practice question 31-45

While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the parent demonstrates understanding the child's developmental needs? "I want to protect my child from any falls or injuries." "I will set limits on exploring the house." "I will provide opportunities to use and practice new skills." "I intend to keep control over our child's behavior."

"I will provide opportunities to use and practice new skills." Erickson describes this stage as a time of developing a sense of control over physical skills and independence. Increased autonomy and the ability to explore the world should be fostered during this developmental period. Allowing the child new opportunities to use and practice new skills is the best way to master this stage. A parent who is overly controlling may stunt this developmental growth. Safety and limits are important and should be considered when permitting the child to try new experiences. Correct! LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS toddlerdevelopmentalneedErickson CONFIDENCE Need Help Fair Strong

A client with cirrhosis of the liver asks the nurse about the purpose of taking lactulose. How should the nurse respond? "It is used to control portal hypertension." It adds dietary fiber to your diet." "It helps to reduce ammonia levels in your blood." "It helps to regenerate your liver."

"It helps to reduce ammonia levels in your blood." Lactulose is a synthetic disaccharide that can be given orally or rectally. It blocks the absorption and production of ammonia from the gastrointestinal tract, reducing serum ammonia levels, and is used to treat hepatic encephalopathy. The other answers are incorrect. LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review KEYWORDS cirrhosislactulosecephulac

The nurse is evaluating understanding of disease management of a client with chronic obstructive pulmonary disease. Which statement by the client indicates an understanding of pursed-lip breathing? "Pursed-lip breathing prevents my mouth from getting too dry." "Pursed-lip breathing helps me control how fast I breathe in and out." "I can reduce my risk of getting pneumonia with pursed-lip breathing." "Pursed-lip breathing reduces carbon dioxide trapped in my lungs."

"Pursed-lip breathing reduces carbon dioxide trapped in my lungs." - Clients with chronic obstructive pulmonary disease (COPD) have difficulty exhaling fully as a result of air trapping in the alveoli due to the disease process. Alveolar collapse can be avoided with the use of pursed-lip breathing, allowing the client to exhale more effectively. This technique facilitates appropriate gas exchange as carbon dioxide-rich air that has been trapped in the lungs is blown off, allowing oxygen-rich air to be inhaled. This is the primary reason to use pursed-lip breathing. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM respiratory KEYWORDS pursed-lip breathinglungdiseaseCOPD

During the well-baby check-up of a 3-week-old newborn, the parent expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is the appropriate response by the nurse? "This birthmark is called seborrheic keratoses and could indicate a cancerous growth." "This birthmark is called a port-wine stain and can be associated with other malformations." "Birthmarks are generally harmless and will disappear as the baby grows." "This birthmark happened during birth and may require surgical removal at a later time."

"This birthmark is called a port-wine stain and can be associated with other malformations." LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review BODY SYSTEM integumentary KEYWORDS infantclinicbirthmark CONFIDENCE Need Help Fair Strong

An emergency department nurse is preparing discharge instructions for a child who experienced a seizure at school. The parent reports that this is the first seizure occurrence and denies a family history of seizures. What information should the nurse include? "Do not worry. Seizure disorder can be treated with medications." "Long-term treatment will prevent future seizures." "This seizure may or may not mean your child has a seizure disorder. Further evaluation is needed." "Since this was the first seizure, it may not happen again."

"This seizure may or may not mean your child has a seizure disorder. Further evaluation is needed." There are many possible causes for a childhood seizure. Some causes are transient, others require long-term treatment to prevent further seizures. Causes of seizure in childhood include include fever, central nervous system conditions, trauma, metabolic alterations and idiopathic (unknown) etiologies. EEG, electroencephalogram, is a test commonly used to evaluate seizure disorders. LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM nervous KEYWORDS seizureepilepsyteachingchild

The nurse is assessing an 8 month-old infant diagnosed with atonic cerebral palsy. Which statement from the parent supports this diagnosis? "When I put my baby on the back to sleep, there is no change in position a few hours later." "When it thundered loudly last night, the baby didn't even jump." "My baby doesn't seem to follow when I shake toys in front of the face." "When I put my finger in one of the hands, there is no grasp response".

"When I put my baby on the back to sleep, there is no change in position a few hours later." Cerebral palsy is a condition whereby motor dysfunction occurs secondary to damage in the motor centers of the brain. It is most commonly associated with cerebral hypoxia during the birth process. Inability to roll over by eight months of age would illustrate motor dysfunction and a delay in attainment of developmental milestones. Not following items could be a sign of a visual disturbance; not responding to a loud noise could be a sign of hearing disturbance; and not grasping at eight months of age is normal as the grasp reflex begins to diminish after six months of age. LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM nervous KEYWORDS infantcerebral palsydevelopment

A client experienced a myocardial infarction and is preparing for discharge from the hospital. The client asks the nurse what activity will indicate it is safe to resume sexual intercourse. Which instruction will the nurse provide? "If you can maintain an active walking program, you will have less risk." "You must regain all your strength before attempting such exertion." "When you can climb one to two flights of stairs without problems, it is generally safe." "Have a glass of wine to relax you, then you can try to have sex."

"When you can climb one to two flights of stairs without problems, it is generally safe." Although it depends on the client's overall medical condition, most experts agree that sexual activity is physically therapeutic and heart healthy. If the client can climb a flight of stairs without feeling tired, short of breath, or have chest pain, then it is generally safe to resume sexual activity. Correct! LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS teachmyocardial infarctionsexintercourse

One hour before the first electroconvulsive therapy (ECT) treatment is scheduled, a client becomes anxious and states, "I do not wish to go through with this." Which response by the nurse is most appropriate? "You'll be asleep and won't remember anything. There is nothing to worry about." "You have the right to change your mind. You seem anxious. Can we talk about it?" "I'll go with you and will be there with you during the treatment." "I'll call the health care providers to notify them of your decision."

"You have the right to change your mind. You seem anxious. Can we talk about it?" This response indicates acknowledgment of the client's rights and allows the opportunity for the client to verbalize and clarify concerns. After discussing concerns and fears with the nurse, if the client still refuses the treatment, the health care provider should be notified. Even though the client will be asleep, and the procedure is generally harmless, telling the client not to worry negates their fears. Offering self by going to the procedure may not be practical as the nurse may not be able to leave the unit for an extended period LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS electroconvulsivetherapyanxious

A client with paranoid delusions stares at a nurse over a period of several minutes. The client suddenly pushes a chair, walks up to the nurse and shouts, "You think you're so perfect, pure and good!" What is the appropriate response for the nurse to make? "I will not speak to you when you are shouting." "Is that why you've been staring at me?" "You seem angry right now." "Perfect? I don't quite understand."

"You seem angry right now." The nurse recognizes the underlying emotion with a matter of fact attitude. The nurse should avoid telling the clients how the nurse feels. A general rule for interactions between clients with a psychiatric diagnosis and staff members is to focus on feelings first when giving responses to behaviors. LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS delusionresponseparanoid

During the admission process, the staff nurse realizes that the information on the identification (ID) bracelet does not match the information on the client's admission face sheet. What action should the nurse take? Communicate with staff the patient must be identified using the admission face sheet only Use a permanent marker to change the incorrect information on the ID bracelet Write the corrected information on the whiteboard in the client's room Contact the admissions department to create a new ID bracelet

1 Contact the admissions department to create a new ID bracelet The admissions department has the responsibility to verify the client's identity, apply the correct bracelet or other identifier to the client, and keep all records in the system accurate and consistent. The other options are unsafe practices that could lead to error and patient harm. lESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS admissionidentificationIDbraceletJoint Commission

The nurse is preparing to administer estrogen 1.25 mg tab orally daily. The available tablet strength is 625 mcg. How many tablets will the nurse administer? Record your answer as a whole number. tablet(s

1.25mg/625mcg)×(1000mcg/1mg)=2

An infant has just had a pyloromyotomy. Initial postoperative nursing care would include which nutritional approach? NPO then glucose and electrolyte solutions Intravenous fluids for three to four days Formula or breast milk as tolerated Bland diet appropriate for age

A Pyloric stenosis is caused when a muscle between the stomach and duodenum grows too large and thick, blocking food from being pushed from the stomach into the duodenum. During a pyloromyotomy, the surgeon cuts through the thickened muscle. Postoperatively, the initial feedings for infants are small quantities of clear liquids, such as glucose water or water with electrolytes in it. If the infant tolerates clear liquids, caregivers will give watered-down breast milk or formula; feedings are then advanced to regular breast milk or formula. LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS infantpyloromyotomypostoperativeglucose

The nurse is providing discharge instructions for a client diagnosed with bacterial pneumonia. What is the most important information to convey to the client? "Complete all of the antibiotics as prescribed." "Take at least two weeks off from work." "Take your temperature every day." "You will need another chest x-ray in six weeks."

A To avoid a recurrence of infection, the client must compete all the prescribed medications at the prescribed dosing intervals. It should be explained to the client that it may take two weeks or more for the energy level to return to normal, but one does not necessarily need to be off work for two weeks. The health care provider may order a follow-up chest x-ray, but this is not always done or a priority at this time. It is also not important to take the temperature daily unless symptoms (such as chills, shortness of breath, chest pain, night sweats) worsen or return. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM respiratory KEYWORDS pneumoniaantibioticteach

A client of Latino descent is diagnosed with ovarian cancer. The client is refusing radiation and chemotherapy, describing them both as "hot." What action should the nurse take next? Ask the client to describe her concerns about "hot" treatments Talk with the client's family about the situation Report the situation to the health care provider Document the situation and client response in the notes Submit

A client of Latino descent is diagnosed with ovarian cancer. The client is refusing radiation and chemotherapy, describing them both as "hot." What action should the nurse take next? Ask the client to describe her concerns about "hot" treatments Talk with the client's family about the situation Report the situation to the health care provider Document the situation and client response in the notes LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review BODY SYSTEM reproductive KEYWORDS Puerto Ricanovariancancerhotradiation

To which nursing home resident could a nurse safely administer tricyclic antidepressants (TCAs) without questioning the health care provider's order? A client with benign prostatic hypertrophy (BPH) A client with narrow-angle glaucoma A client with coronary artery disease (CAD) A client with mild hypertension

A client with mild hypertension Tricyclics can be safely administered to the hypertensive client. The expected anticholinergic effects of tricyclic antidepressants include difficulty in urination, which is why TCAs are contraindicated with BPH. TCAs are also contraindicated in narrow-angle glaucoma (they can cause elevated pressure in the eyes) and for certain heart abnormalities.

A client is scheduled for an abdominal computerized tomography (CT) scan with contrast. Prior to sending the client to the imaging department, what action should the nurse take? Insert an indwelling urinary catheter Confirm that a signed consent is in the chart. Keep the client on bedrest. Hold all of the client's medications.

A signed consent is required for a procedure that uses contrast dye solution. Other protocol include keeping the patient NPO; checking for allergies and past reactions to contrast dye; removing jewelry, hearing aids, and removable dental work. Keeping the client on bedrest, holding medications, and an indwelling urinary catheter is generally not necessary and could actually potentiate harm to the client. LESSON Reduction of Risk Potential Diagnostic Tests COURSE RN & PN Review KEYWORDS CT scancomputerized tomographycontrast media

The nurse is assessing an 8 month-old infant diagnosed with atonic cerebral palsy. Which statement from the parent supports this diagnosis? "When I put my baby on the back to sleep, there is no change in position a few hours later." "When it thundered loudly last night, the baby didn't even jump." "My baby doesn't seem to follow when I shake toys in front of the face." "When I put my finger in one of the hands, there is no grasp response".

A. Cerebral palsy is a condition whereby motor dysfunction occurs secondary to damage in the motor centers of the brain. It is most commonly associated with cerebral hypoxia during the birth process. Inability to roll over by eight months of age would illustrate motor dysfunction and a delay in attainment of developmental milestones. Not following items could be a sign of a visual disturbance; not responding to a loud noise could be a sign of hearing disturbance; and not grasping at eight months of age is normal as the grasp reflex begins to diminish after six months of age.

A client is about to undergo a plaster cast application. Prior to the cast application, the nurse should include what teaching point in the discussion? The wet cast should be handled with the palms of hands until fully dry The cast should be covered with cotton material until it fully dries The cast material will be dipped several times into the tepid water The casted extremity will be placed on a cloth-covered surface

A. The cast will be handled with the palms of the hands and need to be lifted at two points of the extremity while it is drying. This will prevent stress of the injury and pressure indentation areas on the cast. The cast should be uncovered and be placed on a firm surface. LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS plastercastpalmdry

The community health nurse is developing a plan of care for a female adolescent with a body mass index greater than 40. The nurse should recognize that the client has the highest risk for which problem? Social isolation Sexually transmitted infection Developmental delays Learning difficulties

A: A body mass index (BMI) greater than 40 indicates morbid obesity. During adolescence, individuals go through rapid physical and psychological changes which can affect their body image. In addition, adolescents living in Western, industrialized cultures such as the United States tend to experience a significant amount of peer, cultural and social pressure to maintain a certain desired physical appearance. Most often this desired appearance is being thin and physically fit. A morbidly obese adolescent is at risk for bullying, peer pressure, a poor body image and low self-esteem which can put them at a high risk to distance themselves from others, i.e., socially isolate. Correct! LESSON Psychosocial Integrity Coping Mechanisms COURSE RN Review KEYWORDS adolescenceobesitybody image

The nurse is reviewing various group activities with the health care team. When planning a therapeutic milieu, what is the most important factor when selecting a group activity? Provide consistency with clients' skills Achieve clients' therapeutic goals Match it to the clients' preferences Raise the level of group participation

Achieve clients' therapeutic goals Activity groups are used to enhance the therapeutic milieu setting and to meet the clinical and social needs of clients. All activities should be selected by keeping the individual clients' therapeutic goals as a priority. Client preferences may not meet therapeutic goals. It is okay to have clients with different skill ability in the same group as they may learn from each other. Group participation is important, but some clients may not be able to tolerate the intensity of group so should be permitted to sit quietly in group or not participate at all. LESSON Psychosocial Integrity Therapeutic Environment COURSE RN Review KEYWORDS therapeutic milieu group activities CONFIDENCE

The nurse is developing a plan of care for a newly hospitalized adolescent. Which psychosocial problem is the priority for the client in this developmental stage? Altered body image Pain management Separation from family Restricted physical activity

Altered body image LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS adolescent threat hospital image During adolescence, there is a great emphasis on physical appearance. Therefore, the fear of an altered body image due to being hospitalized is a priority problem during this developmental stage. The other problems are not psychosocial or typical during adolescence.

A nurse is suctioning a tracheostomy tube of a client. In order to prevent unnecessary hypoxia during the procedure, what action should the nurse take? Apply suction for no more than 10 seconds Lubricate three to four inches of the catheter tip Withdraw catheter in a circular motion with intermittent suction Maintain sterile technique throughout the procedure

Apply suction for no more than 10 seconds Although all the responses are correct actions during the suctioning process, hypoxia can result from applying suction for more than 10 seconds. The nurse should apply oxygen immediately before and after suctioning to allow the client to rest if more suctioning is indicated. Correct! LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM respiratory KEYWORDS hypoxiasuctiontracheostomy CONFIDENCE Need Help Fair Strong

The nurse is planning care for a 3-month-old infant in the immediate postoperative period after placement of a ventriculoperitoneal shunt for hydrocephalus. In anticipation of complications of the procedure, the nurse should take which action? Pump the shunt at intervals to assess for proper function Assess for abdominal distention or taut abdominal wall Maintain the infant in supine position Begin formula feedings when infant is alert

Assess for abdominal distention or taut abdominal wall The nurse should observe for abdominal distention or a taunt abdominal wall because cerebrospinal fluid could cause peritonitis or a postoperative ileus as a complication of distal catheter placement. The child does not need to remain supine and can be placed in an upright position. The infant would be started on clear liquids initially, not formula. The shunt will not be pumped. LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN Review BODY SYSTEM nervous KEYWORDS infantpostoperativeshunthydrocephalus

A nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first? Initiate CPR Perform defibrillation Assess the pulse Assess the level of consciousness

Assess the level of consciousness Artifact (interference) can mimic ventricular fibrillation on a cardiac monitor. Always treat the patient, not the monitor. If the client is truly in ventricular fibrillation the client will be unresponsive and no pulse will be present. The standard of care is to verify the monitor display with an assessment of the client's level of consciousness, shaking and shouting to arouse followed by a carotid pulse check. If the client is unresponsive without a pulse in ventricular fibrillation, the most effective treatment will be electricity or defibrillation. This should be the priority, supplementing circulation using chest compressions until the defibrillator is set up and ready to deliver the shock.

A child diagnosed with poison ivy dermatitis has not been playing in or exposed to wooded areas. After asking the parent about possible contact, which of these situations should the nurse recognize as the highest risk for exposure to poison ivy? Throwing a ball with a child who has poison ivy Rolling toy cars on the pavement near burning leaves Playing with toys on a backyard patio Playing a contact sport with a child diagnosed with poison ivy last week

B Direct contact with the toxic oil, urushiol, is the most common cause for this dermatitis. However, smoke from burning leaves or stems of the poison ivy plant can produce a reaction. You cannot get poison ivy from another person unless you have direct contact with urushiol that is still on the person or their clothing. None of the other choices present this risk. A child diagnosed with poison ivy last week will no longer have urushiol on the body or clothes. Throwing a ball to a child with poison ivy is not direct contact. A patio is usually made of concrete or brick where there would be less chance of exposure to poison ivy. LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review BODY SYSTEM integumentary KEYWORDS poison ivy rash contact

A client with chronic obstructive pulmonary disease (COPD) is receiving aminophylline 25 mg/hour intravenously (IV). Which finding would be associated with side effects of this medication? Pruritus Restlessness and palpitations Decreased urine volume Flushing and headache

B Aminophylline is a bronchodilator often used to treat symptom of asthma, bronchitis, and emphysema. Side effects include restlessness, palpitations, chest pain or discomfort, increased urine volume, vertigo, and vomiting. The other choices are not side effects of this drug. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM respiratory KEYWORDS aminophylline COPD restlessness palpitations

A client is admitted with a diagnosis of myocardial infarction (MI) and reports having chest pain. The nurse provides care based on the knowledge that pain associated with an MI is related to which of the following findings? Cardiac arrhythmia Insufficient oxygenation of the cardiac muscle An electrolyte imbalance Fluid volume excess in the lungs

B Due to ischemia of the heart muscle, the client will experience pain. This happens because destroyed myocardial tissue can block or interfere with the normal cardiac circulation. LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS myocardial infarctionMIpainoxygenation

The nurse is caring for a client in the postanesthesia care unit (PACU) following corrective surgery for scoliosis. Which action should receive priority in the plan of care? Initiate the prescribed antibiotic therapy Assess the sensation and movement of the lower extremities Teach client isometric exercises for the legs Assist to stand at the bedside within the first few hours post-surgery

B Following corrective surgery for scoliosis, the neurological status of the extremities require priority attention in the PACU, as well as the postoperative surgical units. Initiation of antibiotic therapy should begin as soon as possible after neurological status is obtained. Getting the patient out of bed and teaching isometric exercises will be done after the client is neurologically cleared. LESSON Reduction of Risk Potential System Specific Assessments - RN COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS scoliosisPACUneurologic

The charge nurse assigns the unlicensed assistive personnel (UAP) to measure vital signs. Clear written and verbal instructions were given to the UAP not to take the blood pressure on the left arm of a client. The charge nurse later observes a blood pressure cuff on this client's left arm. Which of these statements is accurate? The charge nurse has no accountability for this situation The UAP is responsible for following instructions given by the charge nurse The UAP is covered by the charge nurse's license The charge nurse did not appropriately make assignments

B. The UAP is responsible for carrying out the activity correctly once instructions have been clearly communicated verbally and in writing. The licensed nurse does retain accountability for the delegation of the assignment and the tasks assigned. Taking vital signs falls within the parameter of tasks that can be assigned to a UAP. The UAP is not covered under the nurse's license. LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS assignUAPlicenseaccountabilityresponsibility

A client is being treated with long-term, low dose glucocorticoids for an autoimmune disorder. Which physical change should the nurse expect to see with this client? Buffalo hump Ascites Jaundice Hirsutism

Buffalo hump Long-term use of glucocorticoids can lead to Cushing's syndrome. Physical changes with Cushing's include weight gain, increased blood glucose, acne, thinning of the skin, easy bruising and changes in body shape such as a hump behind the shoulders due to the accumulation of fat on the back of the neck. This is commonly referred to as a "'buffalo hump". Jaundice, hirsutism and ascites are not typically seen with long-term corticosteroid/glucocorticoid therapy. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN & PN Review KEYWORDS glucocorticoidside effects CONFIDENCE

A client diagnosed with schizophrenia is observed mumbling to self and speaking to the television. The nursing staff are unable to understand what the client is attempting to communicate. At this time, what is the most desirable outcome for this client's behaviors? Interprets accurately the events and behaviors of others Expresses feelings appropriately through verbal interactions Engages in meaningful and understandable verbal communication Demonstrates improved social relationships within the unit

C The client is exhibiting disorganized thinking and difficulty with verbal communication. As the client engages in the therapeutic process, including medication management and milieu therapy, the expected outcome is improved communication. The other choices are important but improved communication is necessary before one can express feelings and relate to others. The correct answer choice also specifically addresses the behavior described. Engages in meaningful and understandable verbal communication; LESSON Psychosocial Integrity Sensory, Perceptual Alterations COURSE RN Review KEYWORDS schizophrenia communication outcome

A client with a history of asthma and kidney stones is admitted with a diagnosis of recurrent renal calculi. The client experiences shortness of breath following a lithotripsy. The nurse auscultates the client's lungs and finds decreased air movement with no wheezing. The arterial blood gas (ABG) results are pH 7.31, PaO2 53 mm Hg, PaCO2 50 mm Hg, and O2 sat 82%. Which of the following actions are appropriate for the nurse to take? Select all that apply. Start oxygen via nasal cannula Call respiratory therapy Prepare for possible intubation Increase IV fluids Administer a short-acting bronchodilator via nebulizer Contact the health care provider Start high flow oxygen via face mask

Call respiratory therapy Prepare for possible intubation Administer a short-acting bronchodilator via nebulizer Contact the health care provider Start high flow oxygen via face mask This client needs emergency treatment to open the airways and improve gas exchange. The absence of lung sounds without wheezing indicates a severe narrowing of the airways in asthma with minimal air movement. Emergent intervention to open the closed airway including possible intubation are indicated. The high PaCO2 and low pH indicate respiratory acidosis due to inadequate gas exchange. The low oxygen saturation and PaCO2 indicate severe hypoxemia requiring high flow oxygen via mask. LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM respiratory KEYWORDS asthmawheezingrespiratory distress

The health care provider orders trazodone ER 150 mg at bedtime. Which common side effect of this drug should the client understand? Decreases acne breakouts Reduces arthritic pain Relieves nasal stuffiness Causes drowsiness

Causes drowsiness Trazodone is an antidepressant medication that produces drowsiness, so it is ordered at bedtime. In addition to treating depression, it targets the symptom of insomnia often experienced by clients who are depressed. Other common side effects of trazodone include dry mouth, stuffy nose, constipation or change in sexual interest/ability. The other choices are not side effects of this medication. LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS trazodoneinsomnia CONFIDENCE Need Help Fair Strong

The nurse is teaching a client how to collect a clean catch urine specimen. What is the appropriate sequence? Void into the toilet, then collect specimen from the toilet Clean the meatus, begin voiding, then collect sample midstream Clean the meatus, then urinate into the container Void a little, clean the meatus, then collect specimen

Clean the meatus, begin voiding, then collect sample midstream A clean catch urine is difficult to obtain and requires clear directions. Instructing the client to carefully clean the meatus, then void naturally with a steady stream prevents surface bacteria from contaminating the urine specimen. As starting and stopping flow can be difficult, once the client begins voiding it's best to just slip the container into the stream. The other techniques are incorrect. LESSON Reduction of Risk Potential Diagnostic Tests COURSE RN Review BODY SYSTEM urinary KEYWORDS urinespecimen CONFIDENCE Need Help Fair Strong

The nurse is caring for a client who had a closed reduction of a fractured wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse's immediate attention? Client reports burning and tingling in the affected hand and arm Capillary refill of fingers on affected hand is about three seconds Slight swelling of fingers of affected hand Skin warm to touch and normally colored

Client reports burning and tingling in the affected hand and arm Burning and tingling as well as intense pain out of proportion to the injury may be an indication of compartment syndrome, requiring immediate action by the nurse to prevent permanent muscle damage. The other findings are normal for a client in this situation. LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS wristfracturecastfiberglass

The nurse enters a client's room as the client begins to have a tonic-clonic seizure. What action should the nurse take? Insert a padded tongue blade in client's mouth Place the client on one side Hold the client's arms at the side Elevate the head of the bed

Clients should be positioned on their side. This position keeps the airway patent and allows saliva to drain from the mouth, which prevents aspiration. The nurse should also protect the client from injury by clearing furniture (if the client is on the floor). The client should not be restrained nor should anything be forced in the client's mouth. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS seizuretonicclonic

The nurse provides regular mouth care to the hospice client who is actively dying at home. The family wants to know why the doctor doesn't order intravenous (IV) fluids since the client's mouth seems so dry. What information can the nurse provide to accurately answer this question? The client will need to have an indwelling catheter inserted if an IV is started Intravenous hydration can delay death Intravenous hydration will increase episodes of delirium The client will need to be hospitalized if an IV is started

Clients who are dehydrated may experience delirium and may benefit from IV therapy. However, this intervention may make the client ineligible for hospice care. There is no justified need for an indwelling catheter currently. IV hydration does not improve dry mouth and can even delay death. The nurse should explain that the client's comfort can be enhanced by providing frequent mouth care and decreased oral intake is a natural and non-painful part of the dying process. LESSON Psychosocial Integrity End-of-life Concepts or Care COURSE RN & PN Review KEYWORDS hospicehydrationdying CONFIDENCE Need Help Fair Strong

Due to a recent rheumatic fever outbreak in the community, the school nurse is speaking to a group of parents and elementary school teachers. Which information is important for the nurse to emphasize? Home schooling is preferred to classroom instruction Children may remain strep carriers for years Most play activities will be restricted indefinitely Clumsiness and behavior changes should be reported

Clumsiness and behavior changes should be reported Sydenham chorea is a major sign of acute rheumatic fever; it may be the only sign of rheumatic fever in some clients. Symptoms include jerky, uncontrollable, and purposeless movements that look like twitches (these disappear during sleep); loss of fine motor control (causing changes in handwriting); and loss of emotional control (as evidenced by inappropriate crying or laughing). Sydenham chorea usually clears up in a few months and no complications are expected. LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS parentschoolrheumatic fever

A health care system utilizes decentralized scheduling on all the nursing units. What is the primary advantage of this management strategy? Allows requests for special privileges Conserves time spent on planning Frees the nurse manager to handle other priorities Considers client and staff needs

Considers client and staff needs Correct! Submit Decentralized scheduling takes into consideration specific unit, client and staff needs. Staffing is decided based on priorities at the unit (micro) level, not the health care system (macro) level.

The nurse is preparing to administer ephedrine 5 mg IV push to a client. The supplied vial contains 50 mg of ephedrine in 10 mL normal saline. How many mL shall the nurse draw up? Record your answer as a whole number.

Correct answer: 1 mL50 mg in 10 mL equals 5 mg per 1 mL. The nurse should draw up 1 mL to administer 5 mg of ephedrine.; 1ml

The nurse is reviewing the list of new client admissions. Which of these clients requires contact precautions? A client diagnosed with mononucleosis A client diagnosed with scarlet fever A client diagnosed with pneumonia A client diagnosed with herpes simplex

D. In addition to standard precautions, clients with herpes simplex infections must have contact precautions implemented due to the associated weeping skin lesions. A client with scarlet fever would be on droplet precautions. Precautions other than standard may be required for pneumonia, but the causative organism would need to be identified. There are not special precautions for mononucleosis. LESSON Safety and Infection Control Standard Precautions, Transmission-Based Precautions, Surgical Asepsis COURSE RN Review KEYWORDS precautionsstandardcontactherpes

The nurse manager has interviewed several nurses for a staff position. The most qualified nurse is one with a sensory impairment. In order to better understand the issue of reasonable accommodations, the nurse manager meets with the director of human resources. Which approach would be most appropriate? Determine the type of accommodations the nurse would require. Recommend to the nurse to consider applying at another facility. Inform the nurse with the disability that the position is not a good fit. Consult with the facility attorney to determine any potential liability.

Determine the type of accommodations the nurse would require.; In the United States, the Americans with Disabilities Act (ADA) is designed to allow individuals with motor, cognitive, psychiatric, or sensory impairment equal access to employment opportunities. Employers must evaluate an applicant's ability to perform the job on a case-by-case basis and cannot discriminate on the basis of a disability. Employers are required to make "reasonable accommodations." An example of this would be installing a ramp for someone who uses a wheelchair. The other approaches are not appropriate and could be considered "discriminatory" and illegal. LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS ADAmanagerdisabilityaccommodate

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

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

A client with heart failure (HF) is referred to a home health care team. The nurse discovers that the client is not following the prescribed diet. What is the appropriate nursing action? Notify the provider of the client's failure to follow the prescribed diet Discharge the client from home health care because of noncompliance Discuss diet with the client to learn the reasons for not following the diet Make a referral to social services to arrange for weekly delivery of meals

Discuss diet with the client to learn the reasons for not following the diet When a client is not adhering to prescribed treatment, the first step is always to gather data from the client's perspective. Collaboration and problem solving can be done together at this point. If a change in the diet is needed, then notify the provider. If access to food is an issue, social services may be able to help the client. It would not be appropriate to label the client as non-compliant and/or discharge the client from services. LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review KEYWORDS homeheartfailurediet

The nurse is assessing the newborn of a mother with diabetes. The nurse should understand that hypoglycemia in the infant is related to what pathophysiological process? Disruption of fetal glucose supply Pancreatic insufficiency Reduced glycogen reserves Maternal insulin dependency

Disruption of fetal glucose supply After delivery, high glucose levels, which crossed the placenta to the fetus, are suddenly stopped. The newborn continues to secrete insulin in anticipation of the glucose. When oral feedings begin, the newborn will adjust insulin production within a day or two. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM endocrine KEYWORDS hypoglycemianewborndiabetes

The nurse is evaluating a client's ability to perform basic activities of daily living (ADLs). Which tasks should the nurse observe the client performing? Select all that apply. Driving safely around town Using the telephone Eating a meal independently Getting fully dressed Making a bank account withdrawal Using the bathroom

Eating a meal independently Getting fully dressed Using the bathroom Basic activities of daily living (ADLs) include feeding, moving, toileting, grooming, bathing and putting on clothes. More complex skills, such as using a telephone, shopping, doing housework, preparing meals, handling finances and taking medications correctly might be evaluated to determine if the client can live independently. Driving is not considered an ADL. Incorrect LESSON Health Promotion and Maintenance Self-Care COURSE RN & PN Review KEYWORDS Activities of Daily Living (ADLs)

The nurse is preparing a client diagnosed with deep vein thrombosis (DVT) for a venous Doppler examination. Which of these actions is necessary to prepare the client for this diagnostic test? Administer sedation medication prior to the test Determine if the client has any allergies to the contrast dye solution Instruct the client not to eat or drink anything after midnight Ensure the client is wearing a hospital gown prior to the test

Ensure the client is wearing a hospital gown prior to the test Correct Response Submit A venous doppler examination uses ultrasound to create a 2-dimensional picture of the veins in the legs. The purpose is to detect blood clots. This is a noninvasive test and does not require sedation; a venography would require injecting contrast material into a vein. The client may eat or drink prior to the test. The client should be wearing a hospital gown so that the ultrasound technician has easy access to the client's legs. LESSON Reduction of Risk Potential Diagnostic Tests COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS dopplerultrasoundDVT

A client is admitted to the psychiatric unit after a suicide attempt. Which of the following interventions is important for the nurse to implement initially? Select all that apply. Identify resources that the client may use after discharge Establish a trusting, therapeutic relationship Ask why the client attempted suicide Help the client identify the stressors that precipitated their current crisis Assign a staff member to stay with the client at all times Ask the client directly if they have suicidal thoughts or plan to commit suicide

Establish a trusting, therapeutic relationship Assign a staff member to stay with the client at all times Ask the client directly if they have suicidal thoughts or plan to commit suicide The most important goal is for the client not to harm themselves. Therefore, client safety is the nursing priority at this time. Nursing interventions include: determining if the client has developed a plan, close observation, establishing trust, using open communication and establishing a physically and emotionally safe environment.Suicide risk assessment uses direct rather than indirect language. Close observation is necessary to ensure clients do not harm themselves in any way. Being alert for suicide and escape attempts facilitates the prevention or interruption of this and other harmful behavior. Establishing trust and open communication encourages clients to share their thoughts and feelings.Asking the client to provide the reasons for their thoughts, feelings, behavior and previous actions—asking why a client did something or feels a certain way—can be very intimidating and implies that the client must defend his or her behavior or feelings.Identifying precipitating stressors and resources for after discharge should be implemented after the initial phase. LESSON Psychosocial Integrity Crisis Intervention COURSE RN & PN Review KEYWORDS depressionsuicidesafety

There are perceived inequities about weekend scheduling on a nursing unit being discussed at a staff meeting. What action should the nurse manager take at this point? Allow the staff to change assignments Help staff understand the complexity of scheduling issues Facilitate a discussion about staffing alternatives Clarify reasons for current assignments

Facilitate a discussion about staffing alternatives Part of the nurse manager role is to be a change agent. By facilitating a discussion about scheduling alternatives, staff become part of the solution and it gives them an opportunity to voice varied perspectives. They become part of the decision making process. This type of discussion will also help the staff understand the complexity of scheduling issues and the rationale for the current assignments. Allowing the staff to change assignments is a temporary solution and may not meet the needs of the unit. Correct! LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS staffweekendmeetingchange agent

A client diagnosed with schizophrenia is paranoid. During visiting hour, the client alertly watches the activities of other clients, visitors and staff. The client's behavior most likely indicates which associated problem? Altered sensory perception Social isolation Feelings of increased anxiety Impaired verbal communication

Feelings of increased anxiety Paranoid thinking and behavior is often exacerbated by anxiety. The visiting hour is a time of increased activity and the presence of other people not known to the client. These factors could increase both anxiety and paranoia, causing hyper-vigilance and being overly alert to surroundings. While a client with schizophrenia may also have impaired verbal communication, altered sensory perception, and be socially isolated, anxiety is the most likely cause of the behavior. LESSON Psychosocial Integrity Mental Health Concepts COURSE RN Review KEYWORDS schizophreniaparanoid

A client, who had their entire stomach surgically removed six months ago, is now readmitted. Which of the following assessment findings would indicate that the client is experiencing complications specifically associated with this surgery? Poor wound healing Findings consistent with fatigue Tendency to bruise easily Decreased night vision

Findings consistent with fatigue When clients have the stomach surgically removed, they no longer have the stomach's production of intrinsic factor, leading to poor Vitamin B12 absorption. This results in anemia with symptoms of fatigue, due to the decreased number of red blood cells to carry oxygen to the body. The client with gastrectomy or gastric bypass surgery is also at risk of experiencing dumping syndrome with abdominal cramping pain, diarrhea, lightheadedness, tachycardia and hypoglycemia. Dumping syndrome is usually associated with eating too much or too rapidly, and can be avoided by following the proper diet (five to six small meals per day, high protein, low carbohydrate and fat, eaten slowly) and by avoiding fluids with meals that move food rapidly into the small intestine.

The nurse is assessing a client diagnosed with chronic obstructive pulmonary disease (COPD). The client is on oxygen for low PaO2 levels. Which assessment is a nursing priority to evaluate the outcome of this therapy? Frequently evaluate oxygen saturation (Sa)2) levels Frequently assess lung sounds Frequently assess coughing and sputum characteristics Frequently observe for skin color changes

Frequently evaluate oxygen saturation (Sa)2) levels The best method to evaluate a client's oxygenation is to evaluate the SaO2. The oxygen saturation should be around 88% to 91% for someone with COPD. This method is equally as effective as an arterial blood gas reading to evaluate oxygenation status, and is less traumatic and expensive. Assessment of lung sounds, coughing and sputum and color should also be components of the respiratory assessment for a client with COPD, but are less precise indicators of the response to oxygen therapy than the oxygen saturation level. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM respiratory KEYWORDS COPDoxygenassess

Following a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which is the appropriate meal to suggest? A bologna sandwich, fresh eggplant, 2 ounces of fresh fruit, tea, and apple juice Fresh turkey 3 oz., a fresh sweet potato, 1/2 cup fresh green beans, milk, and an orange Broiled fish 3 oz., a baked potato, ½ cup canned beets, milk, and an orange Canned salmon 3 oz., fresh broccoli, a biscuit, tea, and an apple

Fresh turkey 3 oz., a fresh sweet potato, 1/2 cup fresh green beans, milk, and an orange Canned fish, canned vegetables, and cured meat (such a bologna) are high in sodium. The correct meal choice does not contain any canned food or cured meats. It also contains healthy food choices from the meat/poultry, fruit/vegetable, and dairy groups of daily dietary recommendations. LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS myocardial infarctiondietsodiumteach

A nurse is teaching parents of a child recently prescribed the medication phenytoin for seizure control. Which side effect will the nurse include? Insomnia Hypertension Increased appetite Gingival hyperplasia

Gingival hyperplasia Gingival hyperplasia (overgrowth of the gums) is a common side effect of phenytoin. Other common side effects include ataxia, central nervous system depression, drowsiness, headache, hypotension, mental confusion, nausea, vomiting, rash and nystagmus. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS phenytoinDilantingingival hyperplasia

A nurse is teaching a parent how to administer oral iron supplements to a 2-year-old child. Which intervention should be included in the teaching? Stop the medication if the stools become tarry green Give the medicine with orange juice and through a straw Add the medicine to a bottle of formula Administer the iron with your child's meals

Give the medicine with orange juice and through a straw Absorption of iron is facilitated in an environment rich in vitamin C. Because liquid iron preparation will stain teeth, a straw should be used. Parents should be informed that dark, tarry stools are expected outcomes of taking iron supplements. Iron is best absorbed on an empty stomach (but it may be given after meals if the child experiences an upset stomach). LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS nutritionschoolchildren CONFIDEN

A nurse documents "effective use of guided imagery to change pain from a 4 to a 1 (on a 10-point scale)." Which definition best describes this technique? The repetition of a word to self with the eyes closed Focus on pleasant, relaxed mental pictures Closure of the eyes to focus on the back of the eyelids Inhalation to a count of four and exhalation to a count of four

Guided imagery is a technique that uses pleasant mental visuals that are recalled by the client to reduce stress, anxiety, or pain. Focusing on the back of the eyelids or a repetition of a word or phrase describes meditation. Counting while inhaling and exhaling is a basic relaxation technique. Focus on pleasant, relaxed mental pictures LESSON Basic Care and Comfort Nonpharmacological Comfort Interventions COURSE RN Review KEYWORDS guided imagerypainstressanxiety

A nurse is caring for a client several days after a cerebral vascular accident (CVA). Coumadin has been prescribed. Today's prothrombin level is 40 seconds. Which finding requires priority follow-up? Generalized weakness Pharyngitis Gum bleeding Anorexia

Gum bleeding Coumadin is an anticoagulant. The normal range of the prothrombin level is 10 to 14 seconds. This prothrombin level is elevated indicating the blood is taking longer to clot and presents a risk of internal bleeding. Generalized weakness post CVA is a normal finding. A sore throat (pharyngitis) and loss of appetite (anorexia) do not pose a serious risk at this time. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS CVAwarfarinCoumadinprothrombin

The client is a 16-year-old with full-thickness burns involving 20% total body surface area. After the initial 24 hours of treatment to replace fluids, which factor is used to determine if the client's fluid needs are being met? Daily weight measurements Hourly urine output Daily hematocrit results Parkland formula for fluids

Hourly urine output Burn victims are at risk for deficient fluid volume. The Parkland formula for fluid replacement is used during the initial fluid resuscitation for burn victims. Thereafter, hourly urine output is used to guide fluid management. The desired urine output is 30-50 mL/hour for most adults and older children. Fluid replacement formulas (like Parkland) depend on the client's weight on admission and daily weights are more commonly used to determine if caloric intake is enough to meet increased metabolic needs. Hematocrit (and hemoglobin) can be used to help identify blood loss and RBC destruction, but they are is not used to determine fluid replacement needs. LESSON Physiological Adaptation Fluid and Electrolyte Imbalances COURSE RN Review BODY SYSTEM integumentary KEYWORDS burnfluidurineoutput

Which client behavior would indicate that the nurse-client relationship has progressed from the orientation phase to the working phase? Expresses a desire to be cared for and nurtured Reestablishes a relationship with an estranged family member Considers regressive behaviors as a positive defense mechanism Identifies painful feelings and expresses a desire to discuss them

Identifies painful feelings and expresses a desire to discuss them Correct! Submit The working phase of the nurse-client relationship refers to the period of time when the client is willing to collaborate with the nurse in making positive changes and achieving goals. By identifying painful feelings and demonstrating a willingness to speak about them, the client has progressed to the working phase of the nurse-client relationship. The other behaviors are not indicative of the client's readiness to make positive changes or do not pertain to the nurse-client relationship.

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

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

A client diagnosed with bipolar disorder is reluctant to take lithium as prescribed. Which response should the nurse make in this situation? "I can see that you are uncomfortable right now. I'll wait until tomorrow to discuss this with you." "What is it about the medicine that you don't like or are concerned about?" "If you refuse your medicine, we'll just have to give you a shot." "You need to take your medicine. This is how you will get well."

LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS bipolar lithium Lithane therapeutic refuse B; This response validates the client's feelings and is exploring concerns. It should generate therapeutic dialogue between the client and nurse. It provides an opportunity for the nurse to teach the client about lithium. Telling the client an injection will be given is coercive and incorrect, since lithium does not come in an injectable form and the client's behavior does not indicate aggression or need for an another as needed medication. Waiting until tomorrow is not a viable option as the client does need to take this medication, which needs to reach a therapeutic serum level. Advising the client to take the medication in order to get well is vague and does not validate feelings or explore concerns.

The nurse in an outpatient clinic is providing discharge instructions for an older adult client who underwent an intravenous pyelogram. Which information is most important to include? Monitor how often you have to urinate and call your health care provider if it is less than usual Rest for the next 24 hours as preparation and the test may cause fatigue You may resume a regular diet Drink at least one 8-ounce glass of fluid every hour while awake for the next two days

LESSON Reduction of Risk Potential Potential for Complications of Diagnostic Tests, Treatments, Procedures COURSE RN Review BODY SYSTEM urinary KEYWORDS renal failure pyelography urine It is important for the client to monitor urine output because this information would alert the client to the complication of acute renal failure. Renal failure may occur as a complication of the dye used during the procedure. Renal failure occurs most often in older adult clients who are often dehydrated before the dye injection. Unless contraindicated, they should force fluids for 24 hours after the test.

The nurse in an emergency department is assessing a client who fell at home 24 hours ago. Which finding requires the nurse's immediate attention? Atrial fibrillation on the ECG monitor Baseline blood pressure of 150/90 mm Hg Heart rate of 98 bpm Large bruise behind one ear

Large bruise behind one ear Correct! Submit Although all of the findings are important, the bruising behind one ear (over the mastoid process) requires immediate attention. Known as "Battle's sign", this sign appears 1 to 2 days post skull fracture. Other signs of a skull fracture can include bruising around the eyes, blood leaking from the ear, headache, changes in orientation and level of consciousness, and nausea and vomiting. LESSON Physiological Adaptation Alternations in Body Systems COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS skullfractureBattle's signbruising

A client with advanced liver disease has been taking rifaximin. Which assessment finding would indicate that the medication is being effective? Increased appetite Less jaundice Less confusion Less edema

Less confusion Clients with advanced liver disease experience elevated serum ammonia levels which typically lead to hepatic encephalopathy. Signs and symptoms of hepatic encephalopathy include personality changes, confusion, restlessness and forgetfulness. Rifaximin is an antibiotic that helps reduce ammonia levels and hepatic encephalopathy by stopping the growth of bacteria and production of ammonia in the GI tract. Lessening confusion would indicate that the medication is being effective.

A client is prescribed a new antipsychotic medication. The nurse is teaching the client about possible side effects, including tardive dyskinesia (TD). Which statement is accurate about tardive dyskinesia? The longer someone is treated with an antipsychotic medication, the higher the risk for developing TD TD occurs within minutes of the first dose of any antipsychotic drug Almost every client treated with antipsychotic medications will eventually develop TD The high fever, sweating and muscle stiffness will last about one week

Long-term use of certain antipsychotic medications put the client at a higher risk of developing TD. The symptoms are characterized by spastic movements of certain muscles, including the tongue, lips, jaw and limbs. Early recognition by the health care provider, including use of the Abnormal Involuntary Movement Scale (AIMS) is key. Once irreversible, there are now drug treatments, such as valbenazine, to treat the condition. It is estimated that up to 30 percent of clients taking antipsychotic medication will develop TD. The combination of high fever, sweating and muscle stiffness indicate neuroleptic malignant syndrome, not TD. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS tardive dyskinesiaantipsychoticNMS

A client in acute respiratory distress is admitted with arterial blood gas results of: PH 7.30; PO2 58; PCO2 34; and HCO3 19. Based on these lab results, the nurse will determine the client is symptomatic of which condition? Respiratory acidosis Metabolic alkalosis Respiratory alkalosis Metabolic acidosis

Metabolic acidosis These lab values indicate metabolic acidosis: the PH is low, PCO2 is normal, and bicarbonate level is low. The oxygen level is not used during the determination of ABG interpretation. LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM respiratory

The client is using nonsteroidal anti-inflammatory drugs (NSAIDs) to manage arthritis pain. The nurse should caution the client about which potential side effect? Nystagmus Occult bleeding Urinary incontinence Constipation

Nonsteroidal anti-inflammatory drugs (NSAIDs) taken for long periods of time may cause serious side effects, including bleeding in the gastrointestinal tract. Clients should be instructed to take the medication with meals if stomach upset occurs. To avoid esophageal irritation, the client should take the drug with a full glass of water and to avoid lying down for 30 to 60 minutes after taking a dose. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS ibuprofenNSAIDbleeding

A nurse is talking to parents about nutrition for their school-aged children. What is the most common nutritional disorder found in this age group? Obesity Malnutrition Anorexia nervosa Bulimia nervosa

OBESITY Pediatric obesity is at epidemic proportions, affecting approximately 18.5% of youth aged 2 to 19 years. Obesity is defined as being more than 20% above ideal weight. Many factors contribute to the high rate of obesity in school-aged children. These include heredity, sedentary lifestyle, social and cultural factors, and poor knowledge of balanced nutrition. Anorexia nervosa is refusal to maintain a minimally normal weight involving weight loss of 15% or more and involves intense fear of gaining weight with a distorted body image. Individuals with bulimia nervosa engage in repeated episodes of binge eating followed by inappropriate purging with compensatory behaviors such as self-induced vomiting and misuse of laxatives or diuretics. Malnutrition typically refers to being under normal weight due to deficiencies in proper nutrients and calories. LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS nutritionschoolchildren

A client with schizophrenia is receiving haloperidol 2 mg orally three times a day. The client approaches the nurse's station presenting with eyes rolled upward towards the head. The nurse recognizes this finding as what type of side effect? Tardive dyskinesia Dysphagia Oculogyric crisis Nystagmus

Oculogyric crisis Oculogyric crisis is an acute dystonic reaction caused by some antipsychotic medications, including haloperidol. Tardive dyskinesia is also caused by antipsychotic medications but typically affects the muscles of the tongue, lips, jaw, and limbs. Nystagmus is an involuntary eye movement and dysphagia is when one has difficulty swallowing. Neither of these conditions are directly caused by antipsychotic medications. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS schizophreniahaloperidolhaldolside effect

A client with schizophrenia is receiving haloperidol 2 mg orally three times a day. The client approaches the nurse's station presenting with eyes rolled upward towards the head. The nurse recognizes this finding as what type of side effect? Dysphagia Oculogyric crisis Nystagmus Tardive dyskinesia

Oculogyric crisis is an acute dystonic reaction caused by some antipsychotic medications, including haloperidol. Tardive dyskinesia is also caused by antipsychotic medications but typically affects the muscles of the tongue, lips, jaw, and limbs. Nystagmus is an involuntary eye movement and dysphagia is when one has difficulty swallowing. Neither of these conditions are directly caused by antipsychotic medications. Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS schizophrenia haloperidolhaldolside effect CONFIDENCE

The nurse is teaching a client about non-pharmacological pain management for moderate osteoarthritis in both knees. Which intervention should the nurse include? Start a regular exercise program Keep the legs elevated when sitting Rest the knees as much as possible Avoid foods high in citric acid

Osteoarthritis (OA) is the progressive deterioration and loss of cartilage and bone in one or more joints. Starting and maintaining a regular exercise program will help strengthen muscles and bones while keeping joints flexible, preventing pain and slowing progression of the disease. Resting the knees and keeping them elevated may temporarily alleviate pain but can lead to joint stiffness and will not help long-term. Avoiding citrus fruit is not indicated for OA.

A newborn presents with a pronounced cephalohematoma after a birth in the posterior position. What is the priority nursing problem at this time? Parental anxiety Pain Impaired mobility Risk for injury

Parental anxiety This hematoma is caused by pressure and/or trauma during labor; it is often caused by forceps used in the delivery. This painless condition is usually benign and resolves on its own in four to six weeks. The swelling does not cross the suture lines. Parental anxiety must be addressed by listening to their fears and explaining the nature of this common alteration.

The nurse is caring for a client who has a wound on the leg from a motorcycle accident. During a home visit, the nurse should use which assessment parameter as an indication that this client is experiencing normal wound healing? Eschar over the surface of the wound White patches on the outside edges of the wound Green drainage from the center of the wound Pebbled red tissue in the wound base

Pebbled red tissue in the wound base Correct! Submit As the wound granulates, pebbled red tissue in the wound base indicates healing. The other findings indicate the wound is not healing properly or could be a indicative of infection. LESSON Reduction of Risk Potential System Specific Assessments - RN COURSE RN Review BODY SYSTEM integumentary KEYWORDS woundheal

The nurse is assessing a client who sustained multiple fractures, contusions, and lacerations in a motor vehicle accident three days ago. The client suddenly becomes confused. Which findings would support the nurse's concern that the client has developed a fat embolism? Select all that apply. Hypertension Petechiae on the upper anterior chest Low oxygen saturation Elevated temperature Dyspnea

Petechiae on the upper anterior chest Correct! Low oxygen saturation Correct! Elevated temperature Correct! Dyspnea Manifestations of acute confusion, hypoxia, fever and hypotension may indicate fat embolism in a client who has sustained multiple fractures, particularly fractures of the long bones. The occlusion of dermal capillaries by fat with increased friability of the capillaries can result in skin petechiae. This is most common on the chest, neck, upper arm, axilla, shoulder, oral mucous membranes and conjunctiva. LESSON Physiological Adaptation Medical Emergencies COURSE RN & PN Review BODY SYSTEM musculoskeletal KEYWORDS fat embolism petechiae dyspnea fracture trauma

A client is treated in the emergency department for diabetic ketoacidosis (DKA) and has a glucose level of 650 mg/dL (36 mmol/L). Which serum lab value would the nurse expect to be altered as a result of the therapy associated with the client's condition? Calcium Magnesium Creatinine Potassium

Potassium is lost in diabetic ketoacidosis during rehydration and insulin administration. Initial laboratory studies for DKA would include blood test for glucose and serum electrolytes every 1-2 hours until the client is stable; initial blood urea nitrogen (BUN) and initial arterial blood gas (ABG) measurements are also ordered. Repeat potassium and glucose (and sometimes phosphorus) are critical during treatment. An ECG may be used to assess the cardiac effects of extremes in potassium levels. LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM endocrine KEYWORDS emergencydiabeticketoacidosisglucoselabpotassium

After successful alcohol detoxification, a client remarks to a friend, "I've tried to stop drinking but I just can't. I can't even work without having a drink." The client's statement and need for alcohol indicates the dependence is primarily of which type? Sociocultural Physical Genetic Psychological

Psychological With psychological dependence, clients have thoughts and attitudes toward alcohol or the desired substance. These thoughts produce cravings and behavior that reinforces compulsive use of the substance. Physical dependence means the client has developed a physiological need for the substance. This often leads to physical withdrawal symptoms if the substance is not used. Since the client has gone through a successful detoxification, there should be no risk for physical withdrawal at this time. There are genetic links to addiction as individuals with a family history of substance use problems are more prone to developing one as well. The sociocultural model of addiction is defined by a culture's attitude towards substance use (whether positive or negative), which in some cases may foster addictive behavior. LESSON Psychosocial Integrity Chemical and Other Dependencies, Substance Use Disorder COURSE RN Review KEYWORDS alcohol detoxification dependence

A nurse admits a premature infant who has been diagnosed with respiratory distress syndrome (RDS). In planning care for the infant, the nurse understands that the pathophysiology of this disorder affects the infant's ability to do what? Adequately clear thick, sticky mucus from the lungs Maintain alveolar surface tension Regulate intrapulmonary airway pressures Stabilize thermoregulation

RDS is primarily a disease related to a developmental delay in lung maturation. Although many factors may lead to the development of the disorder, the central factor is the lack of a normally functioning surfactant system in the alveolar sac from immaturity in lung development because the infant is premature. A lack of surfactant production results in the collapse of the alveolar sacs. LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM respiratory KEYWORDS prematurepediatricrespiratory distress syndromelungsurfactant

The nurse recognizes that cultural practices affect health outcomes. Which statement best reflects what nurses can do to improve health outcomes in clients from different cultures? Incorporate high personal standards and values for all interactions Recommend a plan that meets client goals as well as professional nursing standards Use conventional wisdom to gain a deeper understanding about the client's health practices Explore and describe Western medical perspectives with clients

Recommend a plan that meets client goals as well as professional nursing standards Nurses must provide culturally and linguistically appropriate care in order to help ensure successful outcomes. Nurses should advocate for clients from diverse ethnic and cultural groups by asking them about their health practices. As long as these practices are not harmful, the nurse can recommend a plan that both meets the goals of the client and professional nursing standards. Nurses can emphasize the science behind the plan of care without disparaging the client's culture. LESSON Management of Care or Coordinated Care Advocacy COURSE RN Review KEYWORDS cultureoutcomeadvocatestandardgoal

A client is being discharged with a prescription for warfarin. Which information is most important to be included in the nurse's discharge teaching? Use a soft toothbrush Avoid eating leafy green vegetables Report nose or gum bleeding Take acetaminophen for minor pain

Report nose or gum bleeding The most important teaching is to make sure that the client understands to report any sign of bleeding including nose or gum bleeding, blood noted in stools or urine, coughing up blood, or easy bruising. Dark green leafy vegetables are high in vitamin K which can lower the effectiveness of warfarin (Coumadin). Acetaminophen does not contain aspirin which can cause internal bleeding so is safe to use when taking warfarin. A soft toothbrush will be less irritating to the gums and therefore decrease the risk of bleeding gums. Although green leafy vegetables contain Vitamin K, it is no longer recommended to avoid them but to keep their intake consistent. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS warfarinCoumadinteach

A client with an intravenous (IV) antibiotic infusing is scheduled to have blood drawn at 1:00 pm for a peak antibiotic level measurement. The nurse notes that the IV infusion is running behind schedule and won't be completely infused until 1:30 pm. What action should the nurse take? Reschedule the laboratory test for 2:00 pm Stop the infusion at 1:00 pm and get the blood drawn Notify the client's health care provider Increase the infusion rate to finish it by 1:00 pm

Reschedule the laboratory test for 2:00 pm If the antibiotic infusion will not be completed at the time the peak blood level is scheduled to be drawn, a nurse should ask that the blood sampling time be adjusted. Typically the peak level should be drawn about 30 to 60 minutes after completion of the infusion. The infusion should not be increased because in this situation the volume of fluid to be infused is unknown; rates for IV infusions should not be increased or decreased by more than 10% of the ordered rate. Trough and/or peak levels are commonly drawn for aminoglycosides (such as vancomycin, gentamicin and tobramycin.) LESSON Reduction of Risk Potential Diagnostic Tests COURSE RN Review KEYWORDS peak IV antibiotic infusion

A client is admitted with a tentative diagnosis of left-sided heart failure. Which assessment finding is consistent with this diagnosis? Heart murmur Chest pain Inspiratory crackles Cyanosis

Signs and symptoms of HF are related to the ventricle most affected. Left-sided heart failure affects the left ventricular function. Crackles that do not clear with coughing are an early sign of left-sided heart failure. As pulmonary congestion increases, crackles become more pronounced. Oxygen saturation may decrease at this time. C ; LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS cracklesheart failurepulmonary edema

The nurse is teaching a client about an oral hypoglycemic medication. The nurse should place priority emphasis on which of the following points? Distinguishing signs and symptoms of hypoglycemia and hyperglycemia Consulting with the health care provider about dose changes based on blood glucose Adherence with recommended diet plan Taking the medication at specified times

Taking the medication at specified times Correct Response Submit A regular interval between doses should be maintained because oral hypoglycemics simulate the islets of Langerhans to produce insulin. If doses are not spaced correctly, insulin levels may increase, causing hypoglycemia or decrease, causing hyperglycemia. The other actions are important and would be discussed after this initial point. LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM endocrine KEYWORDS oralhypoglycemicmedication

The nurse is speaking with the parents of a 3-year-old child who are concerned about the child holding its breath during a temper tantrum. Which action should the nurse take? Recommend that the parents give in when the child holds their breath to prevent anoxia. Educate the parents on how to administer rescue breaths and chest compressions. Instruct the parents on how to reason with the child about possible harmful effects. Advise the parents to monitor the child because breathing often resumes automatically.

Temper tantrums are common during the toddler years and represent normal developmental behaviors. Temper tantrums commonly occur when the child is ill, hungry, frustrated, or tired; some children may use temper tantrums to get parental attention, get something they want, or avoid having to do something they do not want to do. The majority of tantrums last 5 minutes or less. During a tantrum, the child may lie down on the floor, kick their feet, and scream as loud as possible. Some have learned the effectiveness of holding their breath until the parent gives in. The nurse should offer anticipatory guidance and advise the parents to not give in to the negative behavior, ensure a consistent response by all caregivers, and praise and reward positive behavior. The other actions are not appropriate or helpful for this developmental stage.;d LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS childbreathtantrumignore

A nurse is caring for a client after a spinal fusion to treat scoliosis. Which nursing intervention is appropriate in the immediate postoperative period? Select all that apply. Encourage use of patient-controlled analgesia Maintain bedrest with the head of the bed elevated at least 30 degrees Encourage passive leg and ankle exercises Perform neurovascular checks every 8 hours Position the client flat in bed and logroll every 2 to 4 hours Assist the client to stand and walk to the bathroom as needed

The client should remain flat in bed for at least 6 hours and turned from side to side every 2 to 4 hours. The day after surgery, the client can sit up in bed a few times; the client will get out of bed to sit in a chair on the second or third day after surgery. Clients should be encouraged to perform isometric exercises right after surgery. Neuro checks will be performed every 2 hours for the first 24 hours. Position the client flat in bed and logroll every 2 to 4 hours Encourage passive leg and ankle exercises Encourage use of patient-controlled analgesia LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN Review BODY SYSTEM musculoskeletal

A client reports the experience of a sudden, deep and throbbing pain in one leg. What is the appropriate action to be taken by the nurse? Maintain the client on bed rest Suggest isometric exercises Ambulate for several minutes Apply ice to the extremity

The finding suggests deep vein thrombosis (DVT). The client must be maintained on bed rest and the health care provider should be notified urgently. Deep vein thrombosis can lead to pulmonary embolism, which is a medical emergency that can cause severe problems with gas exchange and cardiac output and can even cause cardiac arrest. Anticoagulants are used to treat DVT, initially being administered by IV (heparin drip) or subcutaneous injection (low-molecular weight heparin). This is then followed by long-term oral anticoagulation with warfarin. LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS painlegDVTanticoagulantpharmacology

The nurse is talking with parents of a toddler who is newly diagnosed with retinoblastoma. Which point is a priority when discussing this diagnosis with the parents? Inform them that even aggressive treatment is usually ineffective There is a need for genetic counseling Suggest that total blindness may follow surgery Prepare them for their child's permanent disfiguremen

There is a need for genetic counseling Aggressive treatment of retinoblastoma can be effective. If the tumor does not respond to chemotherapy and/or radiation therapy, the eye may need to be removed; however, that does not necessarily mean the child will be permanently disfigured. Regardless, the oncologist is the person who will discuss treatment options and anticipated outcomes with the parents. The parents should be prepared for the effects of the cancer on their child, but they should also understand that retinoblastoma is a rare cancer that runs in families and there is a high risk for future offspring to be affected. LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM nervous KEYWORDS retinoblastomacancereyetoddler CONFIDENCE Need Help Fair Strong

A client is scheduled for an intravenous pyelogram (IVP). Which information from the client's history indicates the greatest potential hazard for this test? Hypertension; prescribed clonidine Constipation; prescribed linaclotide Type 2 diabetes; prescribed metformin Urge incontinence; prescribed tolterodine

Type 2 diabetes; prescribed metformin There is a risk of developing contrast induced renal failure following administration of contrast dye. If kidney damage occurs, metformin can cause lactic acidosis. To avoid this complication, metformin should be held at the time of and 48 hours after the administration of contrast dye. The other conditions and medications do not pose this risk. LESSON Reduction of Risk Potential Potential for Complications of Diagnostic Tests, Treatments, Procedures COURSE RN Review BODY SYSTEM urinary KEYWORDS IVPintravenous pyelogramIVPmetformin

A nurse is assigned to provide care in the pediatric unit. What must be the priority consideration for nurses when communicating with children? Developmental level Nonverbal cues Present environment Physical condition

While each of these factors may affect communication, nurses should recognize that developmental differences have implications for processing and understanding information. The child's developmental level is considered first when selecting a communication approach. Correct! LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS communicating child developmental

The nurse on an inpatient behavioral health unit is assessing a client with schizo-affective disorder. The client says, "I do not like being wet. It's raining outside. Did you know that Patrick the Saint drove the snakes out of Ireland? I've never been to Ireland." How should the nurse document the client's behavior? Loose associations Echolalia Flight of ideas Perseveration

a Loose Associations thinking is a thought disturbance characterized by speech in which ideas shift from one 'unrelated' subject to another. Typically, the individual with loose associations is unaware that the topics are unconnected. When the condition is severe, speech may be incoherent (e.g., "We wanted to take the bus, but the airport took all the traffic. Driving is the ticket when you want to get somewhere. No one needs a ticket to heaven. We have it all in our pockets.") Although it can be challenging to differentiate, flight of ideas is more commonly seen in clients with "mania." During the manic phase, the client may exhibit accelerated thinking and abrupt movement from one thought or idea to another. Because this is often expressed in a very fast speech pattern, making it difficult to follow, it can appear as if they are loose associations when in fact the client is jumping from one formed "related" idea to another, hence the term "flight of ideas." Echolalia is a speech pattern disturbance and perseveration is an obsessive preoccupation that are more commonly seen with neurodegenerative disorders. LESSON Psychosocial Integrity Mental Health Concepts COURSE RN Review KEYWORDS schizophreniabehaviorflight of ideas

A nurse is teaching a client about the use of ego defense mechanisms. Which information will the nurse share with the client? Adaptive use of defense mechanisms helps the client manage anxiety Use of defense mechanisms is always viewed as an unhealthy coping strategy Most people typically use one type of defense mechanism Use of a defense mechanism is always apparent to the client

a; Ego defense mechanisms are automatic coping strategies used by people to protect from anxiety and/or maintain self-image. They can be adaptive or maladaptive in nature. Adaptive use helps people lower anxiety and achieve goals in acceptable, healthy, and appropriate ways. Maladaptive coping tends to be more primitive in nature and viewed as unhealthy. Defense mechanisms are not always evident to the individual using them. Most people use a variety of coping mechanisms. LESSON Psychosocial Integrity Coping Mechanisms COURSE RN Review KEYWORDS ego defense mechanismgoalstress

To establish trust in a nurse-client relationship, which qualities are most important for the nurse to exhibit? Honesty and consistency Genuineness and kindness Confidence and optimism Empathy and understanding

a; To establish trust in a nurse-client relationship, which qualities are most important for the nurse to exhibit? Honesty and consistency. All of the qualities listed are important. Honesty and consistency is the best option because the client will be able to depend on the nurse regardless of a situation; will foster appropriate and clear boundaries; and demonstrate professionalism of the nurse. LESSON Psychosocial Integrity Therapeutic Environment COURSE RN & PN Review KEYWORDS therapeuticrelationshiptrust

Upon entering a client's room, the client is found to be unresponsive and is not breathing. After immediately calling for help, what is the next action the nurse should take? Deliver 30 chest compressions Check for a carotid pulse Give two rescue breaths Maintain an open airway

b According to the American Heart Association's basic life support, the first step after determining a victim is unresponsive is to call for help. The next step is to check for a pulse (for no more than 10 seconds). If there is no pulse, the rescuer should begin CPR (30 chest compressions followed by 2 ventilations). LESSON Physiological Adaptation Medical Emergencies COURSE RN Review KEYWORDS CPRresponsiveaction

A staff nurse reports to the nurse manager that an unlicensed assistive personnel (UAP) consistently does not perform assigned work duties. Which of these statements should the nurse manager make initially? "I will arrange for a conference with you, the UAP, and myself within the next week." "I would like for you to directly approach the UAP about the problem the next time it occurs." "I will add this concern to the agenda for the next unit meeting so all the staff can discuss it." "I can assure you that I will look into the matter in due time."

b It is the nurse manager's role to help staff manage conflict among themselves. If the two staff members cannot resolve the issue, the next step would be to arrange for a private conference with the nurse manager and the staff involved in the conflict. Assuring the matter will be dealt with in due time does not address the issue directly. It would not be appropriate to discuss a conflict between two members in a group (staff meeting) setting, as trust could break down and confidential information could be disclosed. LESSON Management of Care or Coordinated Care Collaboration with Interdisciplinary Team COURSE RN Review KEYWORDS UAPmanagernurse

A client being treated for hypertension and depression tells the nurse at the health clinic, "I recently purchased a handgun because I am thinking about suicide." Which action should the nurse take first? Complete the physical and mental health assessment Notify the health care provider immediately Suggest inpatient psychiatric care Phone the family to warn them of the risk

b. Report of suicidal ideations, an active plan, and means to complete the plan places the client at the highest risk of completing suicide. In this case, the client has means to a gun and admits to suicidal thoughts. Therefore, the primary health care provider (HCP) must be notified first. After notifying the HCP, the nurse should implement the other actions. LESSON Psychosocial Integrity Crisis Intervention COURSE RN Review KEYWORDS suicidegundepression

The nurse is teaching a group of clients diagnosed with arthritis about the use of non-steroidal anti-inflammatory agents (NSAIDs). In order to minimize side effects of these drugs, which action should the nurse emphasize? Take the drug with an antacid Take the medication with food Limit foods high in Vitamin K Eat a diet high in fiber

b. A common side effect of NSAIDs is gastrointestinal distress including heartburn, nausea, and stomach pain. Taking the medication with food will decrease this side effect. The other actions are not appropriate or indicated when taking NSAIDs. Correct! LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS NSAIDnonsteriodal anti-inflammatoryside effectarthritis

A mother has been exclusively breastfeeding her 6-month-old. She requests information about meeting the nutritional needs of her infant. What information should the nurse provide? Decrease the number of times per day the infant receives breast milk Gradually add iron-rich pureed meat and cereal to the infant's diet Offer finger foods to encourage self-feeding Include a variety of food choices with meals and snacks

b; vPureed iron-rich meat, meat alternatives and/or iron fortified cereal are the first complementary foods that are introduced to infants. The mother will continue to breastfeed while introducing these foods. The next food transition is strained or mashed foods; then finger foods may be introduced. By the age of 1 year, children should have a regular schedule of meals and snacks. Breastfeeding may continue during all these transitions. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review KEYWORDS babybreastdietfood

A nurse is assessing a child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. What should the nurse assess next? Urine Lungs Skin Sputum

c; A characteristic sign of rubeola is Koplik spots (tiny white spots). These are found on the buccal mucosa in the mouth about a few days before the onset of the measles rash (which appears as small red, irregularly shaped spots with a bluish white center). Although the nurse should assess the child's lungs with any reports of a respiratory infection, these spots would indicate that the skin should be checked for the presence of a rash. Sometimes a complication of measles is pneumonia, but it may be a bit premature to do a sputum culture. LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM integumentary KEYWORDS measlesspotsskinclinicassess

The nurse is preparing the parents of a healthy newborn for discharge. The nurse provides information about hormonal effects in newborns and tells the parents to expect which of the following conditions in their baby? Mongolian spots Lanugo Gynecomastia Edema of the scrotum

c; Exposure to maternal hormones in utero may cause temporary conditions in the newborn, including gynecomastia in males and females. This swelling of the breasts typically occurs three days after birth and is the result of withdrawal of maternal estrogen. It should go away by the second week after birth. Lanugo (fine downy hair), Mongolian spots (birth marks), and scrotal swelling are not caused by maternal hormones. LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS newbornhormonematernal

A nurse is caring for a client with a new order for bupropion hydrochloride for treatment of depression. The order reads "Wellbutrin 175 mg po twice a day for four days." What is the appropriate action? Monitor neurologic signs frequently Observe the client for mood swings Give the medication as ordered Question this medication dose

d : LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM nervous KEYWORDS bupropionWellbutrindepression CONFIDENCE Need Help Fair Strong Bupropion should be started at 100 mg twice a day for three days then increased to 150 mg twice a day. When used for depression, it may take up to four weeks for effective results. Common side effects are dry mouth, headache and agitation. Doses should be administered in equally spaced time increments throughout the day to minimize the risk of seizures.

In which situation would a child be treated by use of enemas followed by an antitoxin? A child who has eaten an undetermined number of ibuprofen tablets A child who has swallowed a handful of iron-fortified vitamins A child who bit into a laundry detergent packet A child who is diagnosed with botulism

d; Foodborne botulism is treated by removing the contaminated food from the gastrointestinal tract by use of enemas (or inducing vomiting) and by administration of a botulinum antitoxin. Iron poisoning is treated with a strong laxative fluid; severe poisoning may require intravenous chelation therapy. Non-steroidal anti-inflammatory drugs such as ibuprofen are treated with activated charcoal; very large overdoses may require orogastric lavage. Since laundry detergents are alkaline agents, intravenous therapy to promote dilution is used; tracheal intubation with ventilation may also be required. Incorrect LESSON Safety and Infection Control Emergency Response Plan COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS enemaantitoxinemergencybotulism