N1220 Exam 1 Iggy Qs (wks 1 &2)

C loss of both recent and long-term memory is a characteristic of moderate dementia

A 68-year-old patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. difficulty eating and swallowing. c. loss of recent and long-term memory. d. fluctuating ability to perform simple tasks.

A The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years.

C Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely.

A 71-year-old patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? a. Reorient the patient several times daily. b. Have the family bring in familiar items. c. Place the patient in a room close to the nurses' station. d. Ask the patient why the wandering episodes have occurred.

D This question tests the patients short-term memory, which is decreased in the mild stage of Alzheimer's disease or dementia

A 72-year-old female patient is brought to the clinic by the patient's spouse, who reports that she is unable to solve common problems around the house. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Are you sad?" b. "How is your self-image?" c. "Where were you were born?" d. "What did you eat for breakfast?"

D There are three drugs available by prescription for weight loss, including orlistat (Xenical), lorcaserin (Belviq), and phentermine-topiramate (Qsymia). Suicidal thoughts are possible with lorcaserin and phentermine topiramate. Orlistat is also available in a reduced-dose over-the-counter formulation

A client asks the nurse about drugs for weight loss. What response by the nurse is best? a. All weight-loss drugs can cause suicidal ideation. b. No drugs are currently available for weight loss. c. Only over-the-counter medications are available. d. There are three drugs currently approved for this.

C To promote airway clearance, this client should be placed in a semi- or high-Fowlers position. Oral care can be delegated, but that is not the priority. Intake and output should also be recorded but again is not the priority. The inner cannula may or may not need to be cleaned, and the tracheostomy may or may not have a disposable cannula

A client had an oral tumor removed this morning and now has a tracheostomy. What action by the nurse is the priority? a. Delegate oral care every 4 hours. b. Monitor and record the clients intake. c. Place the client in a high-Fowlers position. d. Remove the inner cannula for cleaning.

B Clients with NG tubes need frequent oral care both for comfort and to prevent infection. Lavaging the tube is done by the nurse. Re-positioning the tube, if needed, is also done by the nurse. The UAP can take vital signs, but this is not a comfort measure.

A client had an upper gastrointestinal hemorrhage and now has a nasogastric (NG) tube. What comfort measure may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Lavaging the tube with ice water b. Performing frequent oral care c. Re-positioning the tube every 4 hours d. Taking and recording vital signs

B To avoid exposure to blood and body fluids, the nurse first puts on a pair of gloves. Taking v/s and notifying the surgeon are also appropriate, but the nurse must protect himself or herself first. The surgeon will reinsert the NG tube either at the bedside or in surgery if the client needs to go back operating room.

A client has a nasogastric (NG) tube after a Nissen fundoplication. The nurse answers the call light and finds the client vomiting bright red blood with the NG tube lying on the floor. What action should the nurse take first? a. Notify the surgeon. b. Put on a pair of gloves. c. Reinsert the NG tube. d. Take a set of vital signs.

C The client should be able to turn his or her head to prevent pulling the tube out with movement. The other actions are appropriate.

A client has a nasogastric (NG) tube. What action by the nursing student requires the registered nurse to intervene? a. Checking tube placement every 4 to 8 hours b. Monitoring and documenting drainage from the NG tube c. Pinning the tube to the gown so the client cannot turn the head d. Providing oral care every 4 to 8 hours

A Elevating the extremity above the level of the heart will help with swelling and pain. Fans are not recommended as they can disperse microbes. Having a cool, wet cloth on the wound may macerate the broken skin. Taking the clients temperature provides data but does not increase comfort.

A client has a wound infection to the right arm. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Elevate the arm above the level of the heart. b. Order a fan to help cool the client if feverish. c. Place cool, wet cloths on top of the wound. d. Take the clients temperature every 4 hours.

A The treatment regimen for TB ranges from 6-12 months, making adherence problematic for many people. The nurse should stress the absolute importance of following the treatment plan for the entire duration of prescribed therapy. The other options are appropriate topics to educate this client on, but do not take priority.

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity

A The nurse needs to obtain further information about the spouses specific fears so they can be addressed. This will decrease stress and permit visitation, which will be beneficial for both client and spouse. Precautions for TB prevent transmission to all who come into contact with the client. Explaining isolation precautions and what to do when entering the room will be helpful, but this is too narrow in scope to be the best answer. Telling the spouse its safe to visit is demeaning of the spouses feelings.

A client has been hospitalized with tuberculosis (TB). The clients spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. b. Inform the spouse the precautions are meant to keep other clients safe. c. Show the spouse how to follow the isolation precautions to avoid illness. d. Tell the spouse that he or she has already been exposed, so its safe to visit.

B Visitors may be apprehensive about visiting a client in Transmission-Based Precautions. The nurse would reassure the visitors that taking appropriate precautions will minimize their risks. The nurse would then demonstrate what precautions were needed. The other options do nothing to ease the family's fears

A client has been placed on Contact Precautions. The client's family is very afraid to visit for fear of being "contaminated" by the client. What action by the nurse is best? a. Explain to them that these precautions are mandated by law. b. Show the family how to avoid spreading the disease. c. Reassure the family that they will not get the infection. d. Tell the family it is important that they visit the client.

B Families and clients often have negative reactions to isolation precautions. The nurse can explain that the infection is the problem, not the client, and encourage them to visit because following the precautions will prevent them from acquiring the infection. The other options do not give the family useful information to help them make an informed decision.

A client has been placed on Contact Precautions. The clients family is very afraid to visit for fear of being contaminated by the client. What action by the nurse is best? a. Explain to them that these precautions are mandated by law. b. Inform them that the infection is the issue, not the client. c. Reassure the family that they will not get the infection. d. Tell the family it is important that they visit the client

B INH can cause liver damage, especially if the client drinks alcohol. The ALT (one of the liver enzymes) is extremely high and needs to be reported immediately. The albumin and RBCs are normal. The WBCs are slightly high, but that would be an expected finding in a client with an infection.

A client has been taking isoniazid for tuberculosis for 3 weeks. What laboratory results need to be reported to the primary health care provider immediately? a. Albumin: 5.1 g/dL (7.4 mcmol/L) b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/million/µL (5.2 1012/L) d. White blood cell (WBC) count: 12,500/mm3 (12.5 109/L)

C Omeprazole is a PPI used in the treatment of GERD. Famotidine and Ranitidine are histamine blockers. Maalox is an antacid

A client has gastroesophageal reflux disease (GERD). The provider prescribes a proton pump inhibitor. About what medication should the nurse anticipate teaching the client? a. Famotidine (Pepcid) b. Magnesium hydroxide (Maalox) c. Omeprazole (Prilosec) d. Ranitidine (Zantac)

D The drainage in the NG tube should initially be brown with old blood. The presence of bright red blood indicates bleeding. The nurse should take a set of v/s to assess for shock and then notify the surgeon. Documentation should occur but it is not the first thing the nurse should do. The nurse should not wait and additional hour to reassess.

A client has returned to the nursing unit after an open Nissen fundoplication. The client has an indwelling urinary catheter, a nasogastric (NG) tube to low continuous suction, and two IVs. The nurse notes bright red blood in the NG tube. What action should the nurse take first? a. Document the findings in the chart. b. Notify the surgeon immediately. c. Reassess the drainage in 1 hour. d. Take a full set of vital signs.

C the nurse should hold the feeding until the N/V have subsided and consult with the provider on the rate at which to restart the feeding. Giving antiemetics is not appropriate. After vomiting, a gastric residual will not be accurate. The nurse should not continue to feed the client while they are vomiting.

A client having a tube feeding begins vomiting. What action by the nurse is most appropriate? a. Administer an antiemetic. b. Check the clients gastric residual. c. Hold the feeding until the nausea subsides. d. Reduce the rate of the tube feeding by half.

B, C Rifampin can cause liver damage, as evidenced by the clients high INR and prothrombin time. *normal INR: 0.8-1.8 *normal PT: 11-12.5 sec The BUN and WBC count are normal *normal BUN range: 10-20 *normal WBC range: 5000-10,000 The sodium level is low, but that is not r/t this clients problem. *normal sodium level: 135-145

A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L e. White blood cell (WBC) count: 72,000/mm3

D Prior to administering antibiotics, the nurse obtains the ordered cultures. Broad-spectrum antibiotics will be administered until the culture and sensitivity results are known. Antipyretics are given if the client is uncomfortable; fever is a defense mechanism. Giving antipyretics does not take priority over obtaining cultures. The client may or may not need isolation.

A client is admitted with possible sepsis. Which action should the nurse perform first? a. Administer antibiotics. b. Give an antipyretic. c. Place the client in isolation. d. Obtain specified cultures.

C This allergy test is actually a positive TB test. The client should be placed on Airborne Precautions immediately. The other options do not take priority over preventing the spread of the disease.

A client is admitted with suspected pneumonia from the emergency department. The client went to the primary care provider a few days ago and shows the nurse the results of what the client calls an allergy test, as shown below: What action by the nurse takes priority? a. Assess the client for possible items to which he or she is allergic. b. Call the primary care providers office to request records. c. Immediately place the client on Airborne Precautions. d. Prepare to begin administration of intravenous antibiotics.

A, C A client with suspected TB is admitted to airborne precautions, which includes: - a negative airflow room - special N95 or PAPR masks to be worn when providing care A 3 foot distance is required for droplet precautions. Chlorhexidine is used for clients with a high risk of infection

A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.) a. Admit the client to a negative-airflow room. b. Maintain a distance of 3 feet from the client at all times. c. Order specialized masks/respirators for caregiving. d. Other than wearing gloves, no special actions are needed. e. Wash hands with chlorhexidine after providing care.

B All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs. However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes.

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The clients sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. All my friends and neighbors are planning a party for me. b. I hope I can get my water turned back on when I get home. c. I am going to have my daughter scoop the cat litter box. d. My grandkids are so excited to have me coming home!

D Directly observed therapy is often utilized for managing clients with TB in the community.

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting Nurses for directly observed therapy

D Treatment for this infection involves either triple or quadruple drug therapy, which may make it difficult for clients to remain adherent. The nurse should assess the clients willingness and ability to follow the regimen. The other assessment findings are not as critical.

A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important? a. Alcohol intake of 1 to 2 drinks per week b. Family history of H. pylori infection c. Former smoker still using nicotine patches d. Willingness to adhere to drug therapy

B

A client is diagnosed with C. difficile infection. What nursing action is the priority for the client? A. Provide meticulous skin care. B. Place the client on Contact Precautions. C. Give the client an antipyretic medication. D. Encourage the client to drink extra fluids.

A Medication errors are the most common type of health care mistake. The Joint Commissions Speak Up campaign encourages clients to help ensure their safety. One recommendation is for clients to know all their medications and why they take them. This will help prevent medication errors.

A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors? a. Bring a list of all medications and what they are for. b. Keep the doctors phone number by the telephone. c. Make sure all providers wash hands before entering the room. d. Write down the name of each caregiver who comes in the r

A Hospitalized clients who have 3 or more stools a day for 2 or more days is suspected of having an infection with Clostridium difficile. The nurse should inform the practitioner and request stool cultures. Frequent perianal care is important and can be delegated but is not the priority. The client does not necessarily need to be NPO; if the client is NPO, the nurse ensures he or she is getting appropriate IV fluids to prevent dehydration. Anti-diarrheal medication may or may not be appropriate, and the diarrhea serves as the portal of exit for the infection.

A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important? a. Consult with the provider about obtaining stool cultures. b. Delegate frequent perianal care to unlicensed assistive personnel. c. Place the client on NPO status until the diarrhea resolves. d. Request a prescription for an anti-diarrheal medication

A High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the range of 140 to 180 mg/dL (7.7 to 10 mmol/L.) Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not "made" the client diabetic.

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL (11.6 mmol/L). The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. "High glucose is common in shock and needs to be treated." b. "Some of the medications we are giving are to raise blood sugar." c. "The IV solution has lots of glucose, which raises blood sugar." d. "The stress of this illness has made your spouse a diabetic."

A, B, D, E The AP can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. If the nurse assesses the client is safely able to swallow, small amounts of fluids would be allowed. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the client's painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance

B Odynophagia is painful swallowing. The nurse should assess the client for this either by asking or by having the client attempt to drink water. It is not related to specific foods and is not assessed by palpating the jaw. Being unable to swallow saliva is not odynophagia, but it would be a serious situation.

A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate? a. Ask the client what foods cause trouble swallowing. b. Assess the client for pain when swallowing. c. Determine if the client can swallow saliva. d. Palpate the clients jaw while swallowing.

D Sneezing and coughing into one's sleeve helps prevent the spread of upper respiratory infections. The client does have s/s of the Flu, but it is too late to start antiviral medications. For antiviral meds to be effective, they must be started within 24-48 hours of symptom onset. The client does not need hospital admission. The client would be instructed to have a flu vaccination, but now that he or she has the flu, vaccination will have to wait until next year.

A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes that the client also has a severe headache and muscle aches. What action by the nurse is best? a. Educate the client on oseltamivir. b. Facilitate admission to the hospital. c. Instruct the client to have a flu vaccine. d. Teach the client to sneeze in the upper sleeve.

A This patient has a 12% weight loss. The nurse first determines if the weight loss was unintentional. If not, then the nurse proceeds to do a comprehensive nutritional assessment. Food intolerances are a part of this assessment. Depending on risk factors and other findings, a blood glucose test may be warranted.

A client is in the family practice clinic. Today the client weighs 186.4 pounds (84.7 kg). Six months ago the client weighed 211.8 pounds (96.2 kg). What action by the nurse is best? a. Ask the client if the weight loss was intentional. b. Determine if there are food allergies or intolerances. c. Perform a comprehensive nutritional assessment. d. Perform a rapid bedside blood glucose test

B For bolus feedings, the nurse checks placement of the tube per facility policy prior to each feed, which is often more than every 8 hours during the day. Auscultating lung sounds is also important, but this will indicate a complication that has already occurred. Weighing the client is important to determine if nutritional goals are being met.

A client is receiving bolus feedings through a tube. What action by the nurse is most important? a. Auscultate lung sounds after each feeding. b. Check tube placement before each feeding. c. Check tube placement every 8 hours d. weigh the client daily on the same scale

A This client has clinical indicators of dehydration, so the nurse calculates the clients 24- hour intake, output, and fluid balance. This info is then reported to the provider. The clients oral cavity assessment may or may not be consistent with dehydration. The nurse may need to give the client a fluid bolus, but not as an independent action. The clients dehydration is most likely due to fluid shifts from the TPN, so turning up the infusion rate would make the problem worse, and is not done as an independent action

A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the clients pulse is 128 beats/min, blood pressure is 98/56 mm Hg, and skin turgor is dry. What action should the nurse perform next? a. Assess the 24-hour fluid balance. b. Assess the clients oral cavity. c. Prepare to hang a normal saline bolus. d. Turn up the infusion rate of the TPN.

D Clients on TPN are at a high risk for infection. The nurse performs hand hygiene as a priority intervention. Checking blood glucose is also an important measure, but preventing infection takes priority. The IV dressing is changed every 48 to 72 hours. TPN does not need to be double-checked with another nurse.

A client is receiving total parenteral nutrition (TPN). What action by the nurse is most important? a. Assessing blood glucose as directed b. Changing the IV dressing each day c. Checking the TPN with another nurse d. Performing appropriate hand hygiene

B Clients facing this long, difficult procedure are often anxious and fearful. The nurse should now assess the clients psychosocial status and provide the care and teaching required based on this assessment. An intensive care unit tour may help decrease stress but is too limited in scope to be the best response. Documentation should be thorough, but the nurse needs to do more than document. The client should begin nutritional supplements prior to the operation, but again this response is too limited in scope

A client is scheduled for a traditional esophagogastrostomy. All preoperative teaching has been completed and the client and family show good understanding. What action by the nurse is best? a. Arrange an intensive care unit tour. b. Assess the clients psychosocial status. c. Document the teaching and response. d. Have the client begin nutritional supplements.

A nutritional and lifestyle changes need to continue after surgery as the procedure does not offer a lifetime cure. the other statements show good understanding

A client is scheduled to have a fundoplication. What statement by the client indicates a need to review preoperative teaching? a. After the operation I can eat anything I want. b. I will have to eat smaller, more frequent meals. c. I will take stool softeners for several weeks. d. this surgery may not totally control my symptoms

A, B, E, F The nurse would teach the client that preexisting gout may get worse and the client should report this as medications for gout may need to be adjusted. The nurse would also inform the client about the multi-drug routine used for TB. Optic neuritis can occur with this drug so the client needs to report visual changes right away. The medication should be taken with a full glass of water. Drinking alcohol while taking ethambutol causes severe nausea and vomiting. Avoiding antacids and food (within 2 hours) is a precaution with isoniazid.

A client is taking ethambutol for tuberculosis. What instructions does the nurse provide the client regarding this drug? (Select all that apply.) a. Contact the primary health care provider if preexisting gout becomes worse. b. Report any changes in vision immediately to the health care provider. c. Avoid drinking alcoholic beverages due to the chance of liver damage. d. Do not take antacids or eat within 2 hours after taking this medication. e. You will take this medication along with some others for 8 weeks. f. Take this medicine with a full glass of water.

ANS: 1.6mL order: 4mg morphine sulfate have: 5mg/2mL (2mL / 5mg) x (4mg / dose) = 1.6 mL/dose 2x4= 8 8 divided by 5 = 1.6

A client is to receive 4 mg morphine sulfate IV push. The pharmacy delivers 5 mg in a 2-mL vial. How much should the nurse administer for one dose? (Record your answer using a decimal rounded to the nearest tenth.) ____ mL

D To avoid possible exposure to infectious agents, the nurse dons gloves prior to handling any bodily secretions. Recent exposure to illness is not related to collecting a stool sample. The nurse can visually inspect the stool for food particles, but it still needs analysis in the laboratory. The container should be dated and timed, but safety for the staff and other clients comes first

A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important? a. Ask the client about recent exposure to illness. b. Assess the clients stool for obvious food particles. c. Include the date and time on the specimen container. d. Put on gloves prior to collecting the s

A, B, C, D Chest pain may be common in GERD d/t spasms and stimulation of the pain receptors in the esophagus Hoarseness commonly occurs with coughing and wheezing at night d/t the reflux of acid Dysphagia (difficulty swallowing) is common with GERD d/t the damage that occurs to the esophagus from acid A sore throat is a common symptom d/t the acid in the throat Nausea rarely occurs and is not a common symptom

A client presents to the gastrointestinal clinic for symptoms consistent with GERD. The nurse expects which common symptoms? (select all that apply). a. chest pain b. hoarsness c. dysphagia d. sore throat e. nausea

C while all topics might be important to assess, people who lose and gain weight in cycles are often depressed or have poor self-esteem, which has a negative effect on weight-loss efforts. the nurse assesses the client psychosocial status as the priority.

A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, for what additional data should the nurse assess as the priority? a. Economic ability to join a gym b. Food allergies and intolerances c. Psychosocial influences on weight d. Reasons for wanting to lose weight

A, G

A client who has been taking the four first-line drugs for tuberculosis treatment for a month reports all of the following changes. Which changes would cause the nurse to collaborate quickly with the health care provider? Select all that apply. A. Blurry vision B. Constipation C. Difficulty sleeping D. Nausea when drinking beer E. Red-tinged urine F. Sunburn with minimal sun exposure G. Yellowing of the sclera

B Esophageal dilation can provide immediate relief of esophageal strictures that impair swallowing. Enteral tube feeding is a method of providing nutrition when dysphagia is severe, but esophageal dilation would be attempted before this measure is taken. Nissen fundoplication is performed for severe gastroesophageal reflux disease. Photodynamic therapy is performed for esophageal cancer.

A client with an esophageal tumor is having extreme difficulty swallowing. For what procedure does the nurse prepare this client? a. Enteral tube feeding b. Esophageal dilation c. Nissen fundoplication d. Photodynamic therapy

B, C Comfort measures appropriate for this client include offering frequent cool drinks, and changing linens or gowns when damp. Fever is a defense mechanism and antipyretics should only be administered when the client is uncomfortable. Ice bags can help cool the client quickly but are not comfort measures. Fans are discourages because they can disperse microbes.

A client with an infection has a fever. What actions by the nurse help increase the clients comfort? (Select all that apply.) a. Administer antipyretics around the clock. b. Change the clients gown and linens when damp. c. Offer cool fluids to the client frequently. d. Place ice bags in the armpits and groin. e. Provide a fan to help cool the client.

B

A client with early dementia asks the nurse to find her mother, who is deceased. What is the nurse's most appropriate response? A. "We can call her in a little while if you want." B. "Your mother died over 20 years ago." C. "What did your mother look like?" D. "I'll ask your father to find her when he visits."

ANS: 142 mL/hr The client weighs 250 pounds = 113.63636 kg. The fluid requirement for this client is 30 mL/kg = 3409 mL. To infuse this amount over 24 hours, set the pump at 142 mL/hr (3409/24 = 142).

A client with severe sepsis has a serum lactate level of 6.2 mmol/L. The client weighs 250 pounds. To infuse the amount of fluid this client requires in 24 hours, at what rate does the nurse set the IV pump? (Record your answer using a whole number.) ____ mL/hr

B, C, E If the tube is obstructed, use a 50mL syringe and gentle pressure to attempt to open the tube. Cola products should not be used unless water is not effective. To prevent further problems, determine if any of the medications can be dispensed in liquid form and flush the tube with water before and after medication administration. Do not mix medications with the formula.

A clients small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are best? (Select all that apply.) a. Attempt to dissolve the clog by instilling a cola product. b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. d. Mix all medications in the formula and use a feeding pump. e. Try to flush the tube with 30 mL of water and gentle pressure.

B Delirium is the form of acute, fluctuating confusion which lasts from a few hours to less than 1 month and that may be treatable. Dementia is a chronic state of confusion that may last from a few months to many years and that may not be reversible. Amnesia refers to a loss of memory caused by brain trauma, congenital disorders, or acute health problems

A form of inadequate cognition in older adults which is manifested by an acute, fluctuating confusional state is known as: a. dementia b. delirium c. amnesia d. depression

C Reasoning is the high-level cognitive thinking process that helps individuals make decisions and judgments. Personality is the way an individual feels and behaves Memory is the ability of an individual to retain and recall information. Amnesia refers to a loss of memory caused by brain trauma, congenital disorders, or acute health problems

A high-level thinking process that allows an individual to make decisions and judgments is known as: a. amnesia b. personality c. reasoning d. memory

A, B, D, E Older adults need increased amounts of calcium; vitamins A, C, D; and fiber. Milk has calcium carrots have vitamin A the vitamin D supplement has Vitamin D oranges have vitamin C lean ground beef is healthier than more fatty cuts, but does not contain these needed nutrients

A home health care nurse assesses an older client for the intake of nutrients needed in larger amounts than in younger adults. Which foods found in an older adults kitchen might indicate an adequate intake of these nutrients? (Select all that apply.) a. 1% milk b. Carrots c. Lean ground beef d. Oranges e. Vitamin D supplements

B As a person ages, he or she may experience a decreased sense of touch. The older adult may not be aware of where his or her foot is on the step. Combined with diminished visual acuity, this can create a fall hazard. Holding the handrail would help keep the person safer. If the client does not need an assistive device, he or she would not use a cane or walker just on stairs. Using an alternative door may be necessary but does not address making the front steps safer. A two-footed gait may not help if the client is unaware of where the foot is on the step

A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps? a. Have the client use a walker or cane on the steps. b. Teach the client to hold the handrail when using the steps c. Instruct the client to use the garage door instead. d. Tell the client to use a two-footed gait on the steps.

A This older adult is mostly homebound. Exercise regimens for homebound clients include things to increase functional ability for activities of daily living. Strength and flexibility will help the client to be able to maintain independence longer. The other plans are good but will not specifically maintain the clients functional abilities.

A home health care nurse is planning an exercise program with an older client who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult? a. Building strength and flexibility b. Improving exercise endurance c. Increasing aerobic capacity d. Providing personal training

A Clients in isolation should leave their rooms only when necessary, such as for a CT scan that cannot be done portably in the room. The nurse should ensure that the receiving department is aware of the isolation precautions needed to care for the client. The other options are not needed.

A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate? a. Ensure that the radiology department is aware of the isolation precautions. b. Plan to travel with the client to ensure appropriate precautions are used. c. No special precautions are needed when this client leaves the unit. d. Notify the physician that the client cannot leave the room for t

B All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Up to 98,000 deaths result each year from errors in hospital care, according to the 2000 Institute of Medicine report. Many more clients have suffered injuries and less serious outcomes. Every nurse has the responsibility to guard the clients safety.

A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises the student that which is the priority when working as a professional nurse? a. Attending to holistic client needs b. Ensuring client safety c. Not making medication errors d. Providing client-focused care

A A clients description is the most accurate assessment of pain. The nurse should believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them should not supersede the clients descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippant, and does not provide useful information. This amount of information does not warrant an assessment for drug addiction. Putting the medication back and ignoring the clients report of pain serves no useful purpose.

A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced nurse is best? a. Being able to sleep doesnt mean pain doesnt exist. b. Have you ever experienced any type of pain? c. The client should be assessed for drug addiction. d. Youre right; I would put the medication back.

B The preceptor should try to reassure the nurse that implementing QI measures is not out of line for a newly licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that is possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would not be the best place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the nurse information about how to implement QI in daily practice

A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality improvement (QI) projects. What response by the precepting nurse is best? a. All staff nurses are required to participate in quality improvement here. b. Even being new, you can implement activities designed to improve care. c. Its easy to identify what indicators should be used to measure quality. d. You should ask to be assigned to the research and quality committee.

C, D, E Malnutrition in the older population is multifactorial and has several potential adverse outcomes. Appropriate actions by the nurse include assessing the clients risk for skin breakdown with the Braden Scale, requesting a consultation with a dietitian, and suggesting a high-protein meal supplement. There is no evidence that the client is being abused or needs a feeding tube at this time.

A nurse admits an older client to the hospital who lives at home with family. The nurse assesses that the client is malnourished. What actions by the nurse are best? (Select all that apply.) a. Contact Adult Protective Services or hospital social work. b. Notify the provider that the client needs a tube feeding. c. Perform and document results of a Braden Scale assessment. d. Request a dietary consultation from the health care provider. e. Suggest a high-protein oral supplement between meals.

A Clients receiving PPN typically get large amounts of fluid volume, making the client with HF a poor candidate. The other candidates are appropriate for this type of nutritional support

A nurse and a registered dietitian are assessing clients for partial parenteral nutrition (PPN). For which client would the nurse suggest another route of providing nutrition? a. Client with congestive heart failure b. Older client with dementia c. Client who has multiorgan failure d. Client who is post gastric resection

C All of the actions are appropriate; however, the nurse should put on a pair of gloves first to avoid contamination with blood or body fluids.

A nurse answers a clients call light and finds the client in the bathroom, vomiting large amounts of bright red blood. Which action should the nurse take first? a. Assist the client back to bed. b. Notify the provider immediately. c. Put on a pair of gloves. d. Take a set of vital signs.

A, B, D Fluid intake, estrogen levels, and immune suppression can all increase the change of recurrent cystitis. Family history is usually insignificant & cranberry juice, not grapefruit or OJ, has been found to increase the acidic pH & reduce the risk for bacterial cystitis

A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which questions should the nurse ask? (Select all that apply.) a. How much water do you drink every day? b. Do you take estrogen replacement therapy? c. Does anyone in your family have a history of cystitis? d. Are you on steroids or other immune-suppressing drugs? e. Do you drink grapefruit juice or orange juice daily?

A Bowel elimination varies from client to client and must be evaluated on the basis of the clients normal routine. The nurse asks about bowel and bladder habits to develop a client-centered plan of care. The other answers are correct but are not the best responses. Oral analgesics may cause constipation, but they do not interfere with bladder control. The client is in rehabilitation to assist his or her ability to function independently. Elimination usually is schedules around rehab activities but should be taken into consideration when a plan of care is developed

A nurse assesses a client who is admitted with hip problems. The client asks, Why are you asking about my bowels and bladder? How should the nurse respond? a. To plan your care based on your normal elimination routine. b. So we can help prevent side effects of your medications. c. We need to evaluate your ability to function independently. d. To schedule your activities around your elimination pa

C As AD progresses, the client experiences changes in emotional and behavioral affect. The nurse should be alert to the clients rx to a change in the environment, such as being hospitalized, because the client may exhibit an exaggerated response, such as aggression, to the event. The other assessments should be completed but are not as important as assessing the client's reaction to the environmental change

A nurse assesses a client with Alzheimer's disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete? a. Assess religious and spiritual needs while in the hospital. b. Identify the clients ability to perform self-care activities. c. Evaluate the clients reaction to a change of environment. d. Ask the client about relationships with family members.

B, E Clients who are severely immunocompromised or who have diabetes mellitus are more prone to fungal UTIs. The nurse should assess for these factors by asking about medical history, current medical problems, and the current medication list. A physical examination and a post-void residual may be needed, but not until further information is obtained indicating that these examinations are necessary. Travel to foreign countries probably would not be important because, even if exposed, the client needs some degree of compromised immunity to develop a fungal UTI.

A nurse assesses a client with a fungal urinary tract infection (UTI). Which assessments should the nurse complete? (Select all that apply.) a. Palpate the kidneys and bladder. b. Assess the medical history and current medical problems. ' c. Perform a bladder scan to assess post-void residual. d. Inquire about recent travel to foreign countries. e. Obtain a current list of medications.

B, E Normal changes in the nervous system related to aging include: -recent memory loss, -slower processing time, -decreased sensory perception, -an increased risk for infection, -changes in sleep patterns, -changes in perception of pain, and -altered balance and/or decreased coordination.

A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.) a. Long-term memory loss b. Slower processing time c. Increased sensory perception d. Decreased risk for infection e. Change in sleep patterns

C Females at any age are more susceptible to cystitis than men because of the shorter urethra in women. Postmenopausal women who are not on hormone replacement therapy are at increased risk for bacterial cystitis because of changes in the cells of the urethra and vagina. The middle-aged woman who has never been pregnant would not have a risk potential as high as the older woman who is not using hormone replacement therapy.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of bacterial cystitis? a. A 36-year-old female who has never been pregnant b. A 42-year-old male who is prescribed cyclophosphamide c. A 58-year-old female who is not taking estrogen replacement d. A 77-year-old male with mild congestive heart failure

A, D, E

A nurse assures a client experiencing abdominal surgical pain that comfort measures, including drug therapy, will be provided as the client needs them. Which ethical principles apply in the situation? Select all that apply. A. Beneficence B. Social justice C. Autonomy D. Fidelity E. Veracity

A Although all interventions are or might be important, obtaining a urine sample for urinalysis takes priority. Often UTI symptoms in older adults are atypical and a UTI might present with new onset of confusion or falling. The urine sample should be obtained before starting antibiotics. Dietary requirements and gait training should be implemented after obtaining the urine sample

A nurse cares for a client admitted from a nursing home after several recent falls. What prescription should the nurse complete first? a. Obtain urine sample for culture and sensitivity. b. Administer intravenous antibiotics. c. Encourage protein intake and additional fluids. d. Consult physical therapy for gait training.

B Several strategies may be used to cope with restlessness and wandering. One strategy is to engage the client in structured activities. Another is to take the client for frequent walks. Daily naps and a mild sedative will not be as effective in the management of restless behavior. Consulting the social worker does not address the caregivers concern.

A nurse cares for a client with advanced Alzheimers disease. The clients caregiver states, She is always wandering off. What can I do to manage this restless behavior? How should the nurse respond? a. This is a sign of fatigue. The client would benefit from a daily nap. b. Engage the client in scheduled activities throughout the day. c. It sounds like this is difficult for you. I will consult the social worker. d. The provider can prescribe a mild sedative for restlessness.

B Weight-bearing activity reduces bone mineral loss and promotes bone uptake of calcium, contributing to maintenance of bone density and reducing the risk for bone fracture. Although increasing calcium in the diet is a good intervention, this alone will not reduce the clients susceptibility to bone fracture. A foot support and pressure-relieving devices will not help prevent fracture, but may help with mobility and skin integrity.

A nurse cares for a client with decreased mobility. Which intervention should the nurse implement to decrease this clients risk of fracture? a. Apply shoes to improve foot support. b. Perform weight-bearing activities. c. Increase calcium-rich foods in the diet. d. Use pressure-relieving devices.

B Low estrogen levels decrease moisture and secretions in the perineal area and cause other tissue changes, predisposing it to the development of infection. Urethritis is most common in postmenopausal women for this reason. Although immune function does decrease with aging and sexually transmitted diseases are a known cause of urethritis, the most likely reason in this client is low estrogen levels. Personal hygiene usually does not contribute to this disease process.

A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, I never have urinary tract infections. Why is this happening now? How should the nurse respond? a. Your immune system becomes less effective as you age. b. Low estrogen levels can make the tissue more susceptible to infection. c. You should be more careful with your personal hygiene in this area. d. It is likely that you ha

A, B, E Infection control measures appropriate to all clients include: - hand hygiene with alcohol-based hand rub or soap between client contact - procedures for routine care - cleaning and disinfection of frequently contaminated surfaces - wearing personal protective equipment when contamination is anticipated. Client and visitors would be instructed on appropriate respiratory hygiene and cough etiquette. No information in the stem indicates the clients need anything more than Standard Precautions.

A nurse cares for several clients on an inpatient unit. Which infection control measures will the nurse implement? (Select all that apply.) a. Wear a gown when contact of clothing with body fluids is anticipated. b. Teach clients and visitors respiratory hygiene techniques. c. Obtain powered air purifying respirators for all staff members. d. Do not use alcohol-based hand rub between client contacts. e. Disinfect frequently touched surfaces in client-care areas.

C The client has several indicators of sepsis with systemic inflammatory response. The nurse should notify the HCP immediately. normal WBC range: 5,000-10,000 normal glucose level: 70-100 Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may or may not need insulin.

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes priority? a. Document the findings in the clients chart. b. Give the client warmed blankets for comfort. c. Notify the health care provider immediately. d. Prepare to administer insulin per sliding scal

B In this situation, each facility will have a policy designed for assessing competence. The nurse should bring these concerns to an interdisciplinary care team meeting. There may be physiologic reasons for the client to be temporarily too confused or incompetent to give consent. If an acute condition is ruled out, the staff should follow the legal procedure and policies in their facility and state for determining competence. The key is to bring the concerns forward. Calling Adult Protective Services is not appropriate at this time. Signing the consent should wait until competence is determined unless it is an emergency, in which case the next of kin can sign if there are grave doubts as to the clients ability to provide consent.

A nurse caring for an older client in the hospital is concerned the client is not competent to give consent for upcoming surgery. What action by the nurse is best? a. Call Adult Protective Services. b. Discuss concerns with the health care team. c. Do not allow the client to sign the consent. d. Have the clients family sign the consent.

C poorly fitting dentures and other dental problems are often manifested by a preference for soft foods and constipation from the lack of fiber. The nurse should perform an oral assessment to determine if these problems exist. The other assessments are important, but will not yield information specific to the clients food preferences as they relate to constipation.

A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first? a. Auscultate bowel sounds. b. Check skin turgor. c. Perform an oral assessment. d. Weigh the client.

C Clients who have early-stage Alzheimers disease should be reoriented frequently to person, place, and time. The UAP should reorient the client and not encourage the clients delusions. The room should have a clock and white board with the current date written on it. Validation therapy is used with late-stage Alzheimers disease.

A nurse delegates care for a client with early-stage Alzheimers disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care? a. If she is confused, play along and pretend that everything is okay. b. Remove the clock from her room so that she doesnt get confused. c. Reorient the client to the day, time, and environment with each contact. d. Use validation therapy to recognize and acknowledge the clients concerns.

C, D, E The UAP should make sure food items remain at the appropriate temperatures for maximum palatability. Removing items such as bedpans, urinals, or soiled linens helps make the atmosphere more conducive to eating. The UAP should sit, not stand, next to the client to promote a relaxing experience. The client, especially older clients who tend to eat more slowly, should not be rushed. Assessment is done by the nurse.

A nurse has delegated feeding a client to an unlicensed assistive personnel (UAP). What actions does the nurse include in the directions to the UAP? (Select all that apply.) a. Allow 30 minutes for eating so food doesnt get spoiled. b. Assess the clients mouth while providing premeal oral care. c. Ensure warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed.

B, C, D, E Barrett's esophagus is a complication of GERD d/t inflammation Recurrent reflux can allow aspiration of small amounts of gastric acid into the lungs, at times causing a reaction called pneumonitis (or aspiration pneumonia), but more commonly, a chronic dry cough Esophagitis is a complication resulting from the inflammatory response of GERD Ulcers are a complication of GERD d/t the reflux of acid Hiatal hernia is not a complication of GERD. However, if present, it can exacerbate GERD symptoms

A nurse instructs a client with GERD on potential complications if the disease is left untreated. The nurse includes which complications in the teaching plan? (select all that apply). a. hiatal hernia b. Barrett's esophagus c. Chronic cough d. esophagitis e. ulcers

C

A nurse interviewing an 82-year-old, somewhat confused client who is becoming a nursing home resident today asks the client's daughter if she would consent for the client to receive an influenza vaccination today. The daughter replies "she had one 2 years ago and doesn't need another." What is the nurse's best response? A. "Your mother is older now and is more fragile, so she should have one this year, too, as a booster." B. "The virus causing influenza often changes each year, and a new influenza vaccination is needed every flu season." C. "The "flu shot" she had 2 years ago will still protect her this year, but if she has not had a previous pneumonia vaccination, she should have one now." D. "If you are worried that she is afraid to have an injection, we could use the nasal mist vaccination this year."

C All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults.

A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain assessment tool would the nurse choose for this assessment? a. Numeric rating scale b. Verbal Descriptor Scale c. FACES Pain Scale-Revised d. Wong-Baker FACES Pain Scale

B SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Assessment, and Recommendation. Appropriate background information includes allergies to medications the on-call physician might order. Situation describes what is happening right now that must be communicated; the clients surgery 2 days ago would be considered background. Assessment would include an analysis of the clients problem; asking for a different pain medication is a recommendation. Recommendation is a statement of what is needed or what outcome is desired; this information about the surgeons preference might be better placed in background.

A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed narcotic pain medication. Which statement is part of the SBAR format for communication? a. A: I would like you to order a different pain medication. b. B: This client has allergies to morphine and codeine. c. R: Dr. Smith doesnt like nonsteroidal anti-inflammatory meds. d. S: This client had a vaginal hysterectomy 2 days ag

B Urine output changes are a sensitive early indicator of shock. The nurse would delegate emptying the urinary catheter and measuring output to the AP as a baseline for hourly urine output measurements. The AP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.

A nurse is caring for a client after surgery who is restless and apprehensive. The assistive personnel (AP) reports the vital signs and the nurse sees that they are only slightly different from previous readings. What action does the nurse delegate next to the AP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the side. d. Stay with the client and reassure him or her.

B Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse would conduct a thorough assessment of the patient, focusing on indicators of perfusion. The MEWS score (Modified Early Warning Score) was developed to identify clients at risk for deterioration. The client may need pain medication, but this is not the priority at this time. Documentation would be done thoroughly but would be done after the assessment. The nurse would not increase the rate of the IV infusion without an order.

A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since the client was last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess using the MEWS score. c. Document the findings in the client's chart. d. Increase the rate of the client's IV infusion.

A proteins and sugar molecules in the enteral feeding product contribute to dehydration d/t increased osmolarity. The nurse can administer free-water boluses after consulting with the provider on the appropriate amount and timing of the boluses. per protocol. The client may not be able to change formulas. Diluting the formula is not appropriate. Slowing the rate of infusion will not address the problem.

A nurse is caring for a client receiving enteral feedings through a Dobhoff tube. What action by the nurse is best to prevent hyperosmolarity? a. Administer free-water boluses. b. Change the clients formula. c. Dilute the clients formula. d. Slow the rate of infusion

A Vancomycin is one of a few drugs approved to treat MRSA. The others include: - linezolid (Zyvox) - Ceftaroline fosamil (Teflaro) Visitation does not need to be limited to immediate family only. Hand hygience is performed before and after wearing gloves. A respirator is not needed, but is splashing is anticipated, a face shield can be used.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate? a. Prepare to administer vancomycin (Vancocin). b. Strictly limit visitors to immediate family only. c. Wash hands only after taking off gloves after care. d. Wear a respirator when handling urine output.

B All actions are good for client comfort, but when dealing with an obese client, the staff should take extra precautions, such as ensuring the siderails are not putting pressure on the clients tissues. The other options are appropriate for any client, and are not specific to obese clients.

A nurse is caring for a morbidly obese client. What comfort measure is most important for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Designating quiet time so the client can rest b. Ensuring siderails are not causing excess pressure c. Providing oral care before and after meals and snacks d. Relaying any reports of pain to the RN

A The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse should call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particularly significant. Documentation is vital, but the nurse must do more than document. The primary care provider should be notified, but this is not the priority over calling the RRT. The clients blood pressure should be reassessed frequently, but the priority is getting the rapid care to the client.

A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best? a. Call the Rapid Response Team. b. Document and continue to monitor. c. Notify the primary care provider. d. Repeat blood pressure measurement in 15 minutes.

C The potassium is critically low, perhaps due to hyperglycemia-induced hyperosmolarity. The nurse should see this client first. The blood glucose reading is high, but not extreme. The sodium is normal. The client with the diarrhea should be seen last to avoid cross-contamination. normal potassium level is: 3.5- 5 normal sodium level is: 135-145 normal glucose level is: 70-100

A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first? a. Client with a blood glucose level of 138 mg/dL b. Client with foul-smelling diarrhea c. Client with a potassium level of 2.6 mEq/L d. Client with a sodium level of 138 mEq/L

B A lactate level of 5.4 mg/dL (6mmol/L) is high and is indicative of possible shock.

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the primary health care provider? a. Creatinine: 0.9 mg/dL (68.6 mcmol/L) b. Lactate: 5.4 mg/dL (6 mmol/L) c. Sodium: 150 mEq/L (150 mmol/L) d. White blood cell count: 11,000/mm3 (11 109/L)

B, D, E Some of the goals in this initiative include increasing fruit consumption to 0.9 cups/1000 calories, increasing vegetable intake to 1.1 cups/1000 calories, increasing the number of people at a healthy weight by 10%, decreasing the number of adults who are obese by 10%, and reducing the consumption of saturated fats by 9.5%

A nurse is designing a community education program to meet the Healthy People 2020 objectives for nutrition and weight status. What information about these goals does the nurse use to plan this event? (Select all that apply.) a. Decrease the amount of fruit to 1.1 cups/1000 calories. b. Increase the amount of vegetables to 1.1 cups/1000 calories. c. Increase the number of adults at a healthy weight by 25%. d. Reduce the number of adults who are obese by 10%. e. Reduce the consumption of saturated fat by nearly 10%.

D If pain is present in a certain area of the abdomen, that area should be palpated last to keep the client from tensing up, which could possibly affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation.

A nurse is examining a client reporting right upper quadrant (RUQ) abdominal pain. What technique should the nurse use to assess this clients abdomen? a. Auscultate after palpating. b. Avoid any palpation. c. Palpate the RUQ first. d. Palpate the RUQ last.

A, B, C, D Collaborating with the interdisciplinary team involves planning, implementing, and evaluating client care as a team with all other disciplines included. Simply showing other caregivers nursing care plans is not actively involving them or collaborating with them.

A nurse is interested in making interdisciplinary work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.) a. Consults with other disciplines on client care b. Coordinates discharge planning for home safety c. Participates in comprehensive client rounding d. Routinely asks other disciplines about client progress e. Shows the nursing care plans to other disciplines

C Fans in client care areas are discouraged because they can disperse airborne or droplet-borne pathogens. The other actions are appropriate. If the client has a scalp infection or infestation, the AP will wear gloves; otherwise, it is not required for grooming the hair

A nurse is observing as an assistive personnel (AP) performs hygiene and provides comfort measures to a client with an infection. What action by the AP requires intervention by the nurse? a. Not using gloves while combing the client's hair b. Rinsing the client's commode pan after use c. Ordering an oscillating fan for the client d. Wearing gloves when providing perianal care

A Each action could be important for the client or family to perform. However, encouraging the client to be active in his or her health care as a partner is the most critical. The other actions are very limited in scope and do not provide the broad protection that being active and involved does.

A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to help the client promote his or her own safety? a. Encourage the client and family to be active partners. b. Have the client monitor hand hygiene in caregivers. c. Offer the family the opportunity to stay with the client. d. Tell the client to always wear his or her armband

A, B, E When infusing pantoprazole, use a separate IV line, a pump, and an in-line filter. A brown wrapper and frequent v/s are not needed

A nurse is preparing to administer pantoprazole (Protonix) intravenously. What actions by the nurse are most appropriate? (Select all that apply.) a. Administer the drug through a separate IV line. b. Infuse pantoprazole using an IV pump. c. Keep the drug in its original brown bag. d. Take vital signs frequently during infusion. e. Use an in-line IV filter when infusing.

ANS: 200mL/hr order: 50mL NS over 15 min (50mL/ 15 min) x (60 min/ 1 hour) = 200mL/hr 50x60= 3000 3000 divided by 15 = 200

A nurse is preparing to give an infusion of acetaminophen (Ofirmev). IV acetaminophen (Ofirmev) is given by a 15- minute infusion. The pharmacy delivers a bag containing 50 mL of normal saline and the Ofirmev. At what rate does the nurse set the IV pump to deliver this dose? (Record your answer using a whole number.) ____ mL/hr

B A cholesterol level below 160 mg/dL is a possible indicator of malnutrition, so this client would be at highest priority for a nutritional assessment. The albumin and prealbumin levels are normal. The low Hgb could be from several problems, including dietary deficiencies, hemodilution, and bleeding.

A nurse is reviewing laboratory values for several clients. Which value causes the nurse to conduct nutritional assessments as a priority? a. Albumin: 3.5 g/dL b. Cholesterol: 142 mg/dL c. Hemoglobin: 9.8 mg/dL d. Prealbumin: 28 mg/dL

C Accreditation by The Joint Commission (TJC) or other accrediting body gives assurance that the facility has a focus on safety. Nurse-client ratios differ by unit type and change over time. New technology doesnt necessarily mean the hospital is safe. Affiliation with a health professions school has several advantages, but safety is most important

A nurse is talking with a client who is moving to a new state and needs to find a new doctor and hospital there. What advice by the nurse is best? a. Ask the hospitals there about standard nurse-client ratios. b. Choose the hospital that has the newest technology. c. Find a hospital that is accredited by The Joint Commission. d. Use a facility affiliated with a medical or nursing school

A, C, D, E Chocolate, citrus fruits such as oranges and grapefruit, peppermint and spearmint, and tomato-based products all contribute to the reflux associated with GERD. Caffeinated teas, coffee, and sodas should be avoided.

A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching? (Select all that apply.) a. Chocolate b. Decaffeinated coffee c. Citrus fruits d. Peppermint e. Tomato sauce

C Drug therapy is not effective for treating dementia or halting the advancement of AD. Certain drugs may help suppress emotional disturbances and psychiatric manifestations. Medication therapy may not allow the client to safely live independently

A nurse is teaching the daughter of a client who has Alzheimer's disease. The daughter asks, Will the medication my mother is taking improve her dementia? How should the nurse respond? a. It will allow your mother to live independently for several more years. b. It is used to halt the advancement of Alzheimers disease but will not cure it. c. It will not improve her dementia but can help control emotional responses. d. It is used to improve short-term memory but will not improve problem solving.

C Older adults often lose their sense of thirst. Since they should drink 1 to 2 liters of water a day, the best remedy is to have the older adult drink something each hour or two, whether or not he or she is thirsty. Cutting some sodium from the diet will not address this issue. Although dehydration can cause incontinence from the irritation of concentrated urine, this information will not help prevent the problem of dehydration. Instructing the client to take a diuretic in the morning rather than in the evening also will not directly address this issue.

A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue? a. Cut some sodium out of your diet. b. Dehydration can cause incontinence. c. Have something to drink every 1 to 2 hours. d. Take your diuretic in the morning.

D To help prevent the transmission of MRDOs, wear scrubs and change clothes before leaving work. Keep work clothes separate from personal clothing. The nursing manager would need to correct his or her knowledge if he or she is letting staff know that wearing scrubs home is alright. The other statements are correct about multi-drug resistant organisms.

A nurse manager is preparing an educational session for floor nurses on drug-resistant organisms. Which statement below indicates the need to review this information? a. "Methicillin-resistant Staphylococcus aureus can be hospital- or community-acquired." b. "Vancomycin-resistant Enterococcus can live on surfaces and be infectious for weeks." c. Carbapenem-resistant Enterobacteriaceae is hard to treat due to enzymes that break down antibiotics." d. "If you leave work wearing your scrubs, go directly home and wash them right away."

A, B, C, D A good tool for standardizing hand-off reports and other critical communication is the SHARE model. SHARE stands for: - standardize critical info - hardwire within your system - allow opportunities to ask questions - reinforce quality & measurement - educate and coach Attending hand-off report gives the manager opportunities to educate and coach. Conducting audits is part of reinforcing quality. Creating a template is hardwiring within the system Encouraging the staff to ask questions and think critically about the information is allowing opportunities to ask questions. The manager may to to tie raises into compliance if the staff is resistive and other measures have failed, but this is not part of the SHARE model.

A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.) a. Attend hand-off rounds to coach and mentor. b. Conduct audits of staff using a new template. c. Create a template of topics to include in report. d. Encourage staff to ask questions during hand-off e. Give raises based on compliance with reporting

A, B, D, E The IOM report lists five broad core competencies that all health care providers should practice. These include: collaborating with the interdisciplinary team, implementing evidence-based practice, providing client-focused care, using informatics in client care, and using quality improvement in client care.

A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas should the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select all that apply.) a. Collaborating with an interdisciplinary team b. Implementing evidence-based care c. Providing family-focused care d. Routinely using informatics in practice e. Using quality improvement in client care

B Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset abdominal pain needs to be seen first. The postoperative client needs 45 minutes to an hour for the oral medication to become effective and should be seen shortly to assess for effectiveness. The client going home requires teaching, which should be done after the first two clients have been seen and cared for, as this teaching will take some time. The client resting comfortably can be checked on quickly before spending time teaching the client who is going home.

A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first? a. Client being discharged later on a complicated analgesia regimen b. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale c. Postoperative client who received oral opioid analgesia 45 minutes ago d. Client who has returned from physical therapy and is resting in the recliner

B, C, E Nursing interventions for clients at risk for infection include monitoring WBC count and differential, screening visitors for infections and infectious disease, and promoting sufficient nutritional intake. Standard precautions are required but not transmission-based precautions. Prophylactic antibiotics are not generally used to prevent infections.

A nurse plans care for a client who is at risk for infection. Which interventions will the nurse implement to prevent infection? (Select all that apply.) a. Administer prophylactic antibiotics. b. Monitor white blood cell count and differential. c. Screen all visitors for infections. d. Implement Transmission-Based Precautions. e. Promote sufficient nutritional intake

C Dementia and confusion are not common phenomena in older adults. However, physical impairment related to illness can be expected. Providing opportunities for hazard-free ambulation will maintain strength and mobility (and ensure safety). Providing a call button, providing the date, and seasoning food do not address the clients impaired sensory perception.

A nurse plans care for an 83-year-old client who is experiencing age-related sensory perception changes. Which intervention should the nurse include in this clients plan of care? a. Provide a call button that requires only minimal pressure to activate. b. Write the date on the clients white board to promote orientation. c. Ensure that the path to the bathroom is free from equipment. d. Encourage the client to season food to stimulate nutritional intake.

C Clients with Alzheimers disease have a tendency to wander, especially at night. If possible, alarms should be installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors should have deadbolt locks installed to prevent the client from going outdoors unsupervised. The client should be allowed to exercise within his or her limits. Throw rugs are a slip and fall hazard and should be removed. The client should eat a well-balanced diet. There is no need for a high-calorie or high-protein diet.

A nurse prepares to discharge a client with Alzheimers disease. Which statement should the nurse include in the discharge teaching for this clients caregiver? a. Allow the client to rest most of the day. b. Place a padded throw rug at the bedside. c. Install deadbolt locks on all outside doors. d. Provide a high-calorie and high-protein diet.

A, B, C, E Alcohol can irritate the inflamed tissue and cause heartburn Chocolate causes tissue irritation leading to heartburn Fatty foods cause heartburn d/t the irritation of inflamed tissue Peppermint can cause heartburn d/t the irritation of inflamed tissue Drinking a lot of water with meals can cause the stomach to be overdistended and create reflux. Fluids are best consumed between meals.

A nurse provides dietary instructions to a client with gastroesophageal reflux disease (GERD). The nurse includes which information? (select all that apply). a. avoid alcohol b. avoid chocolate c. decrease fatty foods d. drink a lot of water with meals e. eliminate foods containing peppermint

C Pregnant clients with a urinary tract infection require prompt and aggressive treatment because cystitis can lead to acute pyelonephritis during pregnancy. The nurse should encourage the client to make an appointment and have the infection treated. Burning pain when urinating does not indicate the start of labor or weakening of pelvic muscles.

A nurse provides phone triage to a pregnant client. The client states, I am experiencing a burning pain when I urinate. How should the nurse respond? a. This means labor will start soon. Prepare to go to the hospital. b. You probably have a urinary tract infection. Drink more cranberry juice. c. Make an appointment with your provider to have your infection treated. d. Your pelvic wall is weakening. Pelvic muscle exercises should help.

A The qSOFA score is an abbreviation for Sequential Organ Failure Assessment or "quick". A score of 3 is high and requires the nurse to assess the client further for organ impairment. The client may or may not need a ventilator, but that in not specified in the score. The client does not need protective precautions. The client's family may well need support, but the nurse would assess their needs and wishes prior to calling the chaplain.

A nurse receives hand-off report from the emergency department on a new admission suspected of having septic shock. The client's qSOFA score is 3. What action by the nurse is best? a. Plan to calculate a full SOFA score on arrival. b. Contact respiratory therapy about ventilator setup. c. Arrange protective precautions to be implemented. d. Call the hospital chaplain to support the family.

B A shift to the left indicates an increase in immature neutrophils and is often seen in infections, especially those caused by bacteria. The nurse should notify the provider and request antibiotics. Documentation and teaching need to be done, but the nurse needs to do more. The client does not need protective isolation

A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has a shift to the left on the white blood cell count. What action by the nurse is most important? a. Document findings and continue monitoring. b. Notify the provider and request antibiotics. c. Place the client in protective isolation. d. Tell the client this signifies inflammation.

B An increase in band cells creates a shift to the left. A left shift most commonly occurs with urosepsis and is seen rarely with uncomplicated UTIs. The nurse will be administering antibiotics, most likely via IV, so he or she should notify the provider and prepare to give the antibiotics. The shift to the left is part of a differential WBC count. The nurse would not need to strain urine for stone. Allergic rxs are associated with elevated eosinophils, not band cells

A nurse reviews the laboratory findings of a client with a urinary tract infection. The laboratory report notes a shift to the left in a clients white blood cell count. Which action should the nurse take? a. Request that the laboratory perform a differential analysis on the white blood cells. b. Notify the provider and start an intravenous line for parenteral antibiotics. c. Collaborate with the unlicensed assistive personnel (UAP) to strain the clients urine for renal calculi. d. Assess the client for a potential allergic reaction and anaphylactic shock.

B, C, D, E Compared to sitting, the reduced gravity that occurs while lying down to sleep allows reflux to occur further up the esophagus and remain in the esophagus longer, leading to increased esophageal irritation Certain acidic or spicy foods may increase the production of stomach acid and decrease lower esophageal sphincter (LES) pressure, increasing heart burn symptoms. * decreased LES pressure= bad Increases in abdominal pressure from excess weight or tight clothing aggravate heartburn symptoms by creating pressure against the LES. Nicotine relaxes the LES, allowing acid to reflux into the esophagus from the stomach

A nurse teaches a client recently diagnosed with GERD. The nurse includes which intervention? (select all that apply). a. drink decaffeinated coffee b. elevate the head of the bed c. limit spicy foods d. maintain a healthy weight e. stop smoking

A The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication.

A nurse teaches a young female client who is prescribed amoxicillin (Amoxil) and Cephalexin for a urinary tract infection. Which statement should the nurse include in this clients teaching? a. Use a second form of birth control while on this medication. b. You will experience increased menstrual bleeding while on this drug. c. You may experience an irregular heartbeat while on this drug. d. Watch for blood in your urine while taking this medication.

A Competency in client-focused care is demonstrated when the nurse focuses on communication, culture, respect, compassion, client education, and empowerment. By assessing the effect of the clients culture on health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence. Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client and family to the room is an important safety measure, but not directly related to demonstrating client-centered care.

A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept? a. Assesses for cultural influences affecting health care b. Ensures that all the clients basic needs are met c. Tells the client and family about all upcoming tests d. Thoroughly orients the client and family to the room

A Use of validation therapy with clients who have Alzheimers disease involves acknowledgment of the clients feelings and concerns. This technique has proved more effective in later stages of the disease, when using reality orientation only increases agitation. Telling the client that he or she already ate breakfast may agitate the client. The other statements do not validate the clients concerns.

A nurse witnesses a client with late-stage Alzheimers disease eat breakfast. Afterward the client states, I am hungry and want breakfast. How should the nurse respond? a. I see you are still hungry. I will get you some toast. b. You ate your breakfast 30 minutes ago. c. It appears you are confused this morning. d. Your family will be here soon. Lets get you dressed.

C Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on delegated tasks. The nurse should either have asked the UAP about the vital signs or instructed the UAP to report them right away. An experienced UAP should know how to take vital signs and the nurse should not have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a UAP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequate instruction to the UAP

A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the clients blood pressure is much higher than previous readings, and the clients mental status has changed. What action by the nurse would most likely have prevented this negative outcome? a. Determining if the UAP knew how to take blood pressure b. Double-checking the UAP by taking another blood pressure c. Providing more appropriate supervision of the UAP d. Taking the blood pressure instead of delegating the task

A, B, E Common adverse medication effects include constipation/ impaction, dehydration, and weakness. Mania and incontinence are not among the adverse effects, although urinary retention is.

A nurse working with older adults assesses them for common potential adverse medication effects. For what does the nurse assess? (Select all that apply.) a. Constipation b. Dehydration c. Mania d. Urinary incontinence e. Weakness

A All activities would be beneficial for the older population in the community. However, failure in performing ones own activities of daily living and participating in society has direct effects on morale and life satisfaction. Those who lose the ability to function independently often feel worthless and empty. An exercise program designed to maintain and/or improve physical functioning would best address this need.

A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. What activity would best meet this goal? a. Exercise program to improve physical function b. Financial planning seminar series for older adults c. Social events such as dances and group dinners d. Workshop on prevention from becoming an abuse victim

B Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients not to get dehydrated is important, but not the best answer because it doesn't give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is not as important an issue as staying hydrated. Taking medications as prescribed may or may not be related to hydration.

A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed.

C The client who had an esophagectomy has a respiratory rate of 32/min, which is an early sign of sepsis; this client needs to be assessed first. The client who underwent diverticula removal has a pulse that is out of the normal range (106/min), but not terribly so The client reporting pain needs pain medication, but the client with the elevated respiratory rate needs investigation first. The nurse should see the client who had esophageal dilation prior to and during the first attempt at oral feedings, but this can wait until the other clients are cared for.

A nurse works on the surgical unit. After receiving the hand-off report, which client should the nurse see first? a. Client who underwent diverticula removal with a pulse of 106/min b. Client who had esophageal dilation and is attempting first postprocedure oral intake c. Client who had an esophagectomy with a respiratory rate of 32/min d. Client who underwent hernia repair, reporting incisional pain of 7/10

C The old old is the fastest growing subset of the older population. This group comprises those 85-99 years of age. The young old are between 65- 74 years old. The middle old are between 75- 84 years old. The elite old are over 100 years of age

A nursing faculty member working with students explains that the fastest growing subset of the older population is which group? a. Elite old b. Middle old c. Old old d. Young old

A All methods will help prevent infection; however, health care workers lack of hand hygiene is the biggest cause of HAIs (healthcare associated infections). The manage can start with a hand hygiene audit to see if this is a contributing cause.

A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections? a. Auditing staff members hand hygiene practices b. Ensuring clients are placed in appropriate isolation c. Establishing a policy to remove urinary catheters quickly d. Teaching staff members about infection control methods

B, C, D Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and weakness. Weight gain and dementia are not part of this cluster of manifestations.

A nursing student working in an Adult Care for Elders unit learns that frailty in the older population includes which components? (Select all that apply.) a. Dementia b. Exhaustion c. Slowed physical activity d. Weakness e. Weight gain

C The dx of AD is usually one of exclusion. Age is the most important risk factor for development of AD

A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patient's adult children that: a. the most important risk factor for AD is a family history of the disorder. b. new drugs have been shown to reverse AD dramatically in some patients. c. a diagnosis of AD is made only after other causes of dementia are ruled out. d. the presence of brain atrophy detected by magnetic resonance imaging (MRI) will confirm the diagnosis of AD.

B providing a consistent routine will decrease anxiety and confusion for the patient

A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patient's care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.

A Because Rapid Response Teams (RRTs) have been demonstrated to reduce the number of cardiac or respiratory arrests, the nurse's first action should be to call the RRT. The client is not experiencing a cardiac or respiratory arrest, so calling a Code Blue is not appropriate. Re-checking and determining the cause of the vital sign changes are needed actions, but they are not the first action that the nurse should take because the client's mean arterial pressure is 56, which is below the threshold required for organ perfusion. A 5-minute delay in the client's care could be life-threatening!

A previously stable postoperative client on the medical-surgical unit now has a blood pressure of 88/40 mm Hg and a heart rate of 124 beats/min. After placing the client in Trendelenburg position, which action does the nurse perform next? A. Activate the Rapid Response Team. B. Call for a Code Blue. C. Determine the cause of the changes. D. Re-check the vital signs in 5 minutes.

D Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client.

A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best? a. Numeric pain scale b. Behavioral assessment c. Objective observation d. Clients self-report

B Many members of the LGBTQ community have faced discrimination from health care providers and may be reluctant to seek health care. The nurse should never make assumptions about the needs of members of this population. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any health care need is more likely to answer honestly.

A student nurse asks the faculty to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What answer by the faculty is most accurate? a. Avoid embarrassing the client by asking questions. b. Dont make assumptions about their health needs. c. Most LGBTQ people do not want to share information. d. No differences exist in communicating with this population.

A, B, C, E Older adults have several age-related changes making them more susceptible to infection, including: - decreased immune function - decreased cough and gag reflex - decreased acidity of gastric secretions - thinning skin - fewer lymphocytes and antibodies.

A student nurse asks the nursing instructor why older adults are more prone to infection than other adults. What reasons does the nursing instructor give? (Select all that apply.) a. Age-related decrease in immune function b. Decreased cough and gag reflexes c. Diminished acidity of gastric secretions d. Increased lymphocytes and antibodies e. Thinning skin that is less protective

A, B, D Assessment is the first step of the nursing process and should be completed prior to intervening. Asking about transportation, dentures, and normal food patterns would be part of an appropriate assessment for the client. There is no information in the question about the older adult needing to lose weight, so encouraging him or her to continue the current exercise regimen is premature and may not be appropriate. Teaching about proper nutrition is a good idea, but teaching needs to be tailored to the clients needs, which the nurse does not yet know

A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last months visit. What actions should the nurse perform first? (Select all that apply.) a. Assess the clients ability to drive or transportation alternatives. b. Determine if the client has dentures that fit appropriately. c. Encourage the client to continue the current exercise plan. d. Have the client complete a 3-day diet recall diary. e. Teach the client about proper nutrition in the older population.

A MRSA is spread by direct contact, such as with indwelling catheters, vascular access devices, and endotracheal tubes, in the hospital and community settings.

After lunch, the client asks how MRSA was contracted. What is the appropriate nursing response? A. "MRSA is spread by direct contact in the hospital and community settings." B. "People who travel to third-world countries always return with MRSA." C. "MRSA is transmitted through the air like TB." D. "The most common way to get MRSA is when someone coughs on you."

C Phenazopyridine discolors urine, most commonly to a deep reddish orange. Many clients think they have blood in their urine when they see this. In addition, the urine can permanently stain clothing. Phenazopyridine is safe to take if the client is pregnant. There are no dietary restrictions or needs while taking this medication.

After teaching a client with bacterial cystitis who is prescribed phenazopyridine (Pyridium), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will not take this drug with food or milk. b. If I think I am pregnant, I will stop the drug. c. An orange color in my urine should not alarm me. d. I will drink two glasses of cranberry juice

A, C, E Woman can reduce their risk of contracting UTIs by voiding before and after intercourse, NOT douching or using scented feminine products, and wiping from front to back. If spermicides are currently used, the woman should consider another form of birth control. Loose-fitting cotton underwear is best.

After treating several young women for urinary tract infections (UTIs), the college nurse plans an educational offering on reducing the risk of getting a UTI. What information does the nurse include? (Select all that apply.) a. Void before and after each act of intercourse. b. Consider changing to spermicide from birth control pills. c. Do not douche or use scented feminine products. d. Wear loose-fitting nylon panties. e. Wipe or clean the perineum from front to back.

A Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom will help reduce the likelihood of falling. The client does not need a commode or a toileting schedule. Siderails used to keep the client in bed are considered restraints and should not be used in that fashion.

An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this client? a. Keep the light on in the bathroom at night. b. Order a bedside commode for the client. c. Put the client on a toileting schedule. d. Use siderails to keep the client in be

C Color-coded stickers are a fast, easy-to-remember system. One color is for morning meds, one for evening meds, and the third color is for nighttime meds. Arranging medications by time in a drawer might be helpful if the person doesnt accidentally put them back in the wrong spot. Easy-open tops are not related. Writing a list might be helpful, but not if it gets misplaced. With stickers on the medication bottles themselves, the reminder is always with the medication.

An older adult client takes medication three times a day and becomes confused about which medication should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying Those are for old people. What action by the nurse would be most helpful? a. Arrange medications by time in a drawer. b. Encourage the client to use easy-open tops. c. Put color-coded stickers on the bottle caps. d. Write a list of when to take each medication.

B Medication s/e and adverse effects are common in the older pop. Something as simple as a new antibiotic can cause confusion and memory loss. The nurse should determine if the client is taking any new medications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important once more is known about the clients condition.

An older adult is brought to the emergency department because of sudden onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important? a. Assess for orthostatic hypotension. b. Determine if there are new medications. c. Evaluate the client for gait abnormalities. d. Perform a delirium screening test.

C Often older adults lose support systems when their roles change. For instance, when people retire, they may lose their social network, leading them to feeling depressed and lonely. The nurse should first assess the role that work played in the clients life.

An older adult recently retired and reports being depressed and lonely. What information should the nurse assess as a priority? a. History of previous depression b. Previous stressful events c. Role of work in the adults life d. Usual leisure time activities

B Cyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are all on the Beers list of potentially inappropriate medications for use in older adults and should not be suggested. The nurse should suggest hydromorphone hydrochloride.

An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for pain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon, which medication should he or she suggest in place of the morphine? a. Cyclobenzaprine (Flexeril) b. Hydromorphone hydrochloride (Dilaudid) c. Ketorolac (Toradol) d. Meperidine (Demerol)

B The goal of communication between the hospital nurse and the outside health agency is to provide a safe transition of care. Important aspects of care, such as pain medications, oxygen needs, and falls risks must be communicated.

An older client who has had a total hip replacement will be transferred to a rehabilitation center for continuing care before going home. The Joint Commission, along with National Patient Safety Goal standards, mandates communication between hospital nurses and other providers to ensure adequate transition management. Which aspects of this client's care plan are most important for the nurse to communicate to the rehabilitation center care team? A. Third-party payer information B. Pain medication needs C. Primary care provider D. Medical history of osteoarthritis

D All these activities are appropriate when discharging a client whose needs will continue after discharge. A home safety assessment would be most important to ensure the safety of this older client.

An older client who lives alone is being discharged on opioid analgesics. What action by the nurse is most important? a. Discuss the need for home health care. b. Give the client follow-up information. c. Provide written discharge instructions. d. Request a home safety assessment.

A The largest application of health care informatics is the growing trend of the use of electronic medical records (EMRs) for documenting interdisciplinary care. Computers may be located at the client's bedside or in the treatment room for ease of access for documentation.

Bedside computers are an example of informatics used in health care primarily for which purpose? A. Documenting interdisciplinary care B. Enhancing collaboration and coordination of care C. Offering clients access to e-mail and the Internet D. Retrieving data for evidence-based practice

C

Development of which symptoms indicates to the nurse that a 48-year-old client with seasonal influenza may actually have COVID-19? a. Anorexia and weight loss b. Intermittent fever and sweating c. Chest tightness and SpO2 of 86% d. Productive cough and yellow-colored sputum

reflux of the gastric contents into the esophagus d/t incompetence of the lower esophageal sphincter (LES). Obesity and the use of certain medications increase the risk of GERD. Patients typically present with heartburn and regurgitation

GERD definition:

- esophagitis - esophageal strictures - esophageal cancer - Barrett's esophagus * Barrett's esophagus refers to an abnormal change in the epithelium cells lining the esophagus. It is a premalignant condition that places the client at high risk for esophageal cancer. * Interventions are aimed at dietary changes and use of medications that counteract gastric acid

In addition to chronic cough and ulcers, the inflammatory responses in the esophagus resulting from GERD can cause many complications including:

- maintaining a healthy weight (as evidenced by a BMI less than 25) - elevating the head of the bed - avoiding smoking - clients may avoid aggravating and acidic foods including citrus or tomato-based foods, spicy foods, alcohol, chocolate, carbonated beverages, and caffeine * clients are advised to limit these foods and beverages, monitoring for symptom triggers, and reintroducing to the diet if tolerated

Lifestyle modifications that can improve symptoms of GERD include:

NG tube is inserted to decompress the bowel when an obstruction is present. After insertion, verification of placement should be done to ensure that tube is in the stomach Verification methods include aspirating gastric contents and checking for color, consistency, and pH level A CO2 detector can identify if the tube is in the airway as opposed to the stomach. An x-ray is the most definitive test to confirm placement. Correct placement of the NG tube should always be confirmed before applying suction or administering medications

Nasogastric Tube (NG Tube)

anti-ulcer medication - it helps to prevent stress-related ulcers

Pantoprazole (Protonix) is what type of medication?

esophagus, stomach, small intestine, and large intestines

The GI tract includes the:

B Changes in weight are the best indicator of fluid volume changes in the body. Monitoring blood pressure, checking pulse rate and quality, and assessing skin and mucous membranes for dryness are strong secondary indicators.

The best indicator of fluid volume changes in the body is: a. skin dryness b. weight changes c. blood pressure d. pulse rate

B Preventing the spread of pandemic flu is equally important as caring for the clients who have it. Preventing the spread of disease is vital. The nurse would ask the "clients" about recent overseas travel to assess the risk of a pandemic flu. Clients with possible pandemic flu need to be in Contact and Airborne Precautions the infectious organism is identified and routes of transmission known. There is no specific danger to pregnant caregivers. Droplet Precautions are not appropriate

The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the "clients" on Contact Precautions. b. Inquire as to recent travel outside the United States. c. Do not allow pregnant caregivers to care for these "clients." d. Place the "clients" on enhanced Droplet Precautions.

B Preventing the spread of pandemic flu is equally important as caring for the clients who have it. Clients can be cohorted together in the same set of rooms on one part of the unit to use distancing to help prevent the spread of the disease. The other actions are not appropriate.

The charge nurse on a medical unit is preparing to admit several clients who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Admit the clients on Contact Precautions. b. Cohort the clients in the same area of the unit. c. Do not allow pregnant caregivers to care for these clients. d. Place the clients on enhanced Droplet Precautions.

C Pain and emotional stress are the two leading causes of discomfort for a patient. For example, patients who are having surgery are often anxious and feel stressed about the procedure. This emotional stress may negatively impact the outcome of surgery.

The most common causes of decreased comfort for a patient are pain and ____________. a. light-headedness b. nausea c. emotional stress d. depression

C A BMI of over 30 indicates that the client is obese

The nurse assesses a newly admitted client and documents a body mass index (BMI) of 31.2. What does this value indicate to the nurse? a. The client has a healthy weight. b. The client is underweight. c. The client is obese. d. The client is overweight

B, D, E

The nurse assesses an older adult with a diagnosis of severe, late-stage Alzheimer's disease. Which assessment findings would the nurse expect for this client? Select all that apply. A. Acute confusion B. Hallucinations C. Wandering D. Urinary incontinence E. Difficulty eating

A, C, D, E Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change. Limiting the client's visitors is not a caring action. The nurse would ensure they perform proper hand hygiene on entering and leaving the room and that visitors are not ill themselves.

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures f. Limiting the client's visitors until more stable

A, B, C, D, F Immobility, decreased thirst response, diminished immune response, malnutrition, and use of diuretics can place the older adult at higher risk of developing shock. Overhydration is not a common risk factor of shock.

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration f. Use of diuretics

A, D, E

The nurse collaborates with the registered dietitian nutritionist to improve the nutritional status of clients on a hospital unit. Which priority professional nursing concepts apply in this situation? Select all that apply. A. Quality Improvement B. Ethics C. Health Care Disparities D. Systems Thinking E. Teamwork and Collaboration

A, D, E Attitude, knowledge, and skills are the patient-centered care competencies needed to ensure quality care. These characteristics, which were developed by the Institute of Medicine and the Quality and Safety Education for Nurses (QSEN) groups, are the areas cited and enumerated by both groups. A delineation (and examples of each) of knowledge, skills, and attitudes constitutes competent nursing practice. Environment, sound nursing judgments, and values are important to the client's care but are not included in the patient-centered care competencies.

The nurse educator is instructing newly hired registered nurses about patient-centered care. Which competency categories are included in this content? (select all that apply) A. Attitudes B. Environments C. Judgments D. Knowledge E. Skills F. Values

A This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of worsening perfusion status and possible shock. The nurse would assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate that the client's pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is above the normal range, which is 30 mL/hr

The nurse gets the hand-off report on four clients. Which client would the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours

B The scope of med-surg nursing, sometimes called adult health nursing, is to promote health and prevent illness or injury in clients from 18-100 years or older. The most common practice setting is acute care hospital

The nurse has recently been assigned to a medical-surgical clinical rotation. According to the scope of medical-surgical nursing, what type of client assignments does the nurse expect to see? A. Hospitalized children with acute and chronic illnesses B. Hospitalized adults with acute and chronic illnesses C. Older adults in a nursing home D. Working adults in a corporate setting

A, B, C, D Lifestyle modifications can help control GERD and include losing weight if needed; avoiding chocolate, caffeine, and carbonated beverages; eating frequent small meals or snacks; and remaining upright after meals. Tobacco is a risk factor for GERD and should be avoided in all forms

The nurse has taught a client about lifestyle modifications for gastroesophageal reflux disease (GERD). What statements by the client indicate good understanding of the teaching? (Select all that apply.) a. I just joined a gym, so I hope that helps me lose weight. b. I sure hate to give up my coffee, but I guess I have to. c. I will eat three small meals and three small snacks a day. d. Sitting upright and not lying down after meals will help. e. Smoking a pipe is not a problem and I dont have to stop.

D The most reliable assessment to determine correct feeding tube placement is to have an x-ray to visualize where the tip of the tube is located

The nurse inserts a small-bore nasoduodenal tube for a client who is undernourished. What priority nursing action is required prior to starting the continuous tube feeding to confirm correct tube placement? a. Assess for carbon dioxide using capnometry. b. Perform pH testing of gastric fluid. c. Auscultate over the epigastric area. d. Request an x-ray before starting the feeding.

A, B, C, E Attentiveness/surveillance of clients, mandatory reporting, medication administration, and prevention of errors or complications are initiatives of the National Council of State Boards of Nursing (NCSBN) published findings about breakdowns in nursing practice. Participation in professional organizations and teaching clients about their care regimens are not initiatives of the NCSBN.

The nurse is appointed to a hospital committee whose goal is to "improve the safety of nursing practice." Which areas of practice are included in the committee's task? A. Attentiveness/surveillance of clients B. Mandatory reporting C. Medication administration D. Participation in professional organizations E. Prevention of errors or complications F. Teaching clients about their care regimens

B, C The case manager and the health care provider must see the client on a daily basis to collaborate with the nurse caring for the client. The anesthesiologist, occupational therapist, and chaplain are not needed on a daily basis.

The nurse is asked to collaborate with others to implement an interdisciplinary plan of care for a client. Which health care team members are essential for the client's daily care regimen? (select all that apply) A. Anesthesiologist B. Case manager C. Health care provider D. Occupational therapist E. Chaplain

A, B, C, D, E, F All of these body changes occur due to nutrient deficiencies associated with low protein, zinc, vitamin A, and complex B vitamins.

The nurse is assessing a client who has undernutrition. What signs and symptom(s) would the nurse expect? (Select all that apply.) a. Alopecia b. Stomatitis c. Muscle wasting d. Peripheral edema e. Anemia f. Dry, scaly skin

A, B, C, D Many factors predispose a person to GERD, including delayed gastric emptying, eating large meals, hiatal hernia, and obesity. Viral infections are not implicated in the development of GERD, although infection with Helicobacter pylori is.

The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply.) a. Delayed gastric emptying b. Eating large meals c. Hiatal hernia d. Obesity e. Viral infections

A, B, C, D, E, F All of these s/s are commonly seen in patients who have GERD

The nurse is caring for a client diagnosed with probable gastroesophageal reflux disease (GERD). What assessment finding(s) would the nurse expect? (Select all that apply.) a. Dyspepsia b. Regurgitation c. Belching d. Coughing e. Chest discomfort f. Dysphagia

A, B, C, F fever and chills may occur in clients who have a UTI if the infection has expanded beyond the bladder into the kidneys. However, these s/s are not urinary s/s.

The nurse is caring for a client who is diagnosed with urinary tract infection (UTI). What common urinary signs and symptoms does the nurse expect? (Select all that apply.) a. Dysuria b. Frequency c. Burning d. Fever e. Chills f. Hematuria

C

The nurse is caring for a client with chronic confusion who often yells and screams when touched. Which nursing intervention is most appropriate when caring for this client? A. Provide a large clock and calendar for the patient to read B. Use removable restraints such as a roll-waist belt to prevent wandering C. Approach the patient so the nurse can be seen clearly D. Place the patient in a room close to the nurses' station for frequent observation

A, B, C, E, F Within the first hour of suspecting severe sepsis, the nurse would: - draw (or facilitate) serum lactate levels - obtain blood cultures or other cultures - administer antibiotics after the cultures have been obtained - begin rapid administration of 20mL/kg of crystalloid for hypotension or lactate levels greater than or equal to 4 mmol/L - administer vasopressors if hypotensive during or after fluid resuscitation to maintain mean arterial pressure greater than or equal to 65 mmHg. Initiation hemodynamic monitoring would be done after these "bundle" measures have been accomplished.

The nurse is caring for a client with suspected septic shock. What does the nurse prepare to do within 1 hour of the client being identified as possibly having sepsis? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures. f. Administer rapid bolus of IV crystalloids.

A, B, E within the first 3 hours of suspected severe sepsis, the nurse should draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), and administer antibiotics (after the cultures have been obtained). Infusing vasopressors and measuring CVP are actions that should occur within the first 6 hours

The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures.

C Aspiration pneumonia is one of the most common complications in older adults who have enteral nutrition via a nasoduodenal tube because their gag reflex is often decreased. Intermittent diarrhea may also occur, but that is not potentially life threatening if the client does not become dehydrated.

The nurse is caring for an older client receiving total enteral nutrition via a small-bore nasoduodenal tube. For what priority complication would the nurse assess? a. Intermittent diarrhea b. Cholecystitis c. Aspiration pneumonia d. Peptic ulcer disease

A, B, C, D, E

The nurse is caring for an older client who is experiencing acute confusion and agitation following a fractured hip repair this morning. Which risk factors may be contributing to the client's delirium? Select all that apply. A. Anesthesia used during surgery B. Surgical pain C. Unfamiliar environment D. Noisy hospital unit E. Medications used to manage pain

D

The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider to order an antipsychotic drug. c. instruct family members to remain with the patient and prevent injury. d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.

A

The nurse is conducting assessments for clients at potential risk for infection. Which client is most at risk for acquiring an infection? A. A client who had an open incision for abdominal surgery B. A client who has not been immunized for pneumonia or influenza C. A client who works in a high-stress job for an accounting practice D. A client who is 85 years old and in good health

A The most important assessment would be to observe the skin around the tube for irritation, redness, and skin breakdown. The skin should be cleaned frequently to keep it free of drainage and moisture which can lead to excoriation or other type of skin breakdown. For a client who is undernourished, he or she is usually weighed every day and prealbumin is a more sensitive indicator of over nutritional health. The G-tube is not routinely irrigated

The nurse is managing care for a client receiving feeding through a gastrostomy tube (G-tube). What assessment would the nurse perform? a. Check the skin around the tube insertion site. b. Weigh the client every shift with the same scale. c. Draw blood to assess albumin every shift. d. Irrigate the tube at least once a day.

A, B, C, D, E Any of these complications may occur in clients who have uncontrolled GERD

The nurse is teaching a client about the risk of uncontrolled or untreated the client's gastroesophageal reflux disease (GERD). What complication(s) may occur if the GERD is not successfully managed? (Select all that apply.) a. Asthma b. Laryngitis c. Dental caries d. Cardiac disease e. Cancer

B, C The client having this procedure does not have an incision and will not require a nasogastric tube (NGT). The client should avoid an NGT placement for at least a month after the procedure. A liquid diet is required for only 24 hours after the procedure and then the client should progress to include soft floods like custard and applesauce

The nurse is teaching a client diagnosed with gastroesophageal reflux disease (GERD) who is planning to have an endoscopic radiofrequency (Stretta) procedure. What pre-procedure health teaching would the nurse include? (Select all that apply.) a. "You will need to be on a liquid diet for the first week after the procedure." b. "Avoid taking any NSAIDs like ibuprofen for 10 days before the procedure." c. "Contact the primary health care provider after the procedure if you have increased pain." d. "You will need a nasogastric tube for a few days after the procedure." e. "You will have a small incision in your stomach area that will have a wound closure.

D The RRT should be called whenever a client has a slow or sudden deterioration in clinical condition, such as a sudden drop in blood pressure. The older adult client awakening in a confused state and then reorienting can be a normal occurrence because of the client's age. Pain medication should be indicated in the health care provider's prescription. If it is not, the admitting health care provider should be called, not the RRT. Drainage on the dressing of the postoperative client is normal.

The nurse is working in the intensive care unit. When does the nurse call the Rapid Response Team (RRT)? A. An 87-year-old client awakens confused, then reorients quickly. B. A newly admitted client requests pain medication. C. A postoperative client's dressing has bloody drainage. D. A postoperative client's blood pressure suddenly drops.

A

The nurse provides an SBAR hand-off communication regarding a client whose blood pressure and respiratory rate have decreased. Where will the nurse include these data as part of the SBAR format? A. Situation B. Background C. Assessment D. Recommendation

A, C the common s/s of shock, no matter the cause, are directly r/t the effects of anaerobic metabolism and hypotension.

The nurse studying shock understands that the common signs and symptoms of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased systemic perfusion

D Self-determination refers to the idea that clients are autonomous individuals capable of making informed decisions about their care. When the client is not capable of self-determination, the nurse is ethically obligated to protect the client as an advocate in the professional scope of practice

The nurse supports the client and family in deciding on a "Do Not Resuscitate" order. Which ethical principle that guides nursing clinical decision making is demonstrated in this situation? A. Beneficence B. Justice C. Legality D. Self-determination

A, B, C, D, E

The nurse takes a history for a client admitted to the hospital. Which factors in the nursing history indicate that the client is at risk for infection? Select all that apply. A. Diabetes mellitus type 2 for 20 years B. 52-pack year history of cigarette smoking C. Admitted from a long-term care facility D. Has a history of multiple urinary tract infections E. Is 84 years of age

A, C, D, E Many factors increase the hospitalized clients risk for nutritional deficits. Cultural food preferences may make hospital food unpalatable. Ill clients have increased nutritional needs but may be NPO for testing or treatment, or have a loss of appetite from their illness. Staff shortages impact clients who need to be fed or assisted with meals. The family may bring snacks that are either healthy or unhealthy, so without further information, the nurse cannot assume the snacks are leading to malnutrition.

The nurse understands that malnutrition can occur in hospitalized clients for several reasons. Which are possible reasons for this to occur? (Select all that apply.) a. Cultural food preferences b. Family bringing snacks c. Increased need for nutrition d. Need for NPO status e. Staff shortages

B, C, D, E EBP consists of utilizing current evidence, the client values and preferences, and the nurses expertise when planning care. It does not include cost- saving measures.

The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all that apply.) a. Cost-saving measures b. Nurses expertise c. Client preferences d. Research findings e. Values of the client

A, B, C, E Several age-related changes occur in the gastrointestinal system. These include decreased hydrochloric acid production, diminished nerve function that leads to decreased sensation of the need to pass stool, decreased fat digestion, decreased peristalsis in the large intestine, and calcification of pancreatic vessels.

The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.) a. Decreased hydrochloric acid production b. Diminished sensation that can lead to constipation c. Fat not digested as well in older adults d. Increased peristalsis in the large intestine e. Pancreatic vessels become calcified

D The skin and mucous membranes are the most important barrier against infection. The other options are also barriers, but are considered secondary to skin and mucous membranes.

The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection? a. Colonization by host bacteria b. Gastrointestinal secretions c. Inflammatory processes d. Skin and mucous membranes

B Medical-surgical nurses, as part of the Quality and Safety Education for Nurses (QSEN) and evidence-based practice improvement (EBPI) quality improvement competency, are expected to be able to identify indicators to monitor quality and effectiveness of health care. Data that demonstrate evidence of improvement in falls after implementation of a protocol is a type of indicator of quality and effectiveness of care.

The nursing student asks the supervising nurse whether a certain fall protocol used on the nursing unit is effective. To demonstrate effectiveness, what does the supervising nurse identify? A. Information about how to implement a fall protocol and what nurses need to document B. Data about the number of falls after the protocol was introduced compared with previous fall rates C. The number of clients who currently have a fall protocol in place D. National statistics about the use of fall protocols to prevent serious injury from falls

A Members of the RRT are critical care experts who are on site in the hospital and are available at any time

The nursing student has been assigned to the hospital's Rapid Response Team (RRT). Which statement by the student indicates a correct understanding of the RRT member's purpose? A. "I will be caring for clients in the hospital." B. "I will be riding along in the hospital's ambulance." C. "I will be admitting clients to the hospital." D. "I will be participating in Code Blue resuscitations."

A, B, C, D

The oncoming nurse has received report regarding a 79-year-old client with delirium. Which assessment finding does the nurse anticipate may be present? Select all that apply. A. Psychosis B. Bacteria in urine C. Temperature 101.9°F D. Oxygen saturation 89% E. Has been present for 6 months

- regurgitation - indigestion (dyspepsia) *heartburn accompanies as well Other common symptoms include hoarseness, sore throat, dysphagia, chest pain, and odynophagia (painful swallowing).

The primary symptoms of GERD are:

A cellular regulation is the term used to describe both the positive and negative aspects of cellular function within the body

The process to control cellular growth, replication, and differentiation to maintain homeostasis is called: a. cellular regulation. b. cellular impairment. c. cellular reproduction. d. cellular tumor.

B, C, D, E Factors that must be present in order to transmit infection include: - host with a portal of entry - a mode of transmission - and a reservoir Colonization is not one of these factors

The student nurse caring for clients understands that which factors must be present to transmit infection? (Select all that apply.) a. Colonization b. Host c. Mode of transmission d. Portal of entry e. Reservoir

A, B, D, E In order to be effective, antimicrobial therapy must use the appropriate drug in a sufficient dose, for a sufficient length of time, and given via the appropriate route. Some antimicrobials do require monitoring for peak and trough levels, but not all.

The student nurse learns that effective antimicrobial therapy requires which factors to be present? (Select all that apply.) a. Appropriate drug b. Proper route of administration c. Standardized peak levels d. Sufficient dose e. Sufficient length of treatment

A, B, C, E Risk factors for acute gastritis include alcohol, caffeine, corticosteroids, and chronic NSAID use. Fruit juice is not a risk factor, although in some people it does cause distress

The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (Select all that apply.) a. Alcohol b. Caffeine c. Corticosteroids d. Fruit juice e. Nonsteroidal anti-inflammatory drugs (NSAIDs)

B

Total enteral nutrition (TEN) has been prescribed for a client with terminal cancer. When the nurse notes that no advanced directives are in place, yet a durable power of attorney exists, what is the appropriate action? A. Withhold TEN indefinitely B. Contact the durable power of attorney C. Begin administration of TEN immediately D. Turn over care to the interprofessional ethics committee

1, 2, 3, 4, 5, 6

What is the generalist registered nurse's role related to patient care within a system? Select all that apply. 1. Caring 2. Teaching 3. Collaborating 4. Advocating 5. Researching 6. Prescribing

C Monitor serum electrolytes and glucose daily or per facility protocol. (Some facilities require finger-stick blood sugars [FSBSs] every 4 hours.) If insulin is added to the TPN to manage hyperglycemia, FSBSs should be checked frequently. Infection at the catheter site is a serious risk, as are fluid and electrolyte imbalances.

What possible complication does the nurse observe for when administering total parenteral nutrition (TPN)? A. Infection B. Dehydration C. Hyperglycemia D. Electrolyte imbalance

C Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.

When administering a mental status examination to a patient with delirium, the nurse should: a. wait until the patient is well-rested. b. administer an anxiolytic medication. c. choose a place without distracting stimuli. d. reorient the patient during the examination.

B

When caring for a client with MRSA, which precaution will the nurse institute? A. Droplet B. Contact C. Airborne D. Neutropenic

B The client's immune status plays a large role in determining risk for infection. Congenital abnormalities, acquired health problems (for example, kidney injury, steroid dependence, cancer, AIDS) and advancing age can increase a client's risk of developing immunologic deficiencies. Chronic physical and psychological stress can also depress the immune system, making the client more susceptible to infection.

When caring for four clients, which client does the nurse identify at highest risk for infection? A. 20-year-old with stomach pain B. 31-year-old with chronic kidney disease C. 44-year-old using a 10-day steroid taper D. 62-year-old with history of prostate hyperplasia

A The best EBP will be developed by using information from randomized controlled studies testing the impact of various nursing interventions and outcomes for the clients with pneumonia. This type of data collection is the most scientifically based approach listed here.

When developing a standardized plan of care for clients with a diagnosis of pneumonia, how does the nurse find the best information about providing optimal nursing care? A. Access a website that reports on randomized controlled studies on nursing care for clients with pneumonia. B. Research the most recent articles in nursing magazines that discuss care for clients with pneumonia. C. Review the chart to determine what primary health care provider's prescriptions are frequently written for clients with pneumonia. D. Survey experienced RNs about which nursing actions are effective when caring for clients with pneumonia.

A, C, D, E, F "Hand-off" communication between departments should include info that is essential to the patient's nursing care, such as: - why the patient is being admitted - medication that have been given - the fact that the patient has a high anxiety level - family history of heart disease - needed procedures

When transferring a client who was admitted with chest pain from the emergency department (ED), which information is essential for the ED nurse to communicate to the nurse on the medical-surgical unit? (select all that apply) A. "The client is being admitted for ongoing monitoring of pain and vital signs." B. "The client has private insurance and is also covered by Medicare." C. "Nitroglycerin and morphine sulfate were given to relieve the pain." D. "Frequent reassurance is needed because the client has a high anxiety level." E. "The client has a family history of heart disease and hypertension." F. "A coronary arteriogram should be scheduled as soon as possible."

A, B, C, E Older adults need unhurried and uninterrupted time for eating. Dentures should fit appropriately and glasses, if used, should be on. High-calorie, high-protein snacks are a good choice. Salty snacks are not recommended because all adults should limit sodium in their diets.

When working with older adults to promote good nutrition, what actions by the nurse are most appropriate? (Select all that apply.) a. Allow uninterrupted time for eating. b. Assess dentures for appropriate fit. c. Ensure the client has glasses on when eating. d. Provide salty foods that the client can taste. e. Serve high-calorie, high-protein snacks

B Consistent practice of proper hand hygiene is the best method to prevent infection, as most healthcare- associated infections are due to staff members contaminated hands. Assessing the client and monitoring laboratory values will help the nurse catch signs of infection quickly but will not prevent infection from occurring. Teaching visitors not to come see the client when they are ill will also help prevent infection, but not to the degree that hand hygiene will

Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized? a. Assessing skin and mucous membranes b. Consistently using appropriate hand hygiene c. Monitoring daily white blood cell counts d. Teaching visitors not to visit if they are ill

A Autonomy is self-determination. The client should make decisions regarding care. When the nurse obtains a signature on the consent form, assessing if the client still has questions is vital, because without full information the client cannot practice autonomy. Giving accurate information is practicing with veracity. Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.

Which action by the nurse working with a client best demonstrates respect for autonomy? a. Asks if the client has questions before signing a consent b. Gives the client accurate information when questioned c. Keeps the promises made to the client and family d. Treats the client fairly compared to other clients

A When planning education, the nurse's initial action should be to assess whether the client is receptive to teaching and identify the client's current knowledge level. The other actions may be appropriate depending on the nurse's assessment of the client's learning needs, preferred learning style, and desire to share health information with his family. The family may be needed, but this is not the primary focus if the client is competent.

Which action does the nurse take first when preparing to do discharge teaching for the 73-year-old client who is being discharged after prostate surgery? A. Ask what the client knows about self-care after prostate surgery. B. Have family members available during the teaching. C. Provide written information about postdischarge care D. Plan to teach early in the morning after the client has eaten.

C

Which action to prevent harm is has the highest priority for the nurse to include when teaching a client with tuberculosis about the prescribed first-line drug therapy regimen? a. Expect a change in urine color. b. Be sure to drink at least 2 L of fluids daily. c. Take these drugs daily exactly as prescribed. d. Wear use sunscreen and wear protective clothing when you are out-of-doors.

B The CAM tool has been extensively tested in assessing delirium

Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium? a. Administer the Mini-Mental Status Exam. b. Use the Confusion Assessment Method tool. c. Determine whether there is a family history of dementia. d. Obtain a list of the medications that the patient usually takes.

A DOT direct observation therapy is when the nurse watches the patient swallow the medication

Which action will the nurse take to ensure that a client who requires drug therapy for multi-drug resistant tuberculosis and also is addicted to heroin adheres to the treatment regimen? a. Arranging for a health care worker to directly observe the client take the drugs b. Giving the client written instructions about how and when to take the drugs c. Instructing the client about the consequences of not taking the drugs d. Having the client repeat the drug names and side effects

B, C, D, E

Which adults are at higher risk for development of active tuberculosis? Select all that apply. A. A, 21-year-old college student living in a dorm at a Canadian university B. 38-year-old with AIDS who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years F. 70-year-old with moderate to severe chronic obstructive pulmonary disease (COPD)

A, B, C, E, F Those who have received the BCG vaccine are not at a higher risk for contracting TB, however, their test result will show as positive for 10 years after having the vaccine which complicates testing because this doesn't mean that they are positive for TB

Which adults will the nurse identify as having a higher risk for active tuberculosis? (Select all that apply.) a. Kidney transplant recipients b. Those in the local prison c. Recent immigrants to the United States d. Those who have received bacille Calmette-Guérin (BCG) vaccine e. Those who were treated previously for active tuberculosis f. Homeless adults

A SBAR and PACE are acronyms for "hand-off" methods of communication used by health care organizations to share information between shifts and between departments

Which important aspect of coordinating care within the interdisciplinary team is facilitated by use of the "SBAR" and "PACE" procedures? A. Communication B. Implementation C. Policymaking D. Protocol development

B The patient with moderate dementia will have problems with short- and long- term memory and will need reminded about hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.

C

Which is the priority action for the nurse to take first after applying oxygen when caring for an older client admitted with symptoms of possible seasonal influenza accompanied by vomiting and high fever? a. Asking the client when symptoms began b. Administering IM influenza vaccination c. Starting an IV line to begin hydration therapy d. Placing the client in a negative air pressure room

B The principle of justice refers to equality- all client should be treated equally and fairly, as demonstrated by the respect shown to the client with dementia

Which nursing action demonstrates use of the principle of justice? A. A 32-year-old client is prevented from falling during the initial postoperative period following her hysterectomy. B. A 67-year-old client with dementia is shown the same respect as his 47-year-old roommate with prostate cancer. C. An 82-year-old client is provided access to the hospital Patient Advocate for processing of a complaint. D. The parents of a 13-year-old are included in discussions about the course of their teen's treatment and care.

B Because the patient with dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the drug

Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia? a. Setting the medications up monthly in a medication box b. Having the patient's family member administer the medication c. Posting reminders to take the medications in the patient's house d. Calling the patient weekly with a reminder to take the medication

A Although all of these actions may sometimes be delegated to UAPs, the client with rheumatoid arthritis is the most stable of the clients described here

Which nursing activity is best for the charge nurse on the medical-surgical unit to delegate to staff members who are unlicensed assistive personnel (UAPs)? A. Feeding a client whose hands are affected by rheumatoid arthritis B. Increasing the oxygen flow rate for a client who has wheezes C. Positioning a client who has just returned from hip surgery D. Taking vital signs for a client who is having acute chest pain

A The case manager role includes coordination of acute care & post-discharge community services for the client

Which of these hospital staff members will the nurse manager assign to coordinate the discharge of a client who will need community-based rehabilitation services after a traumatic injury? A. The nurse responsible for the client's case management B. The physical therapist who developed the client's exercise program C. The health care provider assigned as the client's medical resident D. The unit-based RN who has cared for the client during the hospital stay

B, C, E Handwashing is the number one way to prevent infection in clients Checklists can help prevent mistakes in care for the surgical client, thus ensuring a safe environment. Adhering to the 5 rights of med admin helps to prevent errors in this important nursing care activity, providing for increased safety in client care

Which principal nursing actions best support a focus on client safety? (select all that apply) A. Client restraints B. Handwashing C. Preoperative checklists D. Respect for others E. Five rights of drug administration

B In the caregiver role, the med-surg nurse assesses clients, analyzes collected info to determine their needs, develops nursing dx for collaborative problems, plans care and carries out the plan with the health care team, and evaluates the care given In the role of advocate, the medical-surgical nurse assists the client and family through caring interventions. "Communicator" is not a defined nursing role. In the role of educator, the nurse strives to improve health by facilitating client learning regarding health promotion, disease and illness, and specific treatment by teaching clients and family members or other caregivers.

Which role of the medical-surgical nurse is demonstrated when writing a plan of care for a client who is newly admitted to the hospital? A. Advocate B. Caregiver C. Communicator D. Educator

D, E Standard precautions implies that contact with bodily secretions, excretions, and moist mucous membranes and tissues (excluding perspiration) is potentially infectious. Always wear gloves when coming into contact with such material. Other PPE is used based on the care being given. For example, if face splashing is expected, you should also wear a mask. Wearing a gown for hygiene is not required. Sneezing into your sleeve or tissue is a part of respiratory etiquette. Remaining 3 feet from clients is also not a part of standard precautions.

Which statements are true regarding Standard Precautions? (Select all that apply.) a. Always wear a gown when performing hygiene on clients. b. Sneeze into your sleeve or into a tissue that you throw away. c. Remain 3 feet away from any client who has an infection. d. Use personal protective equipment as needed for client care. e. Wear gloves when touching client excretions or secretions

A, B, D

Which statements by assistive personnel indicate understanding regarding infection control measures needed to care for a client who has possible Clostridium difficile infection? Select all that apply. A. "I'll wear an isolation gown when providing direct care." B. "I'll wear gloves when providing direct care." C. "I'll wear a mask each time I enter the client's room." D. "I'll use a hand sanitizer when I can't wash my hands." E. "I'll wear goggles to protect my eyes."

B Any client on antibiotics must be instructed to complete the entire course of antibiotics. Not completing them can lead to complications or drug-resistant strains of bacteria. The other instructions are appropriate, just not the most important.

Which teaching point is most important for the client with bacterial infection? a. Gargle with warm salt water. b. Take all antibiotics as directed. c. Use a humidifier in the bedroom. d. Wash hands frequently.

C MRSA is susceptible to only a few antibiotics such as vancomycin (Vancocin) and linezolid (Zyvox), as well as ceftaroline fosamil.

the nurse is preparing to administer the client's medications. Which drug was likely ordered by the health care provider to address MRSA?