to removing the NGT, it would be appropriate for the nurse to tell the client to take a deep breath and hold it as the tube is removed. The nurse should then pinch the tube and remove the tube quickly and steadily over 3-6 seconds while the client holds their breath or during exhalation.

The patient is using topical glucocorticoids. The nurse should assess for all the following systemic effects of the medication except: A. Mood changes B. Osteoporosis C. Liver toxicity D. Adrenal insufficiency

C. Liver toxicity Liver toxicity is not a systemic effect associated with the use of glucocorticoids. Topical glucocorticoids or corticosteroids are used in cases of dermatitis and eczema to treat symptoms of burning, itching, and inflammation. They may also be used in conjunction with other medical therapies for the treatment of psoriasis.

The LPN is working on the pediatric floor caring for a 2-year-old who receiving 100% FiO2 via a nasal cannula. At the end of her shift, the hospital receives a tornado warning. Which of the following actions should the nurse take to best protect her patient? A. Clock out, her shift is over and she is not responsible. B. Remove the nasal cannula and carry the child to a tornado shelter. C. Move the patient as close to the interior of the room as possible. D. Close all of the doors.

C. Move the patient as close to the interior of the room as possible. During a tornado warning, the appropriate nursing action is to move patients away from windows and as close to the interior of the room as they can safely be moved. This best protects them in the event of a tornado.

A client with streptococcal pharyngitis (tonsillitis) has been placed on droplet precautions. Which of the following statements indicates the best understanding of this type of isolation? A. The client can be placed in a room with another client with measles (rubeola). B. A special mask (N95) should be worn when working with the client. C. Must maintain a spatial distance of 3 feet. D. Gloves should be worn only when giving direct care.

C. Must maintain a spatial distance of 3 feet. A spatial distance of at least 3 feet is recommended. The most common forms of transmission of an organism in a client with tonsillitis are coughing, sneezing, and talking. Droplets can travel no more than 3 ft, so precautions should be maintained when there is a possibility of entering this distance.

The nurse is caring for a patient who is severely hypernatremic. She knows that based on the complications from this electrolyte imbalance, her priority is to monitor which of the following? A. Cardiovascular status B. Genitourinary status C. Neurological status D. Gastrointestinal status

C. Neurological status . When a patient is suffering from severe hypernatremia, monitoring neurological status is the nurse's priority. Sodium plays a major role in the brain and nervous system, and any imbalances can cause serious neurological symptoms.

The nurse is caring for a patient who is severely hypernatremic. She knows that based on the complications from this electrolyte imbalance, her priority is to monitor which of the following? A. Cardiovascular status B. Genitourinary status C. Neurological status D. Gastrointestinal status

C. Neurological status When a patient is suffering from severe hypernatremia, monitoring neurological status is the nurse's priority. Sodium plays a major role in the brain and nervous system, and any imbalances can cause serious neurological symptoms.

While monitoring a client with myocardial infarction who is receiving tissue plasminogen activator (Activase, TPA), the nurse should prioritize which of the following? A. Observe for neurological changes. B. Monitor for any signs of renal failure. C. Observe for signs of bleeding. D. Check the client's food diary.

C. Observe for signs of bleeding. Bleeding is the priority concern for any patient who is taking a thrombolytic medication.

The nurse is participating in a committee with the objective of promoting healthcare justice in the community. Which of the following recommendations should the nurse make to achieve the goal? A. Establishing interdisciplinary collaboration between nursing and nutritional services B. Providing more confidential waste containers at local drug stores C. Offering free telehealth offerings in underserved areas of the community D. Offering inpatient clients the ability to select their meal times

C. Offering free telehealth offerings in underserved areas of the community The premise of social justice is expanding access to affordable healthcare for all individuals. The nurse recommending health services for underserved areas is a way to improve health inequalities in the community. Another example would be the nurse endorsing expanding health services and eligibility for Medicaid.

While caring for a young boy who was brought in for a fractured leg, the healthcare team discovers many other fractures in various stages of healing. They suspect? A. Neglect B. Psychological abuse C. Physical abuse D. That he is a clumsy child

C. Physical abuse Physical abuse is any intentional act causing injury or trauma to another person. In children, multiple fractures in various stages of healing are very suspicious for abuse. This points to repeated injuries over a period of time and needs to be thoroughly investigated.

While caring for a young boy who was brought in for a fractured leg, the healthcare team discovers many other fractures in various stages of healing. They suspect A. Neglect B. Psychological abuse C. Physical abuse D. That he is a clumsy child

C. Physical abuse Physical abuse is any intentional act causing injury or trauma to another person. In children, multiple fractures in various stages of healing are very suspicious for abuse. This points to repeated injuries over a period of time and needs to be thoroughly investigated.

The nurse is helping a patient with a chest tube ambulate to the bathroom. The patient turns suddenly and the chest tube becomes dislodged. Which of the following is the priority nursing action? A. Immediately re-insert the tube and call for help. B. Place your hand over the chest tube site and yell for help. C. Place a sterile dressing taped on three sides over the chest tube site and call for help. D. Monitor the patient's vital signs while he finishes ambulating to the bathroom and then call for help.

C. Place a sterile dressing taped on three sides over the chest tube site and call for help. Placing a sterile dressing taped on three sides over the chest tube site and calling for help is the appropriate action. By placing a sterile dressing over the site the nurse follows infection prevention. By taping the dressing on three sides, the dressing will cover the site, and prevent a tension pneumothorax by allowing exhaled air to escape the dressing. The nurse should then immediately call for help.

Which of the following immunizations is a priority for a client who is 75-years- old and has a history of cerebrovascular disease? A. Hepatitis A vaccine B. Hepatitis B vaccine C. Pneumococcal vaccine D. Lyme disease vaccine

C. Pneumococcal vaccine The pneumococcal vaccine is a priority immunization among elderly clients and those with chronic illnesses. This vaccine should be administered every five years.

Which of the following immunizations is a priority for a client who is 75-years- old and has a history of cerebrovascular disease? A. Hepatitis A vaccine B. Hepatitis B vaccine C. Pneumococcal vaccine D. Lyme disease vaccine

C. Pneumococcal vaccine The pneumococcal vaccine is a priority immunization among elderly clients and those with chronic illnesses. This vaccine should be administered every five years.

The nurse is caring for a client who is receiving prescribed trazodone. Which of the following findings would indicate the client is having an adverse effect? A. Dizziness B. Sedation C. Priapism D. Dry mouth

C. Priapism Trazodone is a serotonergic medication indicated in the treatment of insomnia. Adversely, this medication may cause priapism which is a prolonged, painful erection of the penis. Prompt treatment is necessary because this may result in ischemia.

The nurse understands that a positive home pregnancy test is considered which level of confirmation? A. A possible sign of pregnancy. B. Presumptive sign of pregnancy. C. Probable sign of pregnancy. D. A positive sign of pregnancy.

C. Probable sign of pregnancy. Over-the-counter (OTC) pregnancy tests check for the presence of hCG, which rises when pregnancy has occurred. A positive OTC pregnancy test is a probable sign of pregnancy but requires further testing for a definite diagnosis.

The nurse is working with a 17-year-old diagnosed with cystic fibrosis. Which of the following are most important for patients of this age with cystic fibrosis? A. Provide opportunities for the teen to learn about their condition. B. Facilitate interaction amongst peers. C. Promote independence in decision-making by including the patient in their care. D. Emphasizing the importance of education and remaining in school.

C. Promote independence in decision-making by including the patient in their care. Promoting independence in decision-making by including the patient in their care is the top priority for a 17-year-old with cystic fibrosis (CF). They will soon be making the transition to adult doctors and teams and have a legal say in their treatment as an adult. Facilitating their independence is very important.

The nurse has attended a continuing education conference regarding medication administration and meal times. Which statement, if made by the nurse, would indicate correct understanding? A. Proton pump inhibitors (PPIs) should be given as the client eats their breakfast. B. Glucocorticoids should be given on an empty stomach to prevent gastrointestinal irritation. C. Rapid-acting insulins should be administered approximately 10- 15 minutes before meals D. Levodopa-Carbidopa should be administered with a high-protein snack to enhance its absorption.

C. Rapid-acting insulins should be administered approximately 10-15 minutes before meals This is correct because rapid-acting insulin (lispro, aspart, glulisine) should be given within 10-15 minutes before a meal or while the client is actively eating.

A patient is scheduled to have a thyroidectomy. The nurse understands that the primary reason for giving Lugol's solution to a patient preoperatively is: A. Decrease the risk of agranulocytosis postoperatively. B. Prevent tetany while the client is under general anesthesia. C. Reduce the size and vascularity of the thyroid and prevent hemorrhage. D. Potentiate the other preoperative medication's effect so less medicine can be used while the client is under anesthesia.

C. Reduce the size and vascularity of the thyroid and prevent hemorrhage. Reduce the size and vascularity of the thyroid and prevent hemorrhage. Hyperthyroidism is related to hemodynamic variations, including increased heart rate and cardiac contractility, and decreased peripheral resistance due to serum thyroid hormone excess. Preoperative preparation of the patient is crucial to avoid intraoperative or postoperative complications and decrease the gland's vascularity. The incidence of complications is low in experienced hands; however, a small amount of intraoperative bleeding can reduce the visualization and preservation of the surrounding nerves, vasculature, and parathyroid glands. Lugol's solution (inorganic iodide) has been given preoperatively to patients to limit intraoperative bleeding and related complications resulting from thyroid gland vascularization.

When experiencing conflict with another nurse (that is not resolvable between the parties), what is the most appropriate action for the nurse moving forward? A. Report the conflict to the director of nursing over the unit. B. Report the conflict to the nurse manager of the unit. C. Report the conflict to the assigned charge nurse of the unit. D. Discuss the conflict with another nurse to attempt resolution of the issue. I

C. Report the conflict to the assigned charge nurse of the unit. t is important to follow the appropriate chain of command in a professional setting and not overstep any levels when moving the issue up the ladder. Relationships among healthcare staff can have a powerful influence on how well important information is communicated. Disruptive behaviors may be displayed as aggressive, which is an easier type of behavior to observe, but may also be demonstrated as passive or passive-aggressive. These behaviors may threaten patient safety and quality of care. Nurses and other clinicians who witness these behaviors may be hesitant to point them out because of the fear of retaliation. Additionally, nurses may be reluctant or may refuse entirely to communicate with a disruptive clinician. Delays in patient care, disruptive behaviors, and recurring communication problems may occur due to ongoing or unresolved disputes between clinicians. When any disruptive issue arises, it is important to follow the proper chain of command, report the issue, and attempt a resolution, so that patient outcomes are not negatively affected. Chain of command in healthcare refers to an authoritative structure established to resolve administrative, clinical, or other patient safety issues by allowing healthcare clinicians to present an issue of concern through authority lines until a resolution is reached.

Which of the following situations is an example of negligence? A. The UAP (Unlicensed Assistive Personnel) fills a water basin with warm water while the patient with depression combs her hair. B. A nurse transcribes a new medication order: Questran powder 2 oz bid with wet food or one full glass of water. C. The nurse checks the distal pulses of a patient's legs two hours after they have returned from a cardiac catheterization. D. The nurse observes a UAP enter the room of a patient on contact [4%] precautions wearing gloves and a gown.

C. The nurse checks the distal pulses of a patient's legs two hours after they have returned from a cardiac catheterization. The nurse should have checked the patient's distal pulse immediately after the cardiac catheterization.

The nurse is precepting a new nurse who collects a swab specimen from an open wound of a patient with suspected pseudomonas infection. Which action requires immediate intervention by the nurse? A. The nurse flushes the wound with sterile saline. B. After inserting the swab, the nurse squeezes the culture tube. C. The nurse collects purulent drainage from the deepest part of the wound. D. The nurse uses a rayon swab to collect the specimen.

C. The nurse collects purulent drainage from the deepest part of the wound. Purulent drainage or "pus" can give unreliable results and should not be used as the source for the specimen. The nurse should obtain the swab specimen by pressing and rotating the swab in the cleanest, deepest part of the wound.

A patient with Cushing's disease asks the nurse to help him choose a meal for dinner later. Which of the following meals is the best option? A. Hamburger with french fries and apple slices. B. Pork chops in cream sauce with mashed potatoes and carrots. C. Roasted chicken with corn and green beans. D. Mexican-style beef with guacamole and beans on the side.

C. Roasted chicken with corn and green beans. . A patient with Cushing's disease needs to eat a low sodium, high protein, and low-fat diet. Roasted chicken is high in protein with low in fat. Cushing's disease is a serious condition of an excess of the steroid hormone cortisol in the blood level caused by a pituitary tumor secreting adrenocorticotropic hormone (ACTH). Since cortisol is essential for metabolic processes, hypercortisolism associated with Cushing's can significantly affect how the body processes nutrients. Patients with Cushing's disease are encouraged to reduce sodium intake (to reduce the risk of hypertension and weight gain), increase calcium and vitamin D (Cushing's disease can cause reduced bone density and osteoporosis). Cortisol stimulates the liver to increase blood sugar levels, so people with Cushing's who have perpetually high cortisol levels may also have elevated blood sugar. Chronic, heavy drinking can damage the hypothalamic-pituitary-adrenal axis hormone network, resulting in symptoms nearly identical to those of Cushing's. The so-called pseudo-Cushing syndrome can intensify the symptoms of existing Cushing's disease and make it more difficult to diagnose and treat. A common symptom of Cushing's is high cholesterol levels. Avoiding fatty foods and eating more high-fiber foods such as kidney beans, apples, pears, barley, and prunes may help offset the effects of higher cholesterol associated with Cushing's.

When evaluating developmental milestones for a 6-month-old child, which of the following should the nurse screen during a routine office visit? A. Standing while holding onto something/someone B. Creeping C. Rolling over D. Sitting up

C. Rolling over Rolling over begins between 4 and 6 months of age. The early years of a child's life are crucial for his or her health and development. Healthy development means that children of all abilities, including those with special health care needs, can grow up where their social, emotional, and educational needs are met. It is important to encourage regular well-child visits so that healthcare. professionals can help monitor for expected developmental milestones. If a sign is missed or delayed, this could be an indication of an underlying problem. When the screening tool is used, a formal developmental evaluation may be necessary if an area of concern is found. During the developmental assessment, specialists look more closely at the child's development and perform a more in-depth evaluation to pinpoint the problem's cause. 1 Month Makes slight jerk movements Brings his or her hands within the range of eyes and mouth Turns his or hers head when called by a familiar sound and voice Focuses on near by objects (8-12 inches away) Responds to loud sounds 3 Months Notices their hands by two months Smiles at the sound of a familiar voice by two months Follows moving objects with her eyes by 2-3 months Supports head when on stomach by 3 months Babbles by 3-4 months Attempts to imitate any of your sounds by 4 months Attentive to new faces, and is frightened by them Imitates some movements and facial expressions 7 Months Rolls on to back and front Sits without support of the hands Supports weight on legs Responds to own name Babbles by 3-4 months. Shows responses to "no" Responds to sound by making sounds

The nurse is caring for a client who sustained a fractured tibia and fibula and has a cast applied to the extremity. Which of the following findings would indicate the client has developed compartment syndrome? A. The development of petechiae over the chest B. A new onset of dyspnea and chest pain C. Severe pain that is unrelieved by an opioid analgesic D. Localized bone pain with a fever

C. Severe pain that is unrelieved by an opioid analgesic Early manifestations associated with compartment syndrome, including paresthesia of the affected extremity and pain unrelieved by a prescribed opioid analgesic.

The nurse is setting up the room for a patient newly diagnosed with Celiac disease. She knows to place the patient on which of the following precautions? A. Droplet precautions B. Contact precautions C. Standard precautions D. Neutropenic precautions

C. Standard precautions Celiac disease requires standard precautions. It is not an infectious disease and is not transmitted from person to person; therefore, there is no reason to initiate any additional precautions.

✓ The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure? A. Nasogastric tube (NGT) B. Bottle of sterile water C. Suction equipment D. Tracheostomy

C. Suction equipment A cheiloplasty is a procedure to repair a cleft lip (CL). This procedure is typically done by age three to six months. A concern after this procedure is that the child may have excessive secretions that may trigger aspiration. The nurse should have a bulb syringe or some other suction equipment available if the infant begins to choke. While routine suctioning is not done to minimize pain or trauma, this is necessary to have it available to prevent respiratory distress.

The nurse reinforces teaching to a client with hypertension about the newly prescribed furosemide. Which of the following should the nurse include in the teaching? A. Limit intake of bananas, cantaloupe, and potatoes B. Avoid taking the medication with grapefruit juice C. Take this medication in the early part of the day D. A nagging cough can occur as a side effect of the medication

C. Take this medication in the early part of the day Furosemide is a loop diuretic and may be indicated for conditions such as heart failure or hypertension. The client should be instructed to take this medication in the earlier part of the day to avoid nocturia.

Which of the following descriptions best defines general adaptation syndrome? A. Activation of brain signals followed by avoidance in response to a perceived threat. B. The arousal of the hippocampus after being triggered by a specific memory. C. The body's response to stress over both short and long-term periods. D. The development of depression over time as a result of a negative situation. .

C. The body's response to stress over both short and long-term periods. General adaptation syndrome (GAS) is a stress response in which the body modifies its reaction to stress. Initially, the body alters its response after short-term stressful events. Over time, general adaptation syndrome develops as the body adapts to long-term or chronic levels of stress. General adaptation syndrome (GAS) is the name for the group of nonspecific responses that all people share in the face of stressors. The GAS has three stages: (1) the initial alarm stage, (2) resistance (adaptation), and (3) the final stage of either recovery or exhaustion.

The LPN is training a new nurse on the medical-surgical floor. Which action would warrant intervention by the experienced LPN? A. The nurse administers oral cefdinir 30 minutes early. B. The nurse places a surgical mask on a patient with influenza before transport. C. The nurse obtains green drainage from a nasogastric tube for culture. D. The nurse secures a Jackson-Pratt drain to the patient's gown with a safety pin.

C. The nurse obtains green drainage from a nasogastric tube for culture. Nasogastric tubes drain gastric contents, which are typically yellow/green in color due to the presence of bile. Sending it for cultures may cause unnecessary worry for the patient and would be inappropriate since this is an expected assessment. All other actions listed are appropriate.

The LPN is training a new nurse on the medical-surgical floor. Which action would warrant intervention by the experienced LPN? A. The nurse administers oral cefdinir 30 minutes early. B. The nurse places a surgical mask on a patient with influenza before transport. C. The nurse obtains green drainage from a nasogastric tube for culture. D. The nurse secures a Jackson-Pratt drain to the patient's gown with a safety pin.

C. The nurse obtains green drainage from a nasogastric tube for culture. Nasogastric tubes drain gastric contents, which are typically yellow/green in color due to the presence of bile. Sending it for cultures may cause unnecessary worry for the patient and would be inappropriate since this is an expected assessment. All other actions listed are appropriate.

Which of the following best describes an appropriate outcome for a 75-yr-old patient with a history of Huntington's disease who has developed contractures? A. The patient will monitor for signs of skin breakdown as a result of the contractures. B. The patient will learn to reposition himself in his bed and chair without assistance. C. The patient will participate in a range of motion exercises to reduce the effects of contractures. D. The patient will verbalize the effects of contractures on activities of daily living.

C. The patient will participate in a range of motion exercises to reduce the effects of contractures. Performing range of motion exercises will help decrease the risk of further atrophy and should be encouraged. Huntington's disease is a progressive condition that can lead to muscle atrophy and potential contractures. The patient in this situation should be given a program with range of motion exercises. The nurse can help the patient to increase his range of motion and prevent worsening of contractures by improving flexibility and reducing rigidity.

The nursing student inserts an indwelling urinary catheter for a female patient prior to surgery. Which of the following would require immediate intervention by the nurse? A. The patient states that she feels the need to urinate. B. The patient reports a pinching sensation as the catheter is advanced. C. The student nurse notes resistance when inflating the balloon. D. The student separates the labia majora and labia minora with the non-dominant hand.

C. The student nurse notes resistance when inflating the balloon. This may indicate the balloon is within the urethra, not the bladder. If inflated within the urethra, the balloon may cause significant damage. Any complaints or nonverbal signs of discomfort or resistance are noted by the nurse during balloon inflation and are indications to stop this procedure immediately.

When discussing the Denver II with a preschooler's parents, which of these statements would indicate that they correctly understood the teaching? A. This test will tell me whether or not my child's IQ is normal. B. This test will tell me what developmental tasks my child can do today. C. This test will measure my child's development. D. This will let me know if my child's development is normal or not.

C. This test will measure my child's development. The Denver Developmental Screening Test (DDST) was devised to provide a simple method of screening for evidence of slow development in infants and preschool children. The test covers four functions: gross motor, language, fine motor-adaptive, and personal-social. It has been standardized on 1,036 presumably healthy children (two weeks to six years of age) whose families reflect the occupational and ethnic characteristics of Denver's population.

The nurse is preparing to admit a client following lumbar spinal fusion surgery. The nurse should instruct the unlicensed assistive personnel (UAP) to have which equipment at the bedside? A. Overhead trapeze B. Abduction pillow C. Transfer board D. Continuous passive motion (CPM) Medium

C. Transfer board Following a lumbar spinal fusion, the client will need to be log rolled. A transfer board/sheet, along with an ample amount of staff (at least three), will be necessary to facilitate the log roll.

The nurse is preparing to admit a client following lumbar spinal fusion surgery. The nurse should instruct the unlicensed assistive personnel (UAP) to have which equipment at the bedside? A. Overhead trapeze B. Abduction pillow C. Transfer board D. Continuous passive motion (CPM)

C. Transfer board Following a lumbar spinal fusion, the client will need to be log rolled. A transfer board/sheet, along with an ample amount of staff (at least three), will be necessary to facilitate the log roll.

A client presents to the emergency department (ED) with a suspected ectopic pregnancy. The nurse anticipates which diagnostic test will confirm this finding? A. Nonstress testing B. Abdominal radiograph (x-ray) C. Transvaginal ultrasound D. Doppler transducer

C. Transvaginal ultrasound An ectopic pregnancy (EP) is a medical emergency. The imaging of choice is a transvaginal ultrasound, as this type of ultrasound may visualize an extrauterine gestational sac with a yolk sac or embryo (with or without a heartbeat).

The LPN is assessing a patient diagnosed with an atrioventricular canal. She knows that many infants with an atrioventricular canal also have a diagnosis of which of the following? A. Trisomy 18 B. Turner syndrome C. Trisomy 21 D. DiGeorge syndrome

C. Trisomy 21 Trisomy 21, or Down's syndrome, is commonly associated with an atrioventricular canal. Infants with trisomy 21 also commonly present with an ASD, or VSD.

Which stage of psychosocial development does the nurse know a 2-month-old infant will be in? A. Initiative vs. Guilt B. Autonomy vs. Shame and Self Doubt C. Trust vs. Mistrust D. Industry vs. Inferiority

C. Trust vs. Mistrust Trust vs. Mistrust is the typical development stage for infancy, which lasts from birth to 18 months. This is the stage the nurse would expect for her 2-month-old patient. In this stage, children develop a sense of trust when caregivers provide reliability, care, and affection. When infants do not have that, they will develop mistrust.

The nurse detects an elevated temperature in a patient who is scheduled for surgery. The patient has been afebrile and has no other symptoms of fever. What should be the first nursing action? A. Inform the charge nurse. B. Inform the surgeon. C. Validate the finding. D. Document the finding.

C. Validate the finding. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data.

The nurse caring for a three-year-old with congestive heart failure recognizes which of the following as an early sign of digitalis toxicity? A. Bradypnea B. Tachycardia C. Vomiting D. Failure to thrive

C. Vomiting The earliest sign of digitalis toxicity is vomiting. One episode, however, does not warrant discontinuing the medication. Digoxin increases the force of myocardial contraction, decreases conduction through the SA and AV nodes, and prolongs the refractory period of the AV node. The result is increased cardiac output and reduced heart rate. Therapeutic serum digoxin levels range from 0.5-2 ng/mL. Serum levels may be drawn 6-8 hours after a dose is administered, although they are usually drawn immediately before the next dose. In infants, the first symptoms of overdose are typically cardiac arrhythmias. Gastrointestinal symptoms (like vomiting) are some of the earliest signs.

Why would a patient on IV heparin be started on warfarin? A. Additional medication is needed. B. Warfarin is more effective than heparin. C. Warfarin is not effective until 12-24 hours after the first dose. D. Heparin has a low molecular weight and is only effective for a short time.

C. Warfarin is not effective until 12-24 hours after the first dose. Unlike heparin, warfarin's anticoagulant activity can take several days to reach maximum effect. For this reason, heparin and warfarin therapy are often overlapped.

The nurse assesses a client with schizophrenia who appears to be demonstrating neologisms in their speech. Which of the following would be the expected finding? A. Words that rhyme or have a similar beginning sound B. Reduction in speech; short-worded replies C. Words or phrases with meaning only for the client D. Going off on tangents and never reaching the point .

C. Words or phrases with meaning only for the client A neologism is when a client invents words or phrases that only have meaning for themselves. This is a positive symptom associated with schizophrenia.

Your client is receiving a non-steroidal anti-inflammatory drug (NSAID) in addition to a narcotic analgesic. The client wonders why an NSAID is necessary since the narcotic analgesic offers better pain relief. How would you respond to the client's question? A. I don't know and I suggest that you ask your doctor when you see her the next time. B. You are getting the NSAID because we are trying to wean you off the narcotic analgesic for moderate to severe pain. C. You are getting the NSAID, so the effects of the narcotic analgesic to combat your pain are more effective. D. You are getting the NSAID because it is a placebo, and it is proven [6%] to be effective for severe pain.

C. You are getting the NSAID, so the effects of the narcotic analgesic to combat your pain are more effective. "You are getting the NSAID, so the effects of the narcotic analgesic to combat your pain are more effective" is an appropriate response to the client's query. An NSAID is an "adjuvant" medication used in combination with narcotic analgesics to treat moderate to severe pain. Adjuvant pain medications are used to enhance pain relief provided by other analgesics. The primary function ofNSAIDs is to reduce inflammation. Therefore, NSAIDs are helpful in treating the pain caused by inflammation.

Your client is receiving a non-steroidal anti-inflammatory drug (NSAID) in addition to a narcotic analgesic. The client wonders why an NSAID is necessary since the narcotic analgesic offers better pain relief. How would you respond to the client's question? A. I don't know and I suggest that you ask your doctor when you see her the next time. B. You are getting the NSAID because we are trying to wean you off the narcotic analgesic for moderate to severe pain. C. You are getting the NSAID, so the effects of the narcotic analgesic to combat your pain are more effective. D. You are getting the NSAID because it is a placebo, and it is proven to be effective for severe pain.

C. You are getting the NSAID, so the effects of the narcotic analgesic to combat your pain are more effective. "You are getting the NSAID, so the effects of the narcotic analgesic to combat your pain are more effective" is an appropriate response to the client's query. An NSAID is an "adjuvant" medication used in combination with narcotic analgesics to treat moderate to severe pain. Adjuvant pain medications are used to enhance pain relief provided by other analgesics. The primary function of NSAIDs is to reduce inflammation. Therefore, NSAIDs are helpful in treating the pain caused by inflammation.

The nurse has received four physician orders. The nurse should initially implement which order? Physician Orders Irrigate a wound for a client with a stage III pressure ulcer Complete pin care for a client with a halo fixation device Insert an indwelling urinary catheter for a client with retention Administer diazepam for a client with delirium tremens (DTS). A. irrigate a wound for a client with a stage III pressure ulcer. B. complete pin care for a client with a halo fixation device. C. administer diazepam for a client with delirium tremens (DTS). D. insert an indwelling urinary catheter for a client with retention.

C. administer diazepam for a client with delirium tremens (DTS). Delirium tremens (DTS) is a severe form of alcohol withdrawal. This prescription should be implemented immediately, as the risk of seizure activity is quite significant.

The nurse cares for a client diagnosed with generalized anxiety disorder (GAD). The nurse should anticipate a prescription for which of the following medication? A. haloperidol B. fluphenazine C. buspirone D. methylphenidate

C. buspirone Buspirone is a serotonergic agent that is efficacious in the treatment of anxiety. This medication takes time to work (approximately two to four weeks), and the patient should be counseled accordingly.

The nurse is observing a client ambulate with a walker. It would require follow-up by the nurse if the client A. advances the walker 6-10 inches with each step. B. has their elbow flexed 15-30 degrees. C. tilts the walker forward to help stand up from a chair. D. advances the walker and then the affected leg.

C. tilts the walker forward to help stand up from a chair. This observation requires follow-up because when a client gets up from a chair to the walker, the arm rests of the chair should help the client stand to the walker. Tilting the walker could result in falling and serious injury. When clients get up from a chair to the walker, they should hold the chair's arm rests and push up using their arms. After they stand up, they should position their arms on the walker handles with an elbow bend of 15 to 30 degrees.

The nurse has received an order to prepare a client for a water deprivation test. The nurse understands that this test is used to diagnose A. hyperthyroidism B. pheochromocytoma C. diabetes insipidus (DI) D. syndrome of inappropriate antidiuretic hormone (SIADH)

C. diabetes insipidus (DI) DI can be divided into either neurogenic (central) or nephrogenic. The water deprivation test is used to help differentiate whether the DI is neurogenic or nephrogenic. In this test, the client is deprived of water for up to eight hours (they may still eat dry foods). Serial labs, including plasma and urine osmolality measurements, are obtained during that time. Additionally, the client's urine volume and weight are meticulously measured hourly. If the client's body weight should decrease, this supports the diagnosis of DI. At the end of the eight hours, a dose of desmopressin is administered. If there is an increase in urine osmolarity and a decrease in urine volume, it is considered central/neurogenic DI (because the problem responded to the DDAVP). If no response is observed after the DDAVP is administered, nephrogenic DI is likely.

The nurse has received an order to prepare a client for a water deprivation test. The nurse understands that this test is used to diagnose A. hyperthyroidism B. pheochromocytoma C. diabetes insipidus (DI) D. syndrome of inappropriate antidiuretic hormone (SIADH)

C. diabetes insipidus (DI) DI can be divided into either neurogenic (central) or nephrogenic. The water deprivation test is used to help differentiate whether the DI is neurogenic or nephrogenic. In this test, the client is deprived of water for up to eight hours (they may still eat dry foods). Serial labs, including plasma and urine osmolality measurements, are obtained during that time. Additionally, the client's urine volume and weight are meticulously measured hourly. If the client's body weight should decrease, this supports the diagnosis of DI. At the end of the eight hours, a dose of desmopressin is administered. If there is an increase in urine osmolarity and a decrease in urine volume, it is considered central/neurogenic DI (because the problem responded to the DDAVP). If no response is observed after the DDAVP is administered, nephrogenic DI is likely.

The nurse is caring for a neonate experiencing cold stress. The nurse should also assess the neonate for A. hyperglycemia. B. increased muscle tone. C. hypoglycemia. D. metabolic alkalosis.

C. hypoglycemia. When a neonate develops hypoglycemia, norepinephrine is released, causing tachycardia which causes an increase in glucose metabolism. This increase in glucose metabolism depletes the neonate's reserve of glucose. If a neonate is experiencing cold stress, the nurse should warm the neonate by applying warm clothes, removing the neonate from any drafts, and ensuring the neonate is dry. The nurse should assess the neonate for hypoglycemia via heel stick once the neonate's temperature stabilizes.

The nurse is reviewing the following prescriptions for assigned clients. The nurse should initially administer A. enoxaparin to a patient with a platelet count of 165,000 mm3. B. warfarin to a client with an international normalized ratio of 2.4 seconds. C. lorazepam to a client who had two seizures within the last hour. D. regular insulin to a client with a blood glucose of 285 mg/dl.

C. lorazepam to a client who had two seizures within the last hour. For a client who had two seizures in the last hour, the likelihood of them having another seizure is high. The nurse should prioritize administering lorazepam to this client as this medication will have an inhibitory effect on the brain, therefore, decreasing seizure activity.

The nurse cares for a client who intentionally overdosed on their prescribed lithium. The nurse plans on initially A. developing a therapeutic rapport with the client. B. inserting a peripheral vascular access device. C. obtaining the client's vital signs. D. collecting a serum lithium level on the client.

C. obtaining the client's vital signs. An overdose of lithium may be fatal if not treated. Lithium has a narrow therapeutic index (0.6-1.2 mEq/L), and manifestations of toxicity include gastrointestinal symptoms of nausea, vomiting, diarrhea predominate, and neurologic symptoms are delayed. The neurological findings may consist of confusion, ataxia, and coarse tremors.

The nurse is reviewing the physician orders for a client admitted with anorexia nervosa reporting weakness and abdominal distention. The nurse should prioritize: See the image below. Orders olanzapine 2.5 mg by mouth daily • obtain daily weights • 12-lead electrocardiogram • consult nutritional services A. administering olanzapine. B. consulting nutritional services. C. performing the 12-lead electrocardiogram. D. weighing the client.

C. performing the 12-lead electrocardiogram. The client with anorexia nervosa reporting abdominal distention and weakness is concerning for hypokalemia. The nurse should prioritize performing the 12-lead electrocardiogram because cardiovascular collapse may occur if the client's physical symptoms go unrecognized and untreated. Additional testing is required, including a complete metabolic panel and magnesium level. Features of hypokalemia on the electrocardiogram include U-wave development, ST depression, and shallow, flat, or inverted T wave.

The nurse is preparing a client for a scheduled colonoscopy. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP) while the client is preparing for this procedure? A. docusate B. loperamide C. polyethylene glycol 3350 D. famotidine

C. polyethylene glycol 3350 Polyethylene glycol 3350 is an osmotic laxative commonly used before a colonoscopy. This powder is typically dissolved in a sports drink and can be consumed by the client. Efficacy is usually within one hour. Fluid and electrolyte disturbance is unlikely as the powdered solution contains electrolytes.

The nurse observes a client perform isometric exercises. It would indicate effective understanding if the client A. exercises both extremities simultaneously. B. knows their heart rate should be monitored while exercising. C. practices forced resistance against stable objects. D. swings their limbs through the full range of motion.

C. practices forced resistance against stable objects. Isometric exercises involve applying pressure against a stable object, like pressing the hands together or pushing an extremity against a wall.

The nurse is caring for a client with Buerger's disease. The nurse plans on suggesting that the client receive a referral for A. occupational therapy, B. speech therapy. C. smoking cessation. D. group psychotherapy.

C. smoking cessation. Arterial and venous blood flow impediments characterize Buerger's disease. This impediment is caused by inflammation and is significantly worsened by smoking. The nicotine causes vasoconstriction and worsens blood flow. A critical intervention for a client with this condition is discussing smoking cessation with this client.

The nurse is caring for a client prescribed dutasteride. The nurse understands this medication had achieved its therapeutic effect when the client reports decreased symptoms of A. pyrosis. B. hypothyroidism. C. urinary retention. D. anxiety.

C. urinary retention. Dutasteride works by inhibiting this enzyme 5-alpha reductase, which normally converts testosterone to 5-alpha dihydrotestosterone (DHT). DHT is a more potent form of testosterone and is the principal androgen responsible for stimulating prostatic growth. The growth of the prostate may cause BPH, therefore, causing overflow incontinence which is manifested as urinary retention. Decreased size of the prostate and less urinary retention is a therapeutic findings of this medication.

The nurse is caring for the following assigned clients. The nurse should initially follow-up with the client who A. is repeatedly washing their hands. B. talking over others during group therapy. C. yelling and shouting at others. D. is voluntarily admitted and requesting discharge.

C. yelling and shouting at others. The client yelling and shouting at other clients requires immediate intervention because this situation is hostile and warrants the nurse to de-escalate the situation before it intensifies.

You receive an order to administer 600 mg ibuprofen to your patient as needed every 6 hours. You retrieve the medication, which comes in 200 mg tablets. How many tablets do you administer to your patient? A. 1 tablet B. 5 tablets C.3 tablets D. 2 tablets

C.3 tablets 3 tablets x 200 mg = 600 mg of ibuprofen. This is the correct dose.

The nurse is speaking with her patient, who is undergoing chemotherapy treatment. The patient states, "My friend beat cancer using complementary therapies; I think I should try that too." Which of the following responses from the nurse is most appropriate? A. "Complementary therapies are not safe with your chemotherapy." B. "I would be desperate if I had cancer too." C. "Let us go get your healthcare provider so that we may discuss it with him." D. "Tell me more about what you mean when you say complementary therapies."

D. "Tell me more about what you mean when you say complementary therapies." This is the most therapeutic statement. Effective communication always begins with an open-ended statement. It addresses the question asked by the client and will lead to further discussion. The nurse should explore what therapies the client is interested in talking about first, so that she may better help the client when discussing the therapies with the healthcare provider.

Which of the following clients is at greatest risk for experiencing impaired vascular perfusion? A. A 76-year-old female client who has a history of alcohol abuse. B. A 76-year-old female client who has a history of radon gas exposure. C. A 64-year-old male client who has a history of cigarette smoking. D. A 64-year-old male client who has hypotension.

D. A 64-year-old male client who has hypotension. A 64-year-old male client who has hypotension is at the highest risk for impaired vascular perfusion. Perfusion refers to the continuous supply of oxygenated blood through the blood vessels to vital organs. There are several risk factors associated with impaired vascular perfusion, including: hypovolemia, low hemoglobin (anemia), an immobilized limb, hypoxia, diabetes, decreased output, and hypoventilation.

X The nurse is caring for a teenager who is recovering from a tonsillectomy. She walks in the room, and sees the patient eating chips and salsa from a Mexican restaurant. Which of the following responses is most appropriate? A. "I love that restaurant! Their chips are so good." B. "You cannot eat anything yet, I am sorry" C. "Chips are not a good choice right now because you need a high protein diet after your surgery." D. "Those chips are really hard on the back of your throat where you had your surgery. I'm worried they could cause you to bleed if they damage your incision site. Let's get something softer for you to eat right now."

D. "Those chips are really hard on the back of your throat where you had your surgery. I'm worried they could cause you to bleed if they damage your incision site. Let's get something softer for you to eat right now." This is the most appropriate response by the nurse. She correctly explains to the patient that the sharp tortilla chips would be really hard on the patient's surgical site after a tonsillectomy. Allowing patients to eat foods like chips or popcorn after surgery in the back of the throat would put them at risk for damage to the incision and subsequent hemorrhage. Offering the patient something soft, such as jello or soup, is the most appropriate.

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

D. "What makes you think we are trying to kill you?" A client experiencing psychosis does not exhibit a rational thought process and may have impaired reality testing. If the client is paranoid, the nurse should attempt to understand the paranoia as the client has likely misconstrued an action.

The nurse in the emergency department (ED) is caring for a client with heat stroke. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP)? A. Acetaminophen B. Naproxen C. Ketorolac D. 0.9% saline

D. 0.9% saline 0.9% saline infusion is necessary to administer to a client with heat stroke because this condition induces a significant fluid deficit. Additionally, 0.9% saline may be cooled to provide an adjunctive cooling measure.

While emptying the foley catheter bag for her patient, the nurse sees the following in the exhibit. Which urine-specific gravity level does the nurse expect to see when she reviews the patient's labs based on this urine assessment? A. 0.990 B. 1.000 C. 1.020 D. 1.060

D. 1.060 Urine-specific gravity measures the concentration of urine. The nurse notes that this urine is very dark, and therefore very concentrated. She suspects that the patient is dehydrated based on this assessment of his urine color. There are more particles in the urine in dehydrated patients, creating a higher urine- specific gravity. Normal urine specific gravity is 1.005 to 1.030, so the nurse expects his lab value to be higher than 1.030. This is the only lab value showing an increased urine-specific gravity.

The nurse is reinforcing education to a client about newly prescribed aspart insulin. The nurse should instruct the client to self-administer this insulin A. 30-45 minutes before a meal. B. one hour after a meal. C. 20-30 minutes before a meal. D. 10-15 minutes before a meal.

D. 10-15 minutes before a meal. Aspart insulin is a rapid actin insulin that should be administered to the client no greater than 10-15 minutes prior to the meal or while the client is actively eating. Prior to the administration of this insulin, the client's blood glucose should be obtained.

The nurse is preparing to administer an intramuscular (IM) injection to a neonate. Which gauge and size needle should the nurse use to administer the medication? A. 19 gauge, 1 1/2" (3.8 cm) needle B. 18 gauge, 1" (2.5 cm) needle C. 20 gauge, 1" (2.5 cm) needle D. 25 gauge, 5/8" (1.6 cm) needle

D. 25 gauge, 5/8" (1.6 cm) needle This needle size and gauge are appropriate for a neonate. When administering IM medications to a neonate or young child, the vastus lateralis is the preferred site. For the volume to be administered in an IM, it is recommended to be 0.5 mL or less for infants; up to 2 mL for children.

The nurse is preparing to administer an intramuscular (IM) injection to a neonate. Which gauge and size needle should the nurse use to administer the medication? A. 19 gauge, 1 1/2" (3.8 cm) needle B. 18 gauge, 1" (2.5 cm) needle C. 20 gauge, 1" (2.5 cm) needle D. 25 gauge, 5/8" (1.6 cm) needle

D. 25 gauge, 5/8" (1.6 cm) needle This needle size and gauge are appropriate for a neonate. When administering IM medications to a neonate or young child, the vastus lateralis is the preferred site. For the volume to be administered in an IM, it is recommended to be 0.5 mL or less for infants; up to 2 mL for children.

Which of the following represents the appropriate daily caloric intake for an adolescent male who plays high school soccer four days a week? A. 1600 calories B. 2000 calories C. 2400 calories D. 2800 calories

D. 2800 calories 2800 calories are the appropriate caloric intake for an active adolescent male.

Which of the following patients does the nurse suspect would benefit most from placement of a nasogastric tube? A. A 9-year-old boy with a femur fracture B. An 82-year-old female with congestive heart failure C. A 65-year-old male on dialysis D. A 52-year-old female with leukemia who is receiving chemotherapy

D. A 52-year-old female with leukemia who is receiving chemotherapy The nurse suspects that a 52-year-old female with leukemia who is receiving chemotherapy would benefit most from a nasogastric tube. Nasogastric tubes are placed to help patients meet their nutritional needs. A patient with leukemia has an increased need for calories and protein, but the chemotherapy treatment she is undergoing is likely to cause anorexia and nausea. This patient could benefit from a nasogastric tube to help meet nutritional needs.

Which of the following clients is at greatest risk for impaired vascular perfusion? A. An 80-year-old female with a history of alcoholism. B. A 75-year-old male with a history of radon gas exposure. C. A 59-year-old male with a history of cigarette smoking. D. A 60-year-old male with a diagnosis of hypertension.

D. A 60-year-old male with a diagnosis of hypertension. Many conditions can disrupt the exchange of oxygen and carbon dioxide. Still, diabetes, obesity, anemia, high blood pressure, and coronary artery disease are some of the more common risk factors that can cause ineffective tissue perfusion. Other risk factors include: immobility, hypoxia, decreased cardiac output, diabetes, and hypoventilation.

Which of the following clients is at greatest risk for experiencing impaired vascular perfusion? A. A 76-year-old female client who has a history of alcohol abuse. B. A 76-year-old female client who has a history of radon gas exposure. C. A 64-year-old male client who has a history of cigarette smoking. D. A 64-year-old male client who has hypotension.

D. A 64-year-old male client who has hypotension. A 64-year-old male client who has hypotension is at the highest risk for impaired vascular perfusion. Perfusion refers to the continuous supply of oxygenated blood through the blood vessels to vital organs. There are several risk factors associated with impaired vascular perfusion, including: hypovolemia, low hemoglobin (anemia), an immobilized limb, hypoxia, diabetes, decreased output, and hypoventilation.

After receiving a report on the medical-surgical floor, which of the following clients should the nurse see first? A. A client with a respiratory rate of 24 and an oxygen saturation of 92%. B. A client that is scheduled for stomach surgery in two hours related to peptic ulcer disease. C. A client that is six hours post-op from a hysterectomy and is complaining of nausea. D. A client that had a cast applied two hours ago and now has complaints of her arm feeling like it is "asleep".

D. A client that had a cast applied two hours ago and now has complaints of her arm feeling like it is "asleep". The patient with a cast that describes her arm as feeling like it's asleep is likely experiencing impaired circulation. This patient should be assessed first, and the physician should be notified. Prioritizing patient care related to each patient's status is a critical skill. While all patients are essential and must be monitored, the ability to recognize a potential complication before it gets out of hand and causes more damage is crucial.

Which of the following clients, who is receiving normal saline via IV infusion, is at the highest risk for bloodstream infections? A. A client who has a midline IV catheter in the left antecubital fossa. B. A client with a peripherally inserted central catheter (PICC) line in the right upper arm. C.A client with an implanted port in the right subclavian vein. D. A client who has a non-tunneled central line in the left internal jugular vein.

D. A client who has a non-tunneled central line in the left internal jugular vein. Several factors increase the risk of infection for this client. Central lines are associated with a higher risk of infection because the skin of the neck and chest harbor a high number of microorganisms. Additionally, because the line is non-tunneled, the risk for infection is higher. Non-tunneled catheters are mostly used for short-term access in indications requiring rapid resuscitation or pressure monitoring. Such non-tunneled catheters are good for about 5 to 7 days. They carry a higher risk of infection and are inappropriate for patients who require central venous access for longer than 2 weeks.

When triaging clients who have existing infections, which of the following patients would be most appropriate to assign to the only private room available? A. A client with toxic shock syndrome and a temperature of 102.4° F (39.1° C). B. A client with diarrhea caused by C. difficile. C. A client with a wound infected with VRE. D. A client with a cough suspicious of Koch disease.

D. A client with a cough suspicious of Koch disease. Clients with infections that require airborne precautions (i.e. tuberculosis) need to be in private rooms. Choice A is incorrect. Standard precautions are required for the client with toxic shock syndrome.

The nurse is going over her assigned patients for the shift. She knows that which of the following patients is most at risk for experiencing a fluid volume deficit? A. A patient with cirrhosis. B. A patient with an ileostomy that has a normal amount of output. C. A patient with a BUN of 32 and Cr 2.7. D. A patient with diabetes insipidus and an NG tube to low intermittent wall suction.

D. A patient with diabetes insipidus and an NG tube to low intermittent wall suction. A patient with DI and an NG tube to low intermittent wall suction is at very high risk for a fluid volume deficit. They have 2 risk factors and are therefore the patient at most risk. In DI, the body puts out huge amounts of dilute urine, depleting the body of fluid. Having an NG tube to suction also removes fluid from the patient, by way of their Gl secretions, making it another risk factor for fluid volume deficit.

The nurse is going over her assigned patients for the shift. She knows that which of the following patients is most at risk for experiencing a fluid volume deficit? A. A patient with cirrhosis. B. A patient with an ileostomy that has a normal amount of output. C. A patient with a BUN of 32 and Cr 2.7. D. A patient with diabetes insipidus and an NG tube to low intermittent wall suction.

D. A patient with diabetes insipidus and an NG tube to low intermittent wall suction. A patient with DI and an NG tube to low intermittent wall suction is at very high risk for a fluid volume deficit. They have 2 risk factors and are therefore the patient at most risk. In DI, the body puts out huge amounts of dilute urine, depleting the body of fluid. Having an NG tube to suction also removes fluid from the patient, by way of their Gl secretions, making it another risk factor for fluid volume deficit.

The nurse is assisting a client of the Orthodox Jewish faith while serving lunch. A kosher meal has been delivered to the client. What is the next appropriate action to perform with this client? A. Substitute plastic utensils with metal utensils. B. Unwrap the eating utensils for the client. C.Carefully transfer the food from a styrofoam tray to a ceramic plate. D. Allow the client to unwrap the utensils and prepare their own

D. Allow the client to unwrap the utensils and prepare their own A person of the Orthodox faith should be able to unwrap the utensils and prepare their own meal.

The nurse is caring for a 5-year-old patient whose family is of Orthodox Jewish faith. The mother expresses that she wishes for the patient to remain kosher while in the hospital. Which of the following actions would best respect that request while assisting the child with his lunch? A. Finding metal utensils instead of plastic. B. Placing the food on plastic plates instead of paper. C. Helping the child unwrap the plastic utensils from their packaging. D. Allowing the child and his mother to unwrap the eating utensils.

D. Allowing the child and his mother to unwrap the eating utensils. It is appropriate to allow the child and the mother to unwrap the eating utensils. This is the only action listed that allows the child and the mother to remain kosher as requested.

The nurse is caring for a client with Helicobacter pylori. The nurse should anticipate a prescription for which of the following medications? A. Dicyclomine B. Metoclopramide C.Valacyclovir D. Amoxicillin

D. Amoxicillin Amoxicillin is an antibiotic that is commonly used to treat Helicobacter pylori infections.

A patient tells the nurse that she is ashamed of the way her hair looks and wants a shower and hair washed before her daily routine tests and wound dressing changes. How should the nurse prioritize the patient's care? A. The nurse should explain to the patient that there is not enough time to wash her hair because she has too many tests scheduled. B. The nurse should schedule the testing and meal planning first and then complete hygiene as time permits. C. Perform the dressing changes first, schedule testing, and at last complete hygiene. D. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing.

D. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing As long as time constraints permit, the most important priorities when scheduling nursing care are priorities identified by the patient as being the most important.

A patient tells the nurse that she is ashamed of the way her hair looks and wants a shower and hair washed before her daily routine tests and wound dressing changes. How should the nurse prioritize the patient's care? A. The nurse should explain to the patient that there is not enough time to wash her hair because she has too many tests scheduled. B. The nurse should schedule the testing and meal planning first and then complete hygiene as time permits. C. Perform the dressing changes first, schedule testing, and at last complete hygiene. D. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing.

D. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing. As long as time constraints permit, the most important priorities when scheduling nursing care are priorities identified by the patient as being the most important.

A client has acute bone pain related to metastases of cancer. The best way for a hospice nurse to assess the client's level of pain is: A. Check vital signs after giving pain medication. B. Note observations about the client's behavior. C. Evaluate verbal and non-verbal actions. D. Ask the client to rate his pain on a scale from 0-10.

D. Ask the client to rate his pain on a scale from 0-10. Only the client can report on their pain level; it is a subjective perception that should not be judged or dismissed. Asking him to rate his pain on a scale of 0-10 should be the guide for managing his care and pain relief. Three aspects regarding the definitions of pain have essential implications for nurses. First, pain is a physical and emotional experience, not all in the body or all in the mind. Second, pain is a response to actual or potential tissue damage, so laboratory or radiographic reports may not be abnormal despite the real pain. Finally, emotional responses to pain, such as anxiety, depression, anger, and demoralization, may be described in the place of pain. Given that some clients are reluctant to disclose the presence of pain unless asked, nurses will be unaware of a client's pain until they assess for it. Additionally, it is clear that even clients who are nonverbal (e.g. preverbal children, intubated clients, people with cognitive impairments, or unconscious clients) experience pain that demands a nursing assessment and treatment even though the clients are unable to describe their discomfort. Pain interferes with functional abilities and quality of life. Severe or persistent pain affects all body systems, causing potentially dangerous health problems while increasing the risk of complications, delays in healing, and an accelerated progression of fatal illnesses.

The LPN enters her 5 year old patients room and finds him lying on the floor. His fall was unwitnessed. What is her priority nursing action? A. File an incident report B. Assist the child back to bed C. Call for help D. Assess the child for any injuries

D. Assess the child for any injuries The priority nursing action is to assess the patient!! Before doing anything else, the nurse needs to know if the child was injured during the fall. This will determine what her next steps are.

The nurse is caring for a client newly diagnosed with an abdominal aortic aneurysm. The nurse should anticipate a prescription for which of the following medications? A. Naproxen B. Digoxin C. Prednisone D. Atenolol

D. Atenolol An abdominal aortic aneurysm (AAA) is a serious condition that may lead to potential rupture. Depending on the size of the aneurysm, clients may be taken in for emergent or elective surgery. A priority for all clients is blood pressure control. Thus, beta-blockers such as atenolol are utilized to reduce the size of the aneurysm as well as reduce the risk of rupture.

The nurse is counseling a client and her family who has breast cancer. Which tertiary prevention measure should the nurse recommend? A. Reviewing breast cancer risk factors with the client's family B. Assessing the unaffected breast for abnormalities C. Recommending the client's daughter get screened for the BRCA1 or BRCA2 gene D. Attending a local support group

D. Attending a local support group The emphasis on tertiary prevention promotes functioning by minimizing the severity of the disease. Examples of tertiary prevention include rehabilitation services and support groups. Support groups are effective in fostering psychosocial integrity because they allow an individual to express themselves with individuals who may have similar circumstances.

The nurse is counseling a client and her family who has breast cancer. Which tertiary prevention measure should the nurse recommend? A. Reviewing breast cancer risk factors with the client's family B. Assessing the unaffected breast for abnormalities C. Recommending the client's daughter get screened for the BRCA1 or BRCA2 gene D. Attending a local support group

D. Attending a local support group The emphasis on tertiary prevention promotes functioning by minimizing the severity of the disease. Examples of tertiary prevention include rehabilitation services and support groups. Support groups are effective in fostering psychosocial integrity because they allow an individual to express themselves with individuals who may have similar circumstances.

The nurse is caring for a client diagnosed with Multiple Sclerosis (MS). The nurse should anticipate a prescription for which medication? A. Topiramate B. Risperidone C. Prazosin D. Baclofen

D. Baclofen Multiple Sclerosis (MS) may produce symptoms such as muscle spasticity, optic neuritis, fatigue, heat intolerance, and symptoms that seem to intensify occasionally (relapses). Muscle spasticity is best controlled with muscle relaxers such as baclofen. Other muscle relaxers include cyclobenzaprine, diazepam, and tizanidine.

An 8-year-old boy diagnosed with hemophilia A is brought into the urgent care clinic for a prolonged episode of hematemesis. Which of the following describes this symptom? A. Bleeding into the joints B. Bleeding from the nose C. Dark, black, tar-like stools D. Bloody vomit

D. Bloody vomit Hematemesis is bloody vomit. This symptom is common with hemophilia and can lead to severe complications if not treated promptly.

The licensed practical/vocational nurse (LPN/VN) is collecting data on a client who just received one unit of packed red blood cells (PRBCs). Which of the following findings would indicate a therapeutic response? A. Bounding peripheral pulses B. Hematuria C. Oral temperature 100.4°F (38°C) D. Capillary refill <3 seconds

D. Capillary refill <3 seconds A capillary refill of <3 seconds is an optimal physical assessment finding and would be desired following the administration of PRBCs. PRBCs are indicated for clients with anemia (hemoglobin less than 7 g/dL). Giving a client, PRBCs improves tissue perfusion and may reflect the capillary refill finding.

While working in the emergency department the nurse assesses a 3 day old infant brought in by his mother. She states "he is always so sweaty and hot, and just doesn't want to eat! I think something is wrong." The nurse is unable to palpate a femoral pulse, but notes +3 brachial pulses. Which congenital heart defect does the nurse suspect? A. Hypoplastic left heart syndrome B. Patent ductus arteriosus C. Transposition of the great arteries D. Coarctation of the aorta

D. Coarctation of the aorta The nurse suspects that this infant has coarctation of the aorta. In this defect, there is a stricture in the aorta preventing blood flow out of the left ventricle. It usually occurs beyond the blood vessels that branch off to your upper body and before the blood vessels that lead to your lower body. So blood flow to the upper body is abundant, but hardly any can make it to the lower part of the body. Therefore, there are decreased lower extremity pulses and increased upper extremity pulses.

What is the highest priority nursing goal for a client whose hemoglobin is 10 g/dL (Male: 14-18 g/dL/Female: 12-16 g/dL) and hematocrit is 30%(Male: 42- 52% / Female: 37-47%)? A. Encourage mobility B. Promote skin integrity C. Prevent constipation D. Conserve the client's energy

D. Conserve the client's energy These test results indicate anemia. The impaired oxygen- carrying capacity of red blood cells causes cellular hypoxia which results in fatigue. Conserving energy limits oxygen expenditure and minimizes fatigue. The hematocrit, also known by several other names, is a blood test that measures the volume percentage of red blood cells in the blood. The measurement depends on the number and size of red blood cells. It usually is 40.7% to 50.3% for men and 36.1% to 44.3% for women. Hemoglobin, abbreviated Hb or Hgb, is the iron-containing oxygen-transport metalloprotein in the red blood cells of almost all vertebrates and the tissues of some invertebrates. Hemoglobin in the blood carries oxygen from the lungs or gills to the rest of the body.

The nurse is caring for a client who experienced a myocardial infarction (MI) 24 hours ago. It would be necessary for the nurse to immediately notify the primary health care provider (PHCP) if the client has which of the following? A. An elevated troponin level B. A white blood cell (WBC) count of 13,000 mm3 C. Apprehension about attending cardiac rehabilitation D. Crackles auscultated to the midline of the lung fields

D. Crackles auscultated to the midline of the lung fields Following a myocardial infarction (MI), the client is at risk for developing pulmonary edema. This is caused by the heart's inability to eject blood, consequently caused by an insult to the myocardium. When caring for a patient with an MI, the nurse should monitor the patient for life-threatening ventricular arrhythmias as well as pulmonary edema. If a client is experiencing this complication, they will develop crackles in the lung fields, tachypnea, and hypoxia.

The nurse is caring for a client who experienced a myocardial infarction (MI) 24 hours ago. It would be necessary for the nurse to immediately notify the primary health care provider (PHCP) if the client has which of the following? A. An elevated troponin level B. A white blood cell (WBC) count of 13,000 mm3 C. Apprehension about attending cardiac rehabilitation D. Crackles auscultated to the midline of the lung fields

D. Crackles auscultated to the midline of the lung fields Following a myocardial infarction (MI), the client is at risk for developing pulmonary edema. This is caused by the heart's inability to eject blood, consequently caused by an insult to the myocardium. When caring for a patient with an MI, the nurse should monitor the patient for life-threatening ventricular arrhythmias as well as pulmonary edema. If a client is experiencing this complication, they will develop crackles in the lung fields, tachypnea, and hypoxia.

Which of the following lab values would be most significant in determining renal function in a client with a history of polycystic kidney disease? A. BUN 90 mg/dL B. Serum potassium 7.0 MEq/L C. Uric acid 7.5 D. Creatinine 8.7 mg/dL

D. Creatinine 8.7 mg/dL Creatinine is a specific indicator of renal function/failure. Polycystic kidney disease (PKD) is a genetic disorder that causes fluid-filled cysts to grow inside the kidneys. Unlike simple kidney cysts that may develop later in life, PKD cysts can change the shape of organs and alter their function. Several tests can evaluate renal functioning.

Which of the following conditions may cause an increased cortisol level in a client? A. Addison's disease B. Congestive heart failure C. Renal failure D. Cushing's disease

D. Cushing's disease Cushing's syndrome produces elevated cortisol levels. Cortisol is best known for helping support the body's natural "fight-or-flight" instinct in a crisis. It also plays a vital role in several other body functions, including managing the use of carbohydrates, fats, and proteins, regulating blood pressure, increasing blood sugar levels, controlling the sleep/wake cycle, and boosting energy to help manage stress and restore balance.

Which of the following conditions may cause an increased cortisol level in a client? A. Addison's disease B. Congestive heart failure. C. Renal failure D. Cushing's disease

D. Cushing's disease Cushing's syndrome produces elevated cortisol levels. Cortisol is best known for helping support the body's natural "fight-or-flight" instinct in a crisis. It also plays a vital role in several other body functions, including managing the use of carbohydrates, fats, and proteins, regulating blood pressure, increasing blood sugar levels, controlling the sleep/wake cycle, and boosting energy to help manage stress and restore balance.

The patient with tuberculosis is now on isoniazid. Which laboratory test should be monitored at least monthly? A. PT and PTT B. CBC C. BUN D. Liver enzymes

D. Liver enzymes Although it is rare, liver toxicity is a severe adverse effect of Isoniazid. Healthcare providers should monitor for signs of jaundice, fatigue, elevated liver enzymes, and loss of appetite. Liver enzyme tests are usually performed monthly during therapy to identify early hepatotoxicity. Isoniazid is bacteriocidal for actively growing organisms and bacteriostatic for dormant mycobacteria. It is selective for M. tuberculosis. Isoniazid is used alone for chemoprophylaxis in combination with other antitubercular drugs when treating active disease.

The licensed practical/vocational (LPN/VN) assists a registered nurse (RN) in planning a staff educational conference about indwelling urinary catheters. Which of the following information should be included? A. Sterile gloves should be used to perform urinary catheter care. B. Urinary specimens may be collected from a catheter bag. C. You may irrigate a catheter with warm water for poor outflow. D. Daily use of soap and water should be used around the urinary

D. Daily use of soap and water should be used around the urinary Daily cleaning of the urinary meatus with soap and water is recommended for catheter care. Sterile gloves do not need to be used for this process as it is a clean procedure. Soap and water is an acceptable practice for daily catheter care as alcohol, CHG, and other antiseptics may be highly irritating to the urinary meatus.

The licensed practical/vocational (LPN/VN) assists a registered nurse (RN) in planning a staff educational conference about indwelling urinary catheters. Which of the following information should be included? A. Sterile gloves should be used to perform urinary catheter care. B. Urinary specimens may be collected from a catheter bag. C. You may irrigate a catheter with warm water for poor outflow. D. Daily use of soap and water should be used around the urinary meatus.

D. Daily use of soap and water should be used around the urinary meatus. Daily cleaning of the urinary meatus with soap and water is recommended for catheter care. Sterile gloves do not need to be used for this process as it is a clean procedure. Soap and water is an acceptable practice for daily catheter care as alcohol, CHG, and other antiseptics may be highly irritating to the urinary meatus.

Which of the following members of the intradisciplinary team should be consulted for an infant suspected of having Celiac disease? A. Pharmacist B. Pulmonologist C. Occupational therapist D. Dietician

D. Dietician Consulting with a dietician is of the utmost importance for the patient who is suspected of having Celiac disease. The dietician is the expert in this area and will provide support, education, and a dietary plan for this patient. Learning to avoid gluten can be difficult for the family, and the dietician is the best resource to help them navigate this.

The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. This specimen is then: A. Placed in a separate container and later added to the collection. B. Saved as part of the 24-hour collection. C. Tested then discarded. D. Discarded, then the collection begins.

D. Discarded, then the collection begins. . The first specimen is discarded because it is considered "old urine" or urine in the bladder before the test began. A 24-hour urine collection helps diagnose kidney problems. It is often done to see how much creatinine clears through the kidneys. It's also done to measure protein, hormones, minerals, and other chemical compounds. Proper education on collecting the 24-hour specimen is essential, as retaining the first specimen can cause an error in the result.

When caring for a client with a documented history of aggressive and violent behavior, what is the first thing the nurse should do to help prevent a violent event toward others? A. Restrain the client. B. Place the client in seclusion. C. Get an order for a sedating medication. D. Establish trust with the client. 1

D. Establish trust with the client. The first thing that you should do to prevent violence towards others is to establish trust with the client. The first step in the nurse-client relationship is to build confidence in this therapeutic relationship. Without trust, future collaboration, interventions, and client outcomes cannot facilitate appropriate and safe behaviors. Nurses can be prepared to intervene and perhaps even prevent violence if they recognize risk factors and early warning signs. Nurses should assess factors that increase the risk for aggression, such as mental disorders, being under the influence of alcohol or other drugs, withdrawal from alcohol or other drugs, and history of violence. Clinical conditions such as high fever, epilepsy, head trauma, and hypoglycemia may also lead to violent outbursts.

Increased levels of which of the following hormones is related to hyperemesis gravidarum? A. Testosterone B. Progesterone C. Aldosterone D. Estrogen

D. Estrogen The cause of hyperemesis is related to high estrogen and human chorionic gonadotropin (hCG) levels. Nausea and vomiting, also known as morning sickness, are common during the first trimester of pregnancy for many women. If nausea and vomiting interfere with an inadequate intake of fluid/food and persists past 20 weeks of gestation, it is termed hyperemesis gravidarum. The cause is unknown, but elevated hormone levels and the relaxation of smooth muscles result in delayed gastric emptying, which is believed to contribute to this condition. Hyperemesis can cause problems for the mother and fetus. Severe hyperemesis gravidarum can result in preterm labor. The dehydration that occurs may lead to reduced placental perfusion and inadequate oxygenation to the fetus. Fetal growth can be compromised, leading to an infant who is small for gestational age. Women with hyperemesis gravidarum in the second trimester have an increased risk for preterm labor, pre-eclampsia (i.e. an increase in blood pressure, protein in the urine, and edema), and placental abruption.

The nurse is reinforcing education regarding acid-base imbalances with a group of students. It would be correct to identify the following cause of metabolic alkalosis? A. Hyperventilation B. Urinary retention C. Opioid toxicity D. Excessive vomiting

D. Excessive vomiting Excessive vomiting would cause the discharge of hydrochloric acid and would therefore leave the patient with more bicarbonate. This would put the patient in an alkalotic state (pH greater than 7.45).

When orienting an older patient to his hospital room's safety measures, what is the admission routine's priority component? A. Explain how to use the telephone. B. Introduce the patient to her roommate. C. Review the hospital policy on visiting hours. D. Explain how to operate the call light.

D. Explain how to operate the call light. Knowing how to use the call light is a safety priority.

During a busy shift, the nurse appropriately delegates tasks to the unlicensed assistive personnel (UAP) working with her. After delegating, which is the nurse's primary responsibility? A. Document the completion of the task. B. Make a list of tasks not yet completed to pass on to the next shift. C. Observe the UAP for the duration of the task. D. Follow-up with the UAP to ensure completion of the task by evaluating the outcome.

D. Follow-up with the UAP to ensure completion of the task by evaluating the outcome. The nurse should follow-up with the unlicensed assistive personnel (UAP) to ensure completion of the task, evaluating the outcome. The ultimate responsibility for any task will always remain with the person who delegated it. Therefore, after delegating a task, the nurse's primary responsibility will be to follow up with the UAP.

The emergency department (ED) nurse cares for a client receiving prescribed warfarin and reports dizziness, black tarry stools, and bloody gums. The international normalized ratio (INR) returns at 5. The nurse anticipates the primary healthcare provider (PHCP) will prescribe which blood product? A. Packed red blood cells (PRBCS) B. Platelets C. Granulocytes D. Fresh frozen plasma (FFP)

D. Fresh frozen plasma (FFP) FFP would be prescribed because this client is experiencing bleeding related to the prescribed warfarin. The client's INR is grossly elevated (therapeutic for VTE prophylaxis is 2-3), and FFP includes the Vitamin K-dependent clotting factors (factors II, VII, IX, X, proteins C, and S) that need to be replaced to stop the bleeding. Vitamin K may be prescribed, but the efficacy takes six to eight hours. FFP can treat the bleeding almost immediately.

The nurse is caring for a client who has type 2 diabetes mellitus and hypertension. The client is nothing by mouth status (NPO) before a scheduled surgery. Which of the following prescribed medications should the nurse question? A. Metoprolol B. Phenytoin C. Levothyroxine D. Glipizide

D. Glipizide Glipizide is a sulfonylurea and is given to the client with meals to manage blood glucose. This medication will lower blood glucose and could potentially cause hypoglycemia. The client is NPO and will not receive any food. Thus, the nurse should question the administration of this medication to prevent the client from developing hypoglycemia.

Which lab value alteration is likely a result of corticosteroid treatment in type 1 diabetic patients diagnosed with pneumonitis? A. Potassium 5.1 mEq/L (5.1 mmol/L) B. Sodium 138 mEq/L (138 mmol/L) C. Albumin 3.5 g/dL (5.07 umol/L) D. Glucose 200 mg/dL (11.1 mmol/L)

D. Glucose 200 mg/dL (11.1 mmol/L) Type 1 diabetes is characterized by hyperglycemia secondary to the body's inability to create insulin. Corticosteroids cause a rise in blood sugar even in a non-diabetic patient by increasing insulin resistance and triggering the liver to release additional glucose. Prednisone and other steroids can cause a spike in blood sugar levels by making the liver resistant to insulin. Steroids can make the liver less sensitive to insulin because they cause it to carry on releasing sugar, even if the pancreas is also releasing insulin. This continued release of sugar triggers the pancreas to stop producing the hormone.

When looking for trends in a postoperative patient's vital signs, which documents would the nurse review first? A. Admission sheet B. Admission nursing assessment C. Activity flow sheet D. Graphic record

D. Graphic record The graphic record should be reviewed first.

The nurse is caring for a client who has diabetes mellitus. Which of the following would indicate the client is achieving the treatment goals? A. Fasting blood glucose 145 mg/dl B. Creatinine 2.3 mg/dl C. Urine Specific Gravity 1.043 D. Hemoglobin A1C 6.7%

D. Hemoglobin A1C 6.7% The treatment goal for a client with diabetes mellitus is to minimize episodes of hyperglycemia which will then, in turn, reduce the hemoglobin A1C. The treatment goal for a client with diabetes mellitus is to keep the A1C less than 7%.

Which of the following questions is the least useful in assessing a client who is requesting an AIDS test? A. Are you a drug user? B. Do you have many sex partners? C. What is your method of birth control? D. How old were you when you became sexually active?

D. How old were you when you became sexually active? The age at which sexual activity began is not relevant as it does not usually provide information that identifies risk factors for AIDS. When interviewing clients who are seeking/receiving care, the nurse needs to be nonjudgmental. Also, many patients are reluctant to disclose illicit drug use unless a safe environment has been established. Use words that describe behaviors like "drinking" and "using cocaine" instead of words that describe people such as junkie, crack head, addict, alcoholic, and other pejorative terms. . Start with less threatening questions. Examples: What over-the-counter and prescription medications are you taking? • Do you inject any of those? • How often do you use alcohol? Tobacco? • When was the last time you used a drug from a non-medical source? • Do not assume anything. Drug use occurs in all socioeconomic statuses. If a patient says s/he uses or has used drugs, ask about specific medications (e.g. marijuana, heroin, methamphetamine).Don't forget that people also inject insulin, steroids, and hormones. Sharing injection equipment with these medications can also increase the risk of HIV transmission.

When assessing for dehydration, what will the nurse observe? A. Headache and increased urinary output. B. Weight gain and edema. C. Hypertension and decreased urinary output. D. Hypotension, headache, and dry mucous membranes.

D. Hypotension, headache, and dry mucous membranes. When there is an excessive loss of fluid within the body, dehydration can occur. Dehydration may be caused by acute illness or a chronic disease process. Common symptoms include dry mucous membranes, dark urine, decreased urinary output, confusion, low blood pressure, muscle cramps, and constipation.

This nurse is caring for a client who is receiving prescribed citalopram. Which of the following findings would indicate a therapeutic response? A. Improved muscle coordination B. Circumstantial speech pattern C. Longer attention span D. Increased self-esteem

D. Increased self-esteem Citalopram is an antidepressant. This selective serotonin reuptake inhibitor (SSRI) is prescribed for depressive and anxiety disorders. If a client has depression, one of the associated manifestations is decreased self-esteem/self- worth. This may cause clients to reduce their ability to engage with others and become socially withdrawn.

The nurse is caring for a client with newly prescribed zolpidem. The nurse understands that this medication is indicated for which condition? A. Attention Deficit Hyperactivity Disorder B. Generalized Anxiety Disorder C. Narcolepsy D. Insomnia

D. Insomnia Zolpidem is a non-benzodiazepine indicated in the treatment of insomnia.

The nurse is caring for a client with newly prescribed zolpidem. The nurse understands that this medication is indicated for which condition? A. Attention Deficit Hyperactivity Disorder B. Generalized Anxiety Disorder C. Narcolepsy D. Insomnia

D. Insomnia Zolpidem is a non-benzodiazepine indicated in the treatment of insomnia.

The nurse is caring for a client demonstrating avolition. The nurse would expect to observe which of the following? A. Loss of balance B. Full range of affect C. Diminished expression D. Lack of motivation

D. Lack of motivation Avolition is a lack of motivation and is a key feature in schizophrenia (it is a negative symptom), as well as some depressive disorders.

The licensed practical/vocational nurse (LPN/VN) is assisting a registered nurse (RN) care for a client receiving mechanical ventilation for a traumatic brain injury. Which of the following actions by the RN requires the PN/VN to interevene? A. Suctioning the client when the high-pressure alarm sounds B. Hyperventilating with 100% FiO2 prior to suctioning C. Performs oral care with a chlorhexidine solution D. Maintaining the head of the client's bed at 90 degrees

D. Maintaining the head of the client's bed at 90 degrees Maintaining a client's head of the bed at 90 degrees is detrimental for a client with a traumatic brain injury. The client should avoid hip and neck flexion as this raises ICP. Head of the bed recommendations for a client with a risk for increased ICP is 30 to 45 degrees. This is also recommended to prevent the client from developing ventilator-acquired pneumonia, as the question states the patient is on mechanical ventilation.

The nurse is caring for a patient newly diagnosed with Rheumatoid Arthritis. The nurse should anticipate a prescription for which of the following medications? A. Calcitonin B. Glucosamine C. Allopurinol D. Methotrexate

D. Methotrexate Disease-Modifying Anti Rheumatic Drugs (DMARDs) are indicated in the treatment of Rheumatoid Arthritis. These medications primarily work by suppressing the immune system from attacking the joint spaces. Drugs within this class include methotrexate and hydroxychloroquine.

What behavior would the nurse expect to see in a couple that is over the age of 35 and expecting a baby? A. Increased financial concern related to costs associated with the birth. B. Increased confidence related to previous childbirth experiences. C. Increased anxiety of physical risk related to maternal age. D. Moderate anxiety related to uncertainty about fetal well being.

D. Moderate anxiety related to uncertainty about fetal well being. In addition to nursing diagnoses applicable to all pregnant women, the expectant couple over the age of 35 may have additional concerns about their baby's well-being as it increases the risk of Down syndrome or other genetic disorders. Advanced maternal age for childbearing has been traditionally set at 35 years old, although the average age for a first pregnancy in the United States has increased in recent years. Some of the reasons women delay pregnancy are that they want to be in a stable relationship, have fertility problems, or be established in their careers. An advanced maternal age for childbearing is seen by healthcare professionals to be correlated with poorer outcomes in pregnancy. This may be because of a higher incidence of chronic medical conditions.

What behavior would the nurse expect to see in a couple that is over the age of 35 and expecting a baby? A. Increased financial concern related to costs associated with the birth. B. Increased confidence related to previous childbirth experiences. C. Increased anxiety of physical risk related to maternal age. D. Moderate anxiety related to uncertainty about fetal well being.

D. Moderate anxiety related to uncertainty about fetal well being. In addition to nursing diagnoses applicable to all pregnant women, the expectant couple over the age of 35 may have additional concerns about their baby's well-being as it increases the risk of Down syndrome or other genetic disorders. Advanced maternal age for childbearing has been traditionally set at 35 years old, although the average age for a first pregnancy in the United States has increased in recent years. Some of the reasons women delay pregnancy are that they want to be in a stable relationship, have fertility problems, or be established in their careers. An advanced maternal age for childbearing is seen by healthcare professionals to be correlated with poorer outcomes in pregnancy. This may be because of a higher incidence of chronic medical conditions.

When assessing a client who has been ordered skeletal traction, the assessment reveals her foot is pale, cool, and her pulse is not palpable. What is the priority nursing intervention? A. Reassess the foot in twenty minutes. B. Readjust the traction. C. Administer the ordered as-needed medication. D. Notify the physician.

D. Notify the physician. The symptoms indicate circulatory impairment. The physician (or practitioner) must be notified immediately.

Which of the following is a neurological complication that may occur when a vest restraint is too tight around a patient's body? A. Skin breakdown B. Strangulation C. Changes in skin pallor D. Numbness and tingling

D. Numbness and tingling The neurological complication that can occur when a vest restraint is too tight around the client's body is numbness and tingling. Unless corrected, it can lead to neurological damage.

The nurse is caring for a client who was newly placed on a clozapine prescription. Which of the following teaching points should the nurse reinforce? A. Maintain a healthy diet because of weight gain B. Exercise regularly and maintain hydration C. Expect excessive secretions in the mouth D. Obtain follow-up laboratory work

D. Obtain follow-up laboratory work Follow-up laboratory work is essential for a client taking clozapine. The medication may adversely cause neutropenia. The client will be instructed to obtain this necessary laboratory work to ensure they are not experiencing agranulocytosis, which may make the client susceptible to infection.

The nurse working on a medical-surgical unit is assigned as a preceptor to work with a newly hired nurse. Which of the following, if performed first by the newly hired nurse, would indicate the ability to prioritize appropriately? A. Initiates a referral for a patient needing home health care. B. Performs a central line dressing change on a patient receiving 0.9% saline infusion. C. Collects a urine specimen from a patient's indwelling urinary catheter. D. Obtains capillary blood glucose for a patient receiving continuous regular insulin.

D. Obtains capillary blood glucose for a patient receiving continuous regular insulin. A client receiving continuous regular insulin infusion requires hourly capillary blood glucose checks because of the high risk of hypoglycemia. Regular insulin via intravenous infusion peaks within fifteen to thirty minutes. Thus, the nurse needs to watch for signs of hypoglycemia, including tachycardia, palpitations, and diaphoresis.

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

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

The nurse working on a medical-surgical unit is assigned as a preceptor to work with a newly hired nurse. Which of the following, if performed first by the newly hired nurse, would indicate the ability to prioritize appropriately? A. Initiates a referral for a patient needing home health care. B. Performs a central line dressing change on a patient receiving 0.9% saline infusion. C. Collects a urine specimen from a patient's indwelling urinary catheter. D. Obtains capillary blood glucose for a patient receiving continuous regular insulin.

D. Obtains capillary blood glucose for a patient receiving continuous regular insulin. A client receiving continuous regular insulin infusion requires hourly capillary blood glucose checks because of the high risk of hypoglycemia. Regular insulin via intravenous infusion peaks within fifteen to thirty minutes. Thus, the nurse needs to watch for signs of hypoglycemia, including tachycardia, palpitations, and diaphoresis.

A nursing assistant tells the nurse that her patient with COPD did not get his annual flu shot this year and has not had a pneumonia vaccination. The CNA should report one of the findings to the nurse immediately? A. Blood Pressure of 150/80 mm/Hg B. Respiratory rate of 26 breaths/min C. The heart rate of 92 beats/min D. Oral temperature of 101.4 degrees F

D. Oral temperature of 101.4 degrees F An elevated temperature indicates some form of infection, possibly respiratory in origin. A patient who did not receive pneumonia or influenza vaccine is at increased risk of developing pneumonia and influenza. Monitoring for signs/symptoms of infection is a crucial nursing intervention.

A nursing assistant tells the nurse that her patient with COPD did not get his annual flu shot this year and has not had a pneumonia vaccination. The CNA should report one of the findings to the nurse immediately? A. Blood Pressure of 150/80 mm/Hg B. Respiratory rate of 26 breaths/min C. The heart rate of 92 beats/min D. Oral temperature of 101.4 degrees F

D. Oral temperature of 101.4 degrees F An elevated temperature indicates some form of infection, possibly respiratory in origin. A patient who did not receive pneumonia or influenza vaccine is at increased risk of developing pneumonia and influenza. Monitoring for signs/symptoms of infection is a crucial nursing intervention.

In preparing for an admission of a toddler who has been diagnosed with febrile seizures, which of the following is the most important nursing action? A. Order a stat admission CBC. B. Place a urine collection bag and specimen cup at the bedside. C. Place a cooling mattress on his bed. D. Pad the side rails of his bed.

D. Pad the side rails of his bed. The child has a diagnosis of febrile seizures. Precautions to prevent injury and promote safety should take precedence. Children between 6 months and five years are at higher risk for fever-induced (febrile) seizures. Febrile seizures are not associated with neurological seizure disorders. The priority in nursing care for a patient (of any age) who has experienced a seizure is implementing safety precautions that decrease the likelihood of injury if/when another seizure occurs.

The nurse is assessing a patient with Guillain Barré syndrome. Which of the following would be an expected finding? A. Hyperreflexia B. Perseveration C. Dystonia D. Paresthesia

D. Paresthesia Guillain Barré is a polyneuropathy that is manifested by paralysis, paresthesia, autonomic disturbances, and depressed or absent reflexes. The paresthesia is typically found in the peripheral extremities and may persist for quite some time even after the return of motor function.

Although you were informed that your assigned client has no special skincare needs, you observe reddened areas over bony prominences upon your assessment. What is the next appropriate action? A. Correct the initial assessment form. B. Redo the assessment and document the current findings. C. Conduct and document an emergency assessment. D. Perform and document a focused assessment of skin integrity.

D. Perform and document a focused assessment of skin integrity. Performing and documenting a focused assessment of skin integrity is appropriate since this is a newly identified problem.

Although you were informed that your assigned patient has no special skincare needs, you observe reddened areas over bony prominences upon your assessment. What is the next appropriate action? A. Correct the initial assessment form. B. Redo the assessment and document the current findings. C. Conduct and document an emergency assessment. D. Perform and document a focused assessment of skin integrity.

D. Perform and document a focused assessment of skin integrity. Performing and documenting a focused assessment on skin integrity is appropriate since this is a newly identified problem.

The nurse is caring for a patient with a jejunostomy tube receiving intermittent enteral feedings. Which intervention would be the highest priority to reduce the risk of aspiration for this patient? A. Flush the tubing with 20 mL water after feeding is completed. B. Position the patient in a left-lying position after feedings. C. Assess blood glucose every 6 hours. D. Place the patient in semi-Fowler's following feedings.

D. Place the patient in semi-Fowler's following feedings. The nurse should assist this patient in semi-Fowler's position or lay them on the right side following feedings, as these positions will reduce the risk of leakage, gastric reflux, and aspiration.

The nurse is preparing to insert an indwelling urinary catheter. Which action may be delegated to the unlicensed assistive personnel (UAP)? A. Set up the sterile field B. Palpate the bladder for distention C. Explain the procedure to the client D. Place the urinary catheter kit at the bedside

D. Place the urinary catheter kit at the bedside This task is appropriate to delegate to the UAP. Gathering supplies (suction, vital sign equipment, etc.) is within the scope of a UAP.

The nurse is preparing to perform a fetal non-stress test on a patient who is 34 weeks pregnant. Which action would be most important for the nurse to perform prior to this procedure? A. Explain the possible risk of inducing early labor. B. Confirm the patient's NPO status for at least 4 hours prior to the test. C. Administer oxytocin to stimulate uterine contraction. D. Position the patient in Sims position.

D. Position the patient in Sims position. The nurse should instruct the patient to void prior to the test, then assist her into the left-lying Sims position to promote optimal oxygen delivery to the fetus.

When assessing the posterior tibial pulses, what is the correct method to document that the patient's pulse is weak and thready? A. Grade C posterior tibial pulse. B. Posterior tibial pulse is Grade B. C. The client's posterior tibial is +2. D. Posterior tibial pulse is +1.

D. Posterior tibial pulse is +1. When assessing pulses, the strength, volume, and fullness of the peripheral pulses are categorized and documented as follows: • 0: Absent pulses • 1: Weak pulse • 2: Normal pulse 3: Increased volume . 4: Abounding pulse

A client newly diagnosed with diabetes mellitus has a glycosylated hemoglobin A₁c level of 10% (<5.7%). Based on this laboratory value, the nurse should reinforce which teaching point? A. Avoid infection B. Consume adequate fluids C. Prevent and recognize hypoglycemia D. Prevent and recognize hyperglycemia .

D. Prevent and recognize hyperglycemia Glycosylated Hemoglobin is tested to monitor the long-term control of diabetes mellitus. It measures the amount of glucose bound to the red blood cells from circulating glucose. If the blood glucose level rises, glycosylation is also elevated. This indicates that the client had periods of undetected hyperglycemia. For glycosylated hemoglobin A1c, 7% or less indicates optimal control, 7% to 8% indicates okay control, and 8% or higher indicates poor control. The test result helps the nurse identify the continued need for teaching related to the prevention of hyperglycemic episodes.

A 40-year-old patient who is blind and deaf has been admitted to the medical floor. What is the nurse's primary responsibility for this patient? A. Make others aware of the patient's deficits. B. Communicate with the nursing supervisor any patient safety concerns. C. Continuously update the patient on the social environment. D. Provide a safe and secure environment.

D. Provide a safe and secure environment. The nurse's primary responsibility is patient safety. For this deaf and blind patient, it is critical to provide a secure environment. According to Maslow's hierarchy of needs, first physiological needs and then safety needs should be prioritized. Visual impairment has been associated with falls that often result in fractures and dislocations. A patient with visual impairment may experience disorientation as a consequence of being in a strange hospital environment. Certain important interventions the nurse can undertake in providing a secure environment for a deaf-blind client include: • Escorting the patient around the new environment as and when required. This will help meet the need for safety, promote some orientation and instill a feeling of security in the patient. • Orienting patient to the layout of the room, restrooms, location and operation of the call button, telephone, television, and environmental controls. Such orientation helps prevent accidents. The nurse must also provide adequate supervision when the patient needs to use the restroom. Other measures include placing the bedside locker on the side most appropriate for the individual patient and placing the call button within easy reach. • Orienting patient to treatment room and supplies. • Orienting patient to lounges, recreation rooms, and nursing station in relationship to patient's room. • Communicating evacuation/rescue plans. Orientation to fire alarm pull boxes, fire extinguisher, and emergency exits. • Training in self-care and use of medical equipment. • Assisting with feeding, toileting, bathing, or dressing (only if required).

Which action would be the most appropriate for a nurse to use as an alternative to restraints for an elderly patient who is disoriented and tends to wander the halls of his long-term care facility? A. Sit the patient in a geriatric chair near the nurse's station. B. Use bedsheets to secure the patient snuggly in bed. C. Keep the patient's bed in a high position, so he doesn't get out. D. Put the patient's picture and a balloon on his door, so he knows which room is his. l

D. Put the patient's picture and a balloon on his door, so he knows which room is his. Identifying the patient's door with his picture and a balloon may be a helpful alternative to restraints. If safety is not an issue, the resident should be allowed to move about. Measures to help clients who experience confusion or disorientation should be initiated. Many nursing homes and assisted living facilities allow residents and family members to personalize the client's door in much the same way that a private person would decorate his/her front door of their home.

The nurse is caring for a client diagnosed with diabetes mellitus, type I. Which of the following teaching points is most important for the nurse to reinforce? A. Check a hemoglobin A1C level every three months B. Rotate injection sites for insulin administration C. Examine their feet with a mirror daily D. Recognize the symptoms of hypoglycemia

D. Recognize the symptoms of hypoglycemia This is the most important for the nurse to reinforce because hypoglycemia may cause significant harm. Signs and symptoms of hypoglycemia include palpitations, tachycardia, cool and clammy skin, lethargy, and coma.

The nurse is providing a handoff report to a nurse in the critical care unit. The nurse states that it would be helpful for the primary healthcare provider (PHCP) to refer the client to an outpatient support group at discharge. This statement represents which part of the ISBAR handoff report? A. Situation B. Background C. Assessment D. Recommendation

D. Recommendation The nurse providing this statement to the critical care nurse illustrates recommendations. A recommendation is at the end of the ISBAR format, where the nurse can opine their thoughts on what would be necessary for the client.

The nurse is developing the care plan for an 86-year-old patient with a diagnosis of cor pulmonale. Which nursing intervention would be most important to include in regards to monitoring this patient's peripheral edema? A. Assess for skin tenting over the sternum B. Weigh the patient at the same time daily C. Obtain a baseline BNP level D. Record the calf circumference daily

D. Record the calf circumference daily Cor pulmonale describes right ventricular enlargement due to pulmonary hypertension. The accumulation of fluid in the interstitial spaces results in dependent edema, jugular vein distension, shortness of breath, and weight gain. Measuring and recording the circumference of the extremity at the same location daily is the best way to monitor for changes in the patient's peripheral edema.

The nurse is developing the care plan for an 86-year-old patient with a diagnosis of cor pulmonale. Which nursing intervention would be most important to include in regards to monitoring this patient's peripheral edema? A. Assess for skin tenting over the sternum B. Weigh the patient at the same time daily C. Obtain a baseline BNP level D. Record the calf circumference daily

D. Record the calf circumference daily Cor pulmonale describes right ventricular enlargement due to pulmonary hypertension. The accumulation of fluid in the interstitial spaces results in dependent edema, jugular vein distension, shortness of breath, and weight gain. Measuring and recording the circumference of the extremity at the same location daily is the best way to monitor for changes in the patient's peripheral edema.

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

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

A nurse is reviewing laboratory data for a client with suspected diabetes mellitus (DM). Which of the following actions should the nurse take? See the exhibit. View Exhibit Lab=Glycosylated Hemoglobin A1C Result =6.1% Lab =Fasting Plasma Glucose Result =108 mg/dl A. Data collect on the client for a potential infection B. Instruct the client that the results are within normal limits. C. Review the client's urine analysis for glycosuria. D. Reinforce teaching to the client regarding a diet with low glycemic foods

D. Reinforce teaching to the client regarding a diet with low glycemic foods A fasting blood glucose greater than 100 mg/dL indicates impaired fasting glucose. A hemoglobin A1C falling between 5.7% and 6.4% is prediabetes. This client is showing evidence of poor glucose control and has prediabetes. The client needs to be educated on lifestyle changes such as exercise and consuming foods low in simple carbohydrates. The levels need to be monitored with the goal of both levels decreasing through lifestyle modification.

You suspect that another nurse is verbally and physically abusing a patient. What is the first thing you should do? A. Nothing because you are not certain that it is occurring. B. Nothing because you only suspect the abuse. C. Call the police or the security department. D. Report your suspicions to the charge nurse.

D. Report your suspicions to the charge nurse. LPNs should report suspicions to the charge nurse. The suspicion of abuse is not something to be taken lightly. Nursing and other healthcare providers are mandated by law to report any suspicions of abuse. Knowing the proper protocol for reporting suspected behaviors is essential and should be included in all new employee training.

The nurse is working at the triage desk in the emergency department when a patient arrives and begins speaking in Spanish. The nurse asks if he would like an interpreter, and he shakes his head 'no.' What is the appropriate action for the nurse to take? A. Ask around to see if anyone nearby knows Spanish. B. Call the receptionist who speaks Spanish to translate. C. Pull up Google translate on the internet. D. Request an interpreter from the hospital's interpreter service.

D. Request an interpreter from the hospital's interpreter service. It is most appropriate to request an interpreter from the hospital's interpreter service. A certified medical interpreter has the proper training to quickly and accurately translate the conversation as well as protect client confidentiality. This is the appropriate action by the nurse.

The LPN is taking care of a 9-year-old boy who is undergoing testing for acute myeloid leukemia (AML). She is assisting with the positioning of this patient for a lumbar puncture. Which of the following positions should the nurse place her patient in? A. Prone B. Trendelenburg C. Supine D. Side-lying

D. Side-lying Side-lying is the most appropriate position listed for a lumbar puncture (LP). This will allow the health care provider to identify the lumbar vertebrae and insert the needle into the subarachnoid space at the L3-4 or L4-5 interspace.

When providing bowel training education to a 65-year-old woman with chronic constipation, which of the following indicates that the nurse needs to continue gathering information? A. The client's fluid intake is between 2500-3000 mL per day. B. The client's dietary habits include foods high in bulk. C. The client engages in moderate exercise each day. D. The client states she uses a laxative 4-5 times weekly until bowel regularity is achieved.

D. The client states she uses a laxative 4-5 times weekly until bowel regularity is achieved. The consistent use of laxatives inhibits natural defecation reflexes and is thought to cause rather than cure constipation. The frequent use of laxatives eventually requires larger or stronger doses because the effect is progressively reduced with continual use. Laxatives may also interfere with the body's electrolyte balance and decrease the absorption of specific vitamins. The reasons for constipation can range from lifestyle habits (i.e. lack of exercise) to severe malignant disorders (i.e. colorectal cancer). The nurse should evaluate any complaints of constipation carefully for each individual. A change in bowel habits over several weeks with or without weight loss, pain, or fever should be referred to a primary care provider for a complete medical evaluation.

When providing bowel training education to a 65-year-old woman with chronic constipation, which of the following indicates that the nurse needs to continue gathering information? A. The client's fluid intake is between 2500-3000 mL per day. B. The client's dietary habits include foods high in bulk. C. The client engages in moderate exercise each day. D. The client states she uses a laxative 4-5 times weekly until bowel regularity is achieved.

D. The client states she uses a laxative 4-5 times weekly until bowel regularity is achieved. The consistent use of laxatives inhibits natural defecation reflexes and is thought to cause rather than cure constipation. The frequent use of laxatives eventually requires larger or stronger doses because the effect is progressively reduced with continual use. Laxatives may also interfere with the body's electrolyte balance and decrease the absorption of specific vitamins. The reasons for constipation can range from lifestyle habits (i.e. lack of exercise) to severe malignant disorders (i.e. colorectal cancer). The nurse should evaluate any complaints of constipation carefully for each individual. A change in bowel habits over several weeks with or without weight loss, pain, or fever should be referred to a primary care provider for a complete medical evaluation.

When providing bowel training education to a 65-year-old woman with chronic constipation, which of the following indicates that the nurse needs to continue gathering information? A. The client's fluid intake is between 2500-3000 mL per day. B. The client's dietary habits include foods high in bulk. C. The client engages in moderate exercise each day. D. The client states she uses a laxative 4-5 times weekly until bowel regularity is achieved.

D. The client states she uses a laxative 4-5 times weekly until bowel regularity is achieved. The consistent use of laxatives inhibits natural defecation reflexes and is thought to cause rather than cure constipation. The frequent use of laxatives eventually requires larger or stronger doses because the effect is progressively reduced with continual use. Laxatives may also interfere with the body's electrolyte balance and decrease the absorption of specific vitamins. The reasons for constipation can range from lifestyle habits (i.e. lack of exercise) to severe malignant disorders (i.e. colorectal cancer). The nurse should evaluate any complaints of constipation carefully for each individual. A change in bowel habits over several weeks with or without weight loss, pain, or fever should be referred to a primary care provider for a complete medical evaluation.

The nurse is caring for a 26-year-old patient who is unable to meet their nutritional needs by mouth. The interdisciplinary team decides it would be best to insert an NG tube for enteral feedings. After inserting the tube, the nurse knows that which of the following is the most accurate way to verify the placement of the tube? A. Aspiration of stomach contents B. pH verification of the aspirate C. Auscultation of air in the LUQ when injected into the tube D. Visualization on x-ray

D. Visualization on x-ray Visualization on x-ray is the gold standard for verification of nasogastric tube placement. This allows the radiologist to visualize the tip of the tube in the stomach and recommend any changes in placement that may be needed, such as pulling the tube back or advancing further.

The nurse is teaching a client newly diagnosed with osteoporosis. The nurse should recommend that the client perform which type of exercise? A. Stretching B. Stability and balance C. Cardiovascular D. Weight-bearing

D. Weight-bearing Low-impact weight-bearing exercises are recommended for a client with osteoporosis because of their ability to increase bone density. Examples of this type of exercise include walking and elliptical training.

Which of the following is least likely to influence a client's potential to comply with lithium therapy after discharge? A. The impact of lithium on the client's energy level and lifestyle. B. The need for consistent blood level monitoring. C. The potential side effects of lithium. D. What the client's friends think of his need to take medication.

D. What the client's friends think of his need to take medication. Although a patient's social network may influence compliance, this influence is typically secondary compared to the other factors listed. Lithium is believed to alter neurons' activity containing dopamine, norepinephrine, and serotonin by influencing their release, synthesis, and reuptake. Therapeutic actions are stabilization of mood during periods of depression. It is neither antimanic nor antidepressant in individuals without bipolar disorder.

Which of the following is least likely to influence a client's potential to comply with lithium therapy after discharge? A. The impact of lithium on the client's energy level and lifestyle. B. The need for consistent blood level monitoring. C. The potential side effects of lithium. D. What the client's friends think of his need to take medication.

D. What the client's friends think of his need to take medication. Although a patient's social network may influence compliance, this influence is typically secondary compared to the other factors listed. Lithium is believed to alter neurons' activity containing dopamine, norepinephrine, and serotonin by influencing their release, synthesis, and reuptake. Therapeutic actions are stabilization of mood during periods of depression. It is neither antimanic nor antidepressant in individuals without bipolar disorder.

Following bariatric surgery, which of the following should the nurse give priority to preventing? A. Pain B. Depression C. Thrombophlebitis D. Wound infection

D. Wound infection Wound infection is the most common complication among obese clients who have had surgery. This is mostly in part due to inadequate blood supply in the adipose tissue of obese patients.

Following bariatric surgery, which of the following should the nurse give priority to preventing? A. Pain B. Depression C. Thrombophlebitis D. Wound infection

D. Wound infection Wound infection is the most common complication among obese clients who have had surgery. This is mostly in part due to inadequate blood supply in the adipose tissue of obese patients.

Which statement should the nurse use during client education regarding a vasectomy as a permanent method of contraception? A. If you change your mind in the future, it's simple to reverse the procedure. B. You will need to return for an annual follow-up visit and sperm count. C. If you have a history of cardiac disease, we won't be able to do the vasectomy. D. You'll need to use another type of birth control until your sperm count is zero.

D. You'll need to use another type of birth control until your sperm count is zero. The second method of birth control is necessary until the sperm count is zero. A vasectomy is a form of male birth control that cuts the supply of sperm to your semen. It's done by cutting and sealing the tubes that carry sperm. Vasectomy has a low risk of problems and can usually be performed in an outpatient setting under local anesthesia. Although vasectomy reversals are possible, vasectomy should be considered a permanent form of male birth control. Vasectomy offers no protection from sexually transmitted infections. Vasectomy is a safe and effective birth control choice for men who are sure and don't want to father a child in the future. • Vasectomy is nearly 100 percent effective in preventing pregnancy. • Vasectomy is an outpatient surgery with a low risk of complications or side effects. • A vasectomy cost is far less than the price of female sterilization (tubal ligation) or the long-term value of birth control medications for women.

The nurse is caring for a client who is receiving prescribed risperidone. Which of the following findings would indicate a therapeutic response? The client demonstrates A. a reduction in weight. B. increased mood lability. C. an appropriate gait pattern. D. decreased thoughts of persecution.

D. decreased thoughts of persecution. Risperidone is an atypical (second generation) antipsychotic indicated in psychotic disorders such as schizophrenia. If the client reported decreasing thoughts of persecution (and was observed to have fewer thoughts of persecution), this would be a therapeutic effect.

The nurse is caring for a client who is receiving prescribed risperidone. Which of the following findings would indicate a therapeutic response? The client demonstrates A. a reduction in weight. B. increased mood lability. C. an appropriate gait pattern. D. decreased thoughts of persecution.

D. decreased thoughts of persecution. Risperidone is an atypical (second generation) antipsychotic indicated in psychotic disorders such as schizophrenia. If the client reported decreasing thoughts of persecution (and was observed to have fewer thoughts of persecution), this would be a therapeutic effect.

The nurse is preparing to measure the fundal height of a client at 16 gestational weeks. The nurse should prepare the client for this assessment by instructing the client to A. lay in a side-lying position with the knees bent. B. prepare for the insertion of an intravenous (IV) catheter. C. not to eat or drink two hours after this assessment. D. empty their bladder.

D. empty their bladder. Measuring the fundal height is a painless and noninvasive way to evaluate fetal growth patterns and confirm gestational age. For this assessment, the client should empty their bladder to prevent elevation of the uterus.

The parents of a 9-month-old bring their infant to the nurse who is choking on a foreign object. The infant is conscious and not making any noises. The nurse should immediately A. begin chest compressions at 100-120/minute. B. attempt a blind finger sweep in the mouth. C. perform abdominal thrusts. D. give five back blows and five chest thrusts.

D. give five back blows and five chest thrusts. For the infant choking on a foreign body and conscious and not making any noises, the nurse should immediately give five back blows and five chest thrusts. The nurse should place the baby face down on the forearm to do this. With the arm resting on your thigh and with the heel of your other hand, give the child five quick, forceful blows between the shoulder blades. If this is ineffective, the nurse should turn the infant on its back so that the head is lower than the chest. Place two fingers in the center middle of the breast bone, just below the nipples. Press inward rapidly five times.

The nurse is collecting data on a male client taking prescribed risperidone. Which of the following findings would indicate the client is having an adverse effect? A. ptosis B. gingival hyperplasia C. polycythemia D. gynecomastia

D. gynecomastia Risperidone is an atypical (second-generation) antipsychotic indicated in treating disorders such as schizophrenia, autism with behavioral disturbances, delusional disorder, and bipolar disorder. Risperidone is notorious for causing increased prolactin levels. This increase in prolactin levels may cause a client to develop gynecomastia and/or galactorrhea.

The nurse has become aware of the following client situations. It would be a priority for the nurse to follow up on the client who A. has Cushing's syndrome and their blood glucose has increased from 156 mg/dL to 243 mg/dL. B. is admitted with acute glomerulonephritis and has had 80 mL of urine output over the past four hours. C. is nothing by mouth (NPO) awaiting surgery and receiving glargine insulin two hours ago. D. had a transurethral resection of the prostate six hours ago and has urine output turned bright red in color.

D. had a transurethral resection of the prostate six hours ago and has urine output turned bright red in color. A client who has had a TURP is at high risk for hemorrhage during the first twenty-four hours following this procedure. Signs concerning hemorrhage include large clots and urine that has turned bright red in color. The nurse should obtain vital signs to validate the findings as hemorrhage would be supported by the client having tachycardia and decreased blood pressure.

The nurse has become aware of the following client situations. It would be a priority for the nurse to follow up on the client who A. has Cushing's syndrome and their blood glucose has increased from 156 mg/dL to 243 mg/dL. B. is admitted with acute glomerulonephritis and has had 80 mL of urine output over the past four hours. C. is nothing by mouth (NPO) awaiting surgery and receiving glargine insulin two hours ago. D. had a transurethral resection of the prostate six hours ago and has urine output turned bright red in color.

D. had a transurethral resection of the prostate six hours ago and has urine output turned bright red in color. A client who has had a TURP is at high risk for hemorrhage during the first twenty-four hours following this procedure. Signs concerning hemorrhage include large clots and urine that has turned bright red in color. The nurse should obtain vital signs to validate the findings as hemorrhage would be supported by the client having tachycardia and decreased blood pressure.

The nurse has become aware of the following client situations. The nurse should first assess the client A. with chronic obstructive pulmonary disease (COPD), who is using pursed-lip breathing and reporting a productive cough. B. who had a laparoscopic cholecystectomy three hours ago and is reporting right shoulder pain and abdominal cramping. C. with ulcerative colitis, who had three bloody stools in the past two hours and reporting abdominal cramping. D. two hours postoperative following a tonsillectomy and is reporting throat pain while vomiting.

D. two hours postoperative following a tonsillectomy and is reporting throat pain while vomiting. The client's vomiting following a tonsillectomy requires immediate follow-up because vomiting and coughing may trigger hemorrhage. This client requires immediate follow-up so the nurse may treat the vomiting with prescribed anti-emetics and assess the client for potential hemorrhage.

A client with a history of confusion has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client? A. "Good morning, do you remember where you are?" B. "Hello, my name is Susan Jones, and I am your nurse for today." C. "How are you today? Remember you're in the hospital." D."Good morning, you're in the hospital. I am your nurse, Susan Jones."

D."Good morning, you're in the hospital. I am your nurse, Susan Jones." This option gives the patient information about where he is and who is caring for him. It does not require him to answer questions or risk increasing his agitation if he does not know the answers. When a client is experiencing confusion, it is important for the nurse to provide a calm, predictable environment. Greeting the patient and stating where he is, who you are, and any pertinent information (without overwhelming him) will help prevent increased anxiety, which could lead to worsening confusion.

A client with a history of confusion has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client? A. "Good morning, do you remember where you are?" B. "Hello, my name is Susan Jones, and I am your nurse for today." C. "How are you today? Remember you're in the hospital." D."Good morning, you're in the hospital. I am your nurse, Susan Jones."

D."Good morning, you're in the hospital. I am your nurse, Susan Jones." This option gives the patient information about where he is and who is caring for him. It does not require him to answer questions or risk increasing his agitation if he does not know the answers. When a client is experiencing confusion, it is important for the nurse to provide a calm, predictable environment. Greeting the patient and stating where he is, who you are, and any pertinent information (without overwhelming him) will help prevent increased anxiety, which could lead to worsening confusion.