NCLEX-PN - Medsurgical
The practical nurse is reinforcing osteoporosis prevention education to a group of senior citizens. The nurse realizes teaching has been effective if the senior citizens select which life style choices will help decrease the risk of developing osteoporosis? (Select all that apply.) a. Alcohol in moderation and smoking cessation b. Avoidance of extreme temperatures and altitudes c. Regular weight-bearing exercises d. Implementation of a home safety plan to prevent falls e. Consumption of a diet rich in calcium and vitamin D
a. Alcohol in moderation and smoking cessation b. Avoidance of extreme temperatures and altitudes c. Regular weight-bearing exercises d. Implementation of a home safety plan to prevent falls e. Consumption of a diet rich in calcium and vitamin D
A client comes to the clinic and reports the presence of a painful lesion in the genital area; they described it as a blister 2 days earlier that is now crusty. Which intervention should the practical nurse (PN) implement first? a. Ask the client if they have had unprotected sex. b. Prepare the client for a culture and sensitivity test of the lesion. c. Inform the client this occurrence will have to be reported to the public health department. d. Prepare to administer penicillin intramuscularly into the dorsogluteal area.
a. Ask the client if they have had unprotected sex. Rationale: These are typical signs and symptoms of herpes simplex virus 2 (HSV2), a sexually transmitted disease (STD), so the PN should ask the client if they had unprotected sex and if the client has exposed others to the disease.
A client diagnosed with chronic obstructive pulmonary disease complains to the practical nurse of extreme fatigue after coughing. Which self-care measures can help minimize the client's dyspnea? (Select all that apply.) a. Assume a sitting position with shoulders relaxed and knees flexed. b. Support forearms with a pillow and place both feet flat on the floor. c. Slightly drop the head, bend forward, and slowly exhale with pursed lips. d. Resume sitting up straight, using diaphragmatic breathing to inhale slowly and deeply. e. Repeat inhaling deeply and slowly with pursed lips while bending forward only once. f. Repeat exhaling and wait for the cough reflex to facilitate movement of the secretions. g. After coughing, inhale deeply from abdomen and cough three or four times while exhaling.
a. Assume a sitting position with shoulders relaxed and knees flexed. b. Support forearms with a pillow and place both feet flat on the floor. c. Slightly drop the head, bend forward, and slowly exhale with pursed lips. d. Resume sitting up straight, using diaphragmatic breathing to inhale slowly and deeply. Rationale: Effective coughing can help the client to cough secretions, therefore improving gas exchange and minimize fatigue. The client should assume the sitting position with shoulders relaxed and knees flexed. Their forearms should be supported with a pillow and both feet place flat on the floor. The client should slightly drop their head, bent forward, and slowly exhale through pursed lips using slow and deep diaphragmatic breathing to help facilitate effective coughing. The client should repeat the previous steps two or three times. The client should initiate the cough reflex, not wait for it. The client should also take a deep abdominal breath before initiating a cough.
A client who has had an AV (arteriovenous) fistula placement in the right forearm is transferred from the Post-anesthesia care unit (PACU) to the nursing unit. Which nursing measure is essential in promoting safe, effective care for the client? a. Avoid blood pressures or needlesticks in right arm. b. Place pressure dressing over AV insertion site. c. Do not elevate the right arm. d. Keep right arm immobilized in a splint.
a. Avoid blood pressures or needlesticks in right arm. b. Place pressure dressing over AV insertion site. c. Do not elevate the right arm. d. Keep right arm immobilized in a splint.
A 70-year-old client status post hip replacement is transferred to a rehabilitation facility. Which scale should the practical nurse (PN) identify as the best tool to predict the client's risk for developing skin breakdown? a. Braden Scale b. Morse Scale c. Aldrete Scale d. Wong-Baker Face Scale
a. Braden Scale Rationale: The Braden Scale is made up of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. A hospitalized adult with a score 16 or below or an older adult with a score of 18 or below is at an increased risk for skin breakdown.
A client is diagnosed with acute myocardial infarction (MI). Which diagnostic laboratory value should the practical nurse (PN) anticipate to be the first to elevate to establish a diagnosis of an acute myocardial infarction (MI)? a. Elevated troponin b. Elevated creatine kinase-MB (CK-MB) level c. Prolonged prothrombin time (PT) d. Elevated serum blood urea nitrogen (BUN) and creatinine
a. Elevated troponin Rationale: Tissue damage in the myocardium causes the release of cardiac enzymes into the blood system. According to the American College of Cardiology (ACS) and the European Society of cardiology (ESC), an elevation of the troponin will occur within 2 to 3 hours of an MI and is used to establish the diagnosis. It takes the CK-MB level 6 to 9 hours or longer to elevate.
A client diagnosed with prostate cancer is prescribed radioactive seed implantation (brachytherapy). What is the most important nursing action for the practical nurse (PN) to do? a. Follow radiation exposure precautions. b. Encourage regular meals. c. Collect all urine in sealed containers. d. Avoid touching the client.
a. Follow radiation exposure precautions. Rationale: Clients being treated for prostate cancer with brachytherapy (radioactive seeds implant) should be placed on radiation exposure precautions. The PN needs to follow the institution's protocols put in place regarding the amount of time and distance needed to prevent excessive exposure that would pose a hazard to others.
The nurse has reinforced instructions to a client with diabetes mellitus on how to self-monitor for symptoms of diabetic ketoacidosis (DKA). The nurse realizes the instructions have been effective if the client can list which symptoms? (Select all that apply.) a. Fruity breath odor b. Rapid, weak pulse c. Cold, clammy skin d. Extreme thirst e. Urinary frequency
a. Fruity breath odor b. Rapid, weak pulse d. Extreme thirst e. Urinary frequency Rationale: Diabetic ketoacidosis is caused by a profound deficiency of insulin. Some common characteristics include a sweet, fruity breath odor, a rapid weak pulse, extreme thirst, urinary frequency, and sunken-appearing eyeballs.
The nurse is assisting with planning care for a client who is undergoing chemotherapy to treat breast cancer. Which elements should be included in the client's education on ways to prevent contracting pneumonia? (Select all that apply.) a. Maintain a healthy diet with protein, fruits, and vegetables. b. Ask your health care provider about receiving the flu and pneumonia vaccine. c. Try to find ways you are able to cut back on the number of cigarettes you smoke. d. Try to do your grocery shopping when your local grocery store is the least crowded. e. Stay awake most of the day time hours, so you can sleep uninterrupted during the night.
a. Maintain a healthy diet with protein, fruits, and vegetables. b. Ask your health care provider about receiving the flu and pneumonia vaccine. d. Try to do your grocery shopping when your local grocery store is the least crowded. Rationale: Adequate nutrition reduces the risk of contracting pneumonia. The client should receive all recommended flu and pneumonia vaccines. The client should go in public places when those places are the last crowded to avoid contact with large number of microorganisms. The client should stop smoking, not simply cut back. Adequate rest periods during the day can improve the client's ability to resist infection.
A client has had a permanent pacemaker implanted. Which aspect should the nurse include when reinforcing instructions for care upon discharge? a. Stand 4 feet away from radar detectors in use. b. Stay away from homes and restaurants that use microwaves. c. Immediately report a pulse rate higher than the pacemaker rate setting. d. Request hand wand screenings when going through airport screening stations.
a. Stand 4 feet away from radar detectors in use. Rationale: The client should be educated to stay 4 to 5 feet away from electromagnetic sources, such as radar detectors. It is not necessary to avoid microwaves. The client should be taught the pacemaker rate settings, and it is important to report a pulse lower than the settings, as that would indicate the pacemaker is not functioning. Clients should inform airport security of the presence of a pacemaker; handheld wand screening should NOT be used over the pacemaker site.
A client is diagnosed with fluid volume deficit. Which findings would the practical nurse document consistent with fluid volume deficit? (Select all that apply.) a. Tachycardia b. Diaphoresis c. Cool skin d. Heart failure e. Decreased urine output f. Increased thirst
a. Tachycardia c. Cool skin e. Decreased urine output f. Increased thirst Rationale: Fluid volume deficit causes tachycardia because the body tries to compensate and pump blood efficiently. Cool skin is consistent with fluid volume deficit. Decreased urine output results from reduced fluid volume perfusing the kidneys. Thirst will be stimulated by the hypothalamus because of decreased fluid volume.
A client diagnosed with ulcerative colitis (UC) asks the practical nurse why a low-fiber diet has been prescribed. Which is the most appropriate response? a. To reduce the amount and frequency of stool b. To decrease fats and carbohydrates absorption c. To stop peristalsis and bowel movements d. To cleanse and evacuate stool from the large colon
a. To reduce the amount and frequency of stool Rationale: The purpose of a low-fiber diet is to reduce the amount and frequency of stooling to promote healing of the bowels by consuming foods that do not irritate the intestinal lining and prolong intestinal transit time to encourage optimal absorption of nutrients.
The practical nurse (PN) is reviewing the health histories of assigned clients. Which factors have a potential for development of throat cancer? (Select all that apply.) a. Tobacco use b. Excessive intake of alcohol c. Intake of hot and spicy foods d. Human papillomavirus (HPV) e. Lack of exercise f. Lack of dietary fiber
a. Tobacco use b. Excessive intake of alcohol d. Human papillomavirus (HPV) Rationale: The most common risk factors for throat cancer are tobacco use, alcohol abuse, human papillomavirus (HPV), a diet lacking in fruits and vegetable, and gastroesophageal reflux disease (GERD). Foods seasoned with herbs and spices have shown to have some health benefits in decreasing the risk of developing cancer.
A client has had a gastrectomy to treat stomach cancer. The nurse has reinforced instructions on ways to prevent "dumping syndrome." Which client statement indicates the need for further instruction? a. "My meals need to be mostly protein." b. "I should walk around after each meal." c. "I should eat fewer carbohydrates." d. "I should eat smaller, more frequent meals."
b. "I should walk around after each meal." Rationale: The client should lie down after meals to avoid syncope. The client should eat more protein and less carbohydrates, and smaller more frequent meals.
A client diagnosed with emphysema that is oxygen-dependent lives alone at home and manages self-care with no difficulty. Which finding should prompt the home health practical nurse to consult the registered nurse case manager? a. A pulse oximetry reading of 91% on oxygen at 2 L/m. b. A weight loss of 5 pounds since the last monthly home visit. c. The client reports feeling as tired as at the last visit by the nurse. d. Upon entering the home, the PN noticed dirty dishes and clothing scattered around the home.
b. A weight loss of 5 pounds since the last monthly home visit. Rationale: A weight loss of 5 pounds in 1 month is a concern. Clients with COPD need additional calorie intake because they are using up a lot from the energy they are using to breath. The practical nurse needs to consult with the registered nurse case manager for a nutrition consult.
A client had a bowel resection yesterday and has a nasogastric tube (NGT) attached to low intermittent suction. The client complains to the practical nurse of abdominal distention and nausea. What action should the PN take first? a. Irrigate the nasogastric tube with sterile normal saline. b. Assess the NGT drainage in the collection container. c. Advance the nasogastric tube 5 cm. d. Notify the health care provider.
b. Assess the NGT drainage in the collection container. Rationale: The immediate priority is to determine if the tube is functioning correctly, which the PN can do first by assessing the amount and characteristic of the drainage from the nasogastric tube. Based on the findings of the drainage will determine the PN next nursing intervention.
A client diagnosed with Guillain-Barré syndrome is hospitalized. Which finding is most important for the practical nurse to report to the primary health care provider? a. Ascending numbness from the feet to the knees. b. Decrease in cognitive status of the client. c. Blurred vision and sensation changes. d. Persistent unilateral headache.
b. Decrease in cognitive status of the client. Rationale: A decline in cognitive status in a client is indicative of symptoms of hypoxia that are the result of the respiratory muscles being affected and an indication that the client may require the assistance of mechanical ventilation.
A client diagnosed with a brain tumor is receiving radiation beam treatments to the right frontal area. The practical nurse (PN) should observe this client for which problem during the early post-therapy days? a. Hemiplegia b. Headache c. Hearing loss d. Dysphagia
b. Headache Rationale: Radiotherapy is a local treatment, and most side effects are site-specific, such as inflammation of surrounding brain tissue, swelling, headache, and fatigue.
A client is admitted from the emergency department with a diagnosis of left tibia fracture and the left leg has a splint in place. The client was medicated approximately 2 hours ago with a prescribed analgesic. The client is now complaining of excruciating leg pain and demanding "stronger pain medications." What initial action is most important for the practical nurse (PN) to take? a. Ask about any past history of drug abuse or addiction. b. Measure the pulse strength and capillary refill distal to the fracture. c. Apply an ice pack over the fracture area of the splint. d. Evaluate the fractured leg on two pillows.
b. Measure the pulse strength and capillary refill distal to the fracture. Rationale: The PN needs to measure the pulse strength and capillary refill distal to the fracture. Pain and diminished pulse volume are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast) or internal pressure after an injury resulting in inflammation and edema building up in the fascia space of the muscle which results in the pressure in this space building up and stopping the flow of blood to the tissues in the compartment. This is a medical emergency requiring a fasciotomy to relieve the pressure.
The nurse is caring for a 70-year-old female client who experienced a myocardial infarction. During review of the client's medical records, which signs and symptoms did the client most likely experience? (Select all that apply.) a. Hot dry skin b. Shortness of breath c. Fatigue d. Extreme hunger e. Sleep disturbances f. Melena
b. Shortness of breath c. Fatigue e. Sleep disturbances Rationale: A female client is more likely to experience dyspnea, fatigue, and sleep disturbances. Hot dry skin and extreme hunger are more likely associated with an elevated blood sugar. Melena is blood in the stools.
The nurse should recognize which symptom will be given the highest priority for monitoring for a client with Grave's Disease? a. Hypotension b. Tachycardia c. Hypothermia d. Depression
b. Tachycardia Rationale: A client experiencing symptoms of Grave's disease, or hyperthyroidism should have monitoring for tachycardia as the highest priority of care. Hypotension, hypothermia, and depression are associated with hypothyroidism.
A client has undergone craniotomy to remove a brain tumor. The client spent several days in the intensive care unit, and is now on the post-surgical unit. The nurse has urgently contact the surgeon to report signs of increasing intracranial pressure (ICP). Which was the most likely EARLY sign that the client was experiencing increased ICP? a. The client's blood pressure dropped from 128/70 to 124/68, preoperative BP 122/72 b. The client became more confused than he was upon transfer to the post-surgical unit. c. The client had a large amount of sanguineous drainage noted on the gauze dressings. d. The client's pulse rate had increased from 70 to 82 beats/min.
b. The client became more confused than he was upon transfer to the post-surgical unit. Rationale: A change in the level of consciousness is most likely the earliest symptom of increased ICP. Vital sign changes can also occur, with a widening pulse pressure and bradycardia. Neither of these are indicated by data in the options. Sanguineous drainage does not indicate increased ICP.
The nurse is caring for a female client who has human immunodeficiency virus (HIV) infection. Which aspects does the nurse expect to see included in the plan of care? (Select all that apply.) a. The breastfeeding mother should continue breastfeeding to provide the infant with the appropriate nutrients. b. The client should be educated that cervical cancer is more likely to occur in a client with an HIV infection. c. The client should be educated to report symptoms such as confusion, and any disturbances in vision. d. The client should not be assigned to a nurse or any other care provider who is pregnant or is breastfeeding. e. The client should be educated that dogs, especially those previously in a shelter, should not be brought into the home.
b. The client should be educated that cervical cancer is more likely to occur in a client with an HIV infection. c. The client should be educated to report symptoms such as confusion, and any disturbances in vision. Rationale: Cervical dysplasia is more likely to occur in a client with an HIV infection. Confusion and a disturbance in vision are associated with opportunistic infections and should be reported to the health care provider as soon as possible. The client should be educated not to breastfeed, as the virus can be transmitted to the infant in this manner. Nurses and other caregivers should use universal precautions with any client, not just those clients with known HIV infection. The client needs to know that cleaning the cat litter box exposes the client to toxoplasmosis and the birds and their droppings can contribute to opportunistic infections. If the dog is kept clean, there is no need for the client not to have contact with the dog.
The nurse is caring for a client who has an ileostomy and has reinforced instructions regarding ileostomy care. The nurse realizes the client needs additional instructions if the client makes which statement? a. "I should avoid high-fiber foods such as bran flakes." b. "I will need to empty the ostomy pouch when it is half full." c. "I will need to set a time every day when I can irrigate the ostomy." d. "I can use a simple squirt bottle to rinse out the pouch to remove odors."
c. "I will need to set a time every day when I can irrigate the ostomy." Rationale: The client will not be able to set a time to irrigate the ostomy because the ileostomy drains all the time. A client who has had an ostomy placed on the descending colon will most likely need to irrigate the ostomy at the same time each day. High-fiber foods will cause diarrhea. The client will need to empty the ostomy pouch when it is one-third to one-half full. Water and a simple squirt bottle can be used to remove effluence from the pouch and reduce odors.
The nurse has reviewed the plan of care for a client with rheumatoid arthritis (RA) to a group of unlicensed assistive personnel (UAPs). Which comment by the UAP indicates the need for further teaching? a. "We should bathe the client when she feels most energetic." b. "We can turn on the television if she wants it when she is in pain." c. "We can use ice packs wrapped in washcloths to apply to painful joints." d. "When she is walking with us, we should remind her not to use jerky movements."
c. "We can use ice packs wrapped in washcloths to apply to painful joints." Rationale: A client with RA will benefit from warm moist heat, whirlpool baths, and warm showers. Ice would likely cause more discomfort. The client should be bathed when she feels most energetic. Distraction can somewhat reduce pain, and television can be used if the client prefers it. The UAPs can remind the client to walk with slow, smooth motions.
The nurse is teaching concerned family members of a client who experienced a cardiac arrest prior to admission in the technique of cardiopulmonary resuscitation. The nurse recognizes the family members are performing the technique correctly if they use which depth of manual chest compression on the manikin? a. 0.5 inch (1.27 cm) to 1 inch (2.54 cm) b. 1.5 inch (3.8 cm) to 2 inches (5 cm) c. 2 inches (5 cm) to 2.4 inches (6 cm) d. 2.5 inches (6.4 cm) to 3 inches (7.6 cm)
c. 2 inches (5 cm) to 2.4 inches (6 cm) Rationale: According to the American Heart Association 2015 guidelines, the depth of compressions on an adult during CPR should be at least 2 inches (5 cm) to 2.4 inches (6 cm).
The practical nurse (PN) is taking vital signs on a client who has been treated for melanoma in the past. Which findings would cause the PN to consult the charge nurse? a. Increase of amount of freckles b. Dark liver spots c. An asymmetrical mole d. A mole that is purple in color
c. An asymmetrical mole Rationale: The practical nurse needs to consult the charge nurse about the asymmetrical mole. Melanoma is a skin cancer that is first identified by obvious change in the appearance of skin moles, which is one of the American Cancer Society's caution signs. The American Cancer Society uses the A, B, C, D method. A—asymmetry (a mole that is irregular in shape or two different looking halves); B—border; irregular, blurred, rough, or notched edges; C—changes in color or irregularity in the color of the appearance of the mole; D—diameter; moles larger than ¼ inch or 6 mm larger than a pencil.
A client scheduled for hip replacement surgery is prescribed a transfusion of a unit of packed red blood cells (RBCs). Which intervention is the best method to prevent a blood transfusion reaction? a. Verification of type and crossmatch of blood b. Transfusion of O negative blood c. An autologous transfusion d. Premedicating the client with diphenhydramine
c. An autologous transfusion Rationale: The best method for preventing transfusion reaction is an autologous transfusion (the client's own blood). A client's blood is generally collected 4 weeks before a scheduled surgery.
A client with cirrhosis is being discharged home, with family members to provide the majority of the client's care. Which instructions are important to reinforce with the family regarding this client's care? (Select all that apply.) a. Maintain a low-fiber diet. b. Use a safety razor to shave the client. c. Avoid soap when bathing the client. d. Use a soft toothbrush and gentle oral care. e. Apply moisturizing lotion and turn the client frequently.
c. Avoid soap when bathing the client. d. Use a soft toothbrush and gentle oral care. e. Apply moisturizing lotion and turn the client frequently. Rationale: A client with cirrhosis often has dry itchy skin. Soap can dry and irritate the skin further. To prevent skin breakdown, the skin should be kept moist and the client turned frequently. With cirrhosis, the liver is not able to produce some clotting factors, so bleeding prevention is a priority. The family should be instructed to use electric razors, not a safety razor, and to use a soft toothbrush when providing gentle oral care.
A client diagnosed with viral influenza is prescribed vitamin C 1000 mg PO daily and acetaminophen 650 mg PO every 4 hours prn. The client complains to the practical nurse of abdominal cramping and increasing episodes of diarrhea. Which prescription change should the nurse anticipate? a. Change the acetaminophen to ibuprofen. b. Change the elixir to an injectable route. c. Decrease the dose of vitamin C. d. Begin treatment with an antibiotic.
c. Decrease the dose of vitamin C. Rationale: Diarrhea is an adverse effect of high doses of vitamin C, so the nurse should anticipate a reduction in the dose of vitamin C.
Which interventions should the practical nurse implement to decrease the possibility of the client developing hypercalcemia? (Select all that apply.) a. Measure vital signs every 4 hours. b. Assist the client to turn, cough, and deep breathe every 2 hours. c. Remind the client to ambulate around the room at least three times daily. d. Irrigate the client's nasogastric (NG) tube every 2 hours. e. Increase fluid intake. f. Collaborate with the dietary nurse to increase foods high in calcium.
c. Remind the client to ambulate around the room at least three times daily. e. Increase fluid intake. Rationale: Hypercalcemia can result from immobility. Ambulation of the client helps to prevent calcium from leaking out of bones into the serum. Increasing fluid volume PO or IV helps to decrease calcium levels in the blood.
A client who had an abdominal hysterectomy 48 hours ago suddenly complains of chest pain and becomes short of breath, pale, and diaphoretic. The practical nurse (PN) immediately assesses the client's vital signs and obtains 100/80 mm Hg blood pressure, 110 beats/min heart rate, and 36 breaths/min respiratory rate. What nursing action should the PN to do next? a. Provide a paper bag for hyperventilation. b. Administer a prescribed prn analgesic. c. Lower the head of the bed and raise their feet. d. Apply oxygen at 2 L per nasal cannula.
d. Apply oxygen at 2 L per nasal cannula. Rationale: The PN should immediately provide oxygen while performing further assessment. Pulmonary embolism and pneumothorax are risks associated with major surgery.
The practical nurse (PN) is assigned a client diagnosed with a hemothorax who had a chest tube inserted 36 hours ago; upon entering the room, the PN observes the client resting comfortably in the semi-Fowler position; respirations appear even and unlabored; the water in the suction chamber is bubbling; and there is serous drainage noted in the collection chamber. What is the best initial action for the PN to take? a. Measure and document in the drainage in the chamber. b. Clamp the chest tube while assessing for air leaks. c. "Milk" the tube to remove any excessive blood clot buildup. d. Decrease the bubbling in the suction chamber.
d. Decrease the bubbling in the suction chamber. Rationale: Follow the ABC's (airway, breathing, and circulation) to determine that the airway and breathing are stable, and the next step is to evaluate the extent of the bleeding. It is not necessary to change the amount of bubbling in the suction chamber.
The practical nurse (PN) is providing care to a client who is experiencing slight scrotal edema following indirect herniorrhaphy. Which postoperative prescription should the nurse question for this client? a. Ice packs applied to the scrotum. b. Elevate the scrotum on a soft pillow. c. Application of a scrotal support. d. Encourage deep breathing and coughing.
d. Encourage deep breathing and coughing. Rationale: A client should be discouraged from coughing following a hernia repair. The coughing will create too much intra-abdominal pressure putting increase pressure on the abdominal wall and could cause a dehiscence and/or evisceration of the surgical site. All other interventions are recommended for postop care of a hernia.
The home health practical nurse is visiting with a client who has a history of second-degree heart block and pacemaker placement 6 months ago. Which symptom compliant by the client would be indicative of pacemaker failure? a. Facial flushing b. Nausea c. Pounding headache d. Feelings of dizziness
d. Feelings of dizziness Rationale: Feelings of dizziness may occur as the result of a decreased heart rate, leading to decreased cardiac output as a result of pacemaker failure.
A client status post-cholecystectomy 3 days is being prepared to be discharged home. Which client finding is the best indication to the practical nurse that postoperative nursing interventions have prevented respiratory complications? a. Uses an incentive spirometer (IS) frequently. b. Denies any cough or colored sputum. c. Breathes evenly and unlabored. d. Has a 95% pulse oximeter value on room air.
d. Has a 95% pulse oximeter value on room air. Rationale: Pulse oximetry of 95% on room air indicates adequate oxygenation.
A client with a history of emphysema is hospitalized for an exacerbation of the disease. The nurse expects to see which aspect emphasized in the plan of care? a. Oxygen administered at 6 L/m via nasal cannula. b. Fluids to be restricted to less than 1500 mL/day. c. Supine or low Fowler's position while resting in bed. d. Information on smoking cessation classes and support.
d. Information on smoking cessation classes and support. Rationale: The client should have information provided on smoking cessation classes and support while quitting. Oxygen is given at a low flow rate to prevent respiratory depression due to suppression of the stimulus to breathe. Fluids are encouraged to 3000 mL unless contraindicated. The client should be positioned sitting upright and bending slightly forward to promote breathing.
A client is hospitalized for an acute intestinal obstruction and has a nasogastric (NG) tube connected to low intermittent suction. Which task can be assigned to the unlicensed assistive personnel (UAP)? a. Providing sips of fluid around the clock b. Irrigating the nasogastric tube with normal saline c. Verifying the placement of the nasogastric tube in the stomach d. Measuring and emptying the contents of the nasogastric suction
d. Measuring and emptying the contents of the nasogastric suction Rationale: The nurse can assign the task of measuring and emptying the contents of the NG tube suction to the UAP. The client will not be allowed fluids because the NG tube would empty the fluid out as quickly as the patient drank the fluids. The nurse cannot assign any tasks which require judgment, such as irrigating the NG tube or verifying placement in the stomach.
A client diagnosed with duodenal ulcers is admitted to the hospital. The client was administered ranitidine hydrochloride 150 mg PO at bedtime. Which finding would indicate a therapeutic response of the medication? a. Gastric secretions pH level below 3. b. Hemoccult testing is positive on two different occasions. c. No difficulty falling asleep reported. d. No complaints of abdominal pain or heartburn verbalized.
d. No complaints of abdominal pain or heartburn verbalized. Rationale: Lack of abdominal pain within 4 hours after meals indicates decreased duodenal irritation, a positive outcome in the treatment of duodenal ulcer.
The practical nurse receives shift report on their assigned clients. Based on the change of shift report which situation has the highest priority? a. An IV that is infusing at 125 mL/hour currently has 200 mL left in the bag. b. A client's telemetry interpretation is sinus bradycardia with isolated premature ventricular contractions (PVCs). c. The 12-hour urinary output of a postoperative client which is 720 mL with an intake of 840 mL. d. No output in a hemovac from the abdominal incision of a client who is post-op day 1.
d. No output in a hemovac from the abdominal incision of a client who is post-op day 1. Rationale: The PN should first evaluate the client who has no hemovac output from the abdominal surgical site to determine if the hemovac needs to be compressed, drainage tube kinked, or if the drain is displaced from the wound.
The practical nurse has been assigned a client with a history of chronic obstructive pulmonary disease (COPD) who has been admitted to the hospital with a medical diagnosis of pneumonia. Which intervention poses the greatest risk of respiratory depression for a client with a history of COPD? a. Vancomycin 500 mg administered intravenously every 6 to 8 hours. b. Chest physiotherapy and nebulizers performed every 4 to 6 hours. c. Administration of acetaminophen 600 mg every 4 hours as needed for fever. d. Oxygen administration via nasal cannula 4 L/m.
d. Oxygen administration via nasal cannula 4 L/m. Rationale: Clients with COPD drive to breathe is a hypoxic state. Their body becomes use to the high CO2 levels and too much oxygen could cause the client to decrease their respiratory drive to breath. Oxygen administration in clients with COPD needs to be carefully monitored.
A client diagnosed with congestive heart failure has developed increasing pedal edema and pulmonary edema. What dietary modification is most important for the practical nurse (PN) to reinforce with this client? a. Avoid high carbohydrate foods. b. Decrease intake of fat-soluble vitamins. c. Decrease caloric intake. d. Restrict salt and fluid intak
d. Restrict salt and fluid intake. Rationale: Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and pulmonary edema.
The nurse is reinforcing hygiene instructions to unlicensed assistive personnel (UAP) who will be bathing a client who has been diagnosed with pneumonia. The nurse should instruct the UAP to plan to bathe the client at which time?
d. The client should have activities such as bathing, alternated with rest periods. Rationale: The client should be allowed to rest before activities such as bathing take place. There is no contraindication for bathing a client with pneumonia. Facility schedules are not the primary reason to determine the timing of a client's bath. By using standard and other precautions, it would not matter whether the client with pneumonia is bathed before or after other noninfectious clients.
A client diagnosed with diabetes has a prescription of 5 units of regular insulin and 15 units of NPH insulin. In which order should the practical nurse prepare to administer the insulin?List in order the nursing actions to be performed. Inspect insulin vials for type and expiration dates. Inject 15 units of air into NPH insulin vial. Withdraw 5 units of regular insulin from vial. Withdraw 15 units of NPH insulin from vial. Inject 5 units of air into regular insulin vial. Perform hand hygiene according to facility policy.
1. Perform hand hygiene according to facility policy. 2. Inspect insulin vials for type and expiration dates. 3. Inject 15 units of air into NPH insulin vial. 4. Inject 5 units of air into regular insulin vial. 5. Withdraw 5 units of regular insulin from vial. 6. Withdraw 15 units of NPH insulin from vial. Rationale: The first nursing action is to perform hand hygiene. The next action is to inspect vials for type and expiration dates and then add 15 units of air to NPH insulin vial. Next add 5 units of air into regular insulin vial, then withdraw 5 units of regular insulin from vial, and withdraw 15 units of NPH insulin from vial. Note that it is important to fill the syringe with regular insulin (shorter acting insulin) first to prevent contamination of the NPH insulin (intermediate-acting insulin).
The nurse has reinforced teaching regarding postoperative care for a client who has had a prostatectomy. Which statements indicate the need for further instructions? (Select all that apply.) a. "If I feel the need to void while the catheter is still in, I should try to void around the catheter." b. "I should drink about 12 glasses of water a day, once the indwelling catheter is removed." c. "I should only have intercourse twice weekly once I return home after surgery." d. "I should report bright red blood and large clots in my urine to my surgeon." e. "I can expect to have urine that is lightly tinged with blood when I get home."
a. "If I feel the need to void while the catheter is still in, I should try to void around the catheter." c. "I should only have intercourse twice weekly once I return home after surgery." Rationale: After prostatectomy, the client should not try to void around the catheter. It is common to feel pressure inside the bladder while the irrigating catheter is still in the bladder. The client should not have intercourse immediately after surgery. The client should drink 12 to 14 glasses of fluid once the catheter is removed. Urine that is lightly blood tinged is common; bright red blood in the urine should be reported to the surgeon.
A client sustained a burn injury greater than 25% of total body surface with majority of it lower extremities during a house fire. During the acute phase of care, which intervention is most important for the practical nurse to implement? a. Administer 0.5 mL of tetanus toxoid IM. b. Offer high-protein supplemental feedings. c. Perform active range-of-motion exercises. d. Application of compression stockings and ambulation.
a. Administer 0.5 mL of tetanus toxoid IM. Rationale: Prevention of infection from Clostridium tetani by administering tetanus toxoid has the highest priority for care of a client in the acute phase of burn care.
The nurse has been caring for a client on the medical unit who has a large abscess on his upper arm. The client develops septic shock and the rapid response team has arrived. Which priority action should the nurse do to assist the client while the rapid response team is preparing to transfer the client to intensive care? a. Monitor the client's vital signs every 15 minutes. b. Restrict intravenous fluid flow rate to less than 50 mL/hr. c. Locate the temporary pacemaker unit and bring it to the bedside. d. Assist the team in preparing vasodilating medications to add to the intravenous fluids.
a. Monitor the client's vital signs every 15 minutes. Rationale: The nurse should monitor the client's vital signs every 5 to 15 minutes when the client is experiencing shock. The intravenous fluid flow rate is very rapid, not restricted, with septic shock. There is no data in the question suggesting a pacemaker is necessary; in shock, the heart rate is usually increased. The team will most likely administer vasopressive, not vasodilating medications, because the client's blood pressure is likely very low.
A client has a serum potassium level of 3 mEq/L. Which findings should the practical nurse report to the charge nurse? (Select all that apply.) a. Muscle cramps b. Diarrhea c. Altered blood glucose level d. Increased energy e. Abnormal heart rhythms f. Increased anxiety
a. Muscle cramps e. Abnormal heart rhythms Rationale: A normal potassium level ranges from 3.5 to 5 mEq/L (mmol/L). Signs and symptoms of low potassium include muscle cramps and dysrhythmias.
A client diagnosed with rheumatoid arthritis is prescribed splints for night time use. Which statement by the client demonstrates to the practical nurse (PN) an accurate understanding of the use of the splints? a. Prevention of deformities b. Avoidance of joint trauma c. Relief of joint inflammation d. Improvement in joint strength
a. Prevention of deformities Rationale: Splints may be used at night by clients with rheumatoid arthritis to prevent deformities caused by muscle spasms and contractures.
An adult client is admitted to the emergency department with partial-thickness and full-thickness burns over 40% of the body surface area resulting from a car collision fire. After the health care provider and nurse have intubated the client, which intervention should the practical nurse (PN) do first? a. Remove all the client's clothing, shoes, and jewelry. b. Insert indwelling urinary foley. c. Initiate an intravenous catheter line. d. Obtain blood work and urine sample.
a. Remove all the client's clothing, shoes, and jewelry. Rationale: Interventions for moderate to severe burns of deep partial-thickness and full-thickness, once an airway and circulation is established, then the next thing is to remove all the victims clothing, shoes, and jewelry before the edema sets in and they become constricting, also it is possible to cause more severe burns by leaving clothing on.
Which educational materials should the practical nurse select for reinforcement of teaching for secondary prevention? (Select all that apply.) a. Video that teaches client to do breast self-examinations. b. Pamphlets describing how to do testicular self-examinations. c. Chart that emphasizes childhood immunization schedule. d. Chart that emphasizes childhood immunization schedule. e. Postcard reminders for clients to get papanicolaou (Pap) smears and mammograms.
a. Video that teaches client to do breast self-examinations. b. Pamphlets describing how to do testicular self-examinations. e. Postcard reminders for clients to get papanicolaou (Pap) smears and mammograms. Rationale: Secondary prevention deals with early diagnosis to treat disease in the beginning of its development. Breast self-examinations, testicular self-examinations, mammograms, and Pap smears are considered secondary prevention methods.
The practical nurse (PN) is reinforcing colostomy care teaching to a client who is 3 days following placement of their colostomy. The client asked the PN why is it necessary to measure the colostomy's stoma each time when changing into a new appliance/wafer. What is the best response by the PN? a. Reassure the client that he will become accustomed to the stoma appearance in time. b. Inform the client that the stoma will become smaller when the initial swelling diminishes. c. Offer to contact a member of the local ostomy support group to help him with his concerns. d. Encourage the client to handle the stoma equipment to gain confidence with the procedure.
b. Inform the client that the stoma will become smaller when the initial swelling diminishes. Rationale: Postoperative swelling causes enlargement of the stoma. The PN needs to reinforce to the client that the stoma will become smaller when the swelling is diminished. This is necessary in order to prevent irritation to the surrounding skin from the colostomy's drainage (effluent). The purpose of the colostomy appliance is to provide a protective barrier surrounding the stomal skin, along with containing effluent from the colostomy.
Which abnormal laboratory finding should the practical nurse (PN) identify that indicates that a client with diabetes needs further evaluation for diabetic nephropathy? a. Hypokalemia b. Microalbuminuria c. Elevated serum lipids d. Ketonuria
b. Microalbuminuria Rationale: Microalbuminuria is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation.
Which actions demonstrate to the practical nurse that the client understands the correct procedure administration of a metered dose inhaler (MDI)? (Select all that apply.) a. Sit or stand. b. Shake the inhaler. c. Attach the canister of medication to the mouthpiece. d. Breathe in through the mouth, filling the lungs. e. Use a spacer attachment and place the mouthpiece in the mouth. f. Close the lips around the mouthpiece. g. After inhaling the medication, hold the breath 10 seconds.
b. Shake the inhaler. c. Attach the canister of medication to the mouthpiece. e. Use a spacer attachment and place the mouthpiece in the mouth. f. Close the lips around the mouthpiece. g. After inhaling the medication, hold the breath 10 seconds. Rationale: The correct sequence of MDI administration includes shaking the inhaler, attaching the canister to the mouthpiece, attaching the spacer, the client should then let their breath out through the mouth to empty the lungs and place the mouthpiece in the mouth, closing the lips and mouth around the mouthpiece, and inhaling medication and holding the breath for 10 seconds.
A client diagnosed with lymphoma is receiving chemotherapy. The client's hemoglobin is currently 6 g/dL. The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) to provide personal hygiene for this client. What instruction should the PN provide to the UAP? a. Report any signs of nausea or vomiting immediately. b. The client will be weak and unsteady and tire easily. c. Watch carefully for any signs of bleeding. d. The client's skin will be fragile and bruise easily.
b. The client will be weak and unsteady and tire easily. Rationale: A hemoglobin of 6 g/dL indicates anemia (normal for a female is 12 to 16 g/dL, for a male is 14 to 18 g/dL), which is a common adverse effect of chemotherapy. The UAP should be given instructions about how this will cause weakness and unsteadiness in the client and they will tire easily.
A client diagnosed with status asthmaticus is admitted to the unit. Which breath sounds would the practical nurse anticipate to hear when auscultating the client's lungs? a. Fine crackles b. Wheezes c. Course crackles d. Stridor
b. Wheezes Rationale: Wheezes are continuous, high-pitched musical or squeaking-type sounds. They are reflective of the narrowing of the airways as a result of the inflammation from the asthma. Wheezes are generally heard with expiration, but can be heard with inspiration in severe cases of asthma.
The nurse is caring for a client with glaucoma. The nurse expects which aspect to be included in the plan of care? a. Encourage the client to anticipate the return of vision once treatment has begun. b. Explain that the cloudy lens can be removed with surgery, usually as an outpatient. c. Encourage the client to place prescribed eye drops directly over the pupil of the eye. d. Explain to the client that eye drop use will be necessary for the rest of the client's life.
d. Explain to the client that eye drop use will be necessary for the rest of the client's life. Rationale: Glaucoma is increased intraocular pressure, which can eventually cause blindness if untreated. Eye drop instillation will be necessary for the rest of the client's life. Even with early treatment, vision loss cannot be reversed. A cloudy lens is associated with cataracts, not glaucoma. Eye drops should be placed in the conjunctival sac, not directly over the pupil.