Qbank test 11

The nurse manager reviews EMR documentation for clients on the unit. Which nursing documentation requires an intervention? *select all that apply* 1. client reports chest pain that is radiating to the jaw and left arm. MSO4 2 mg IV administered 2. client reports drinking 6-8 beers QD for the past 3 months 3. at 0100, client reports difficulty falling asleep. medicated w/diphenhydramine 50 mg PO 4. chest tube drainage system intact, suction control chamber filled w/20 cm sterile H2O w/gentle fluctuation noted. client in no acute distress 5. humalog insulin 4U administered in right lower abdominal area for blood glucose of 240 6. dextrose 5% in 0.45% sodium chloride infusing via infusion pump at 75 mL/hr in left anterior forearm w/o complications

1, 2, 5 The abbreviation MSO4 (morphine sulfate) can be confused w/MgSO4 (magnesium sulfate); MSO4 is on The Joint Commission Do Not Use list as it has the potential to be misinterpreted, leading to error; the recommendation is to write "morphine sulfate" rather than write "MSO4" The abbreviation AD is on The Joint Commission Do Not Use list as it has the potential to be misinterpreted, leading to error; the recommendation is to write "daily" rather than "QD" The abbreviation U is on The Joint Commission Do Not Use list as it has the potential to be misinterpreted, leading to error; the recommendation is to write "units" rather than "U"

A client is admitted to the postanesthesia recovery unit (PACU) after an open cholecystectomy. Which action is a *priority* of the nurse? 1. assess the client for signs of pain 2. check the client's T-tube for signs of infection 3. remind the client to do coughing exercises 4. teach the client to avoid fatty foods

1 An open cholecystectomy requires a large incision In the PACU, a priority is to assess the client for pain The nurse would also maintain the airway, check the dressing for bleeding, and monitor VS and T-tube drainage

The nurse provides care for a client dx w/obesity-hypoventilation syndrome. The nurse expects to see signs of chronic respiratory acidosis in the client's arterial blood gas results. Which finding does the nurse look for based on the current information? 1. decreased PaCO2 2. increased HCO3 3. decreased HCO3 4. increased pH

2 As respiratory mechanisms fail, increased PaCO2 levels cause the body to excrete hydrogen The kidneys are stimulated to retain HCO3 and sodium ions, resulting in an increase in sodium bicarbonate

The hospital has been notified of a pending disaster and will need to discharge and transfer clients in order to accept higher acuity clients. Which client does the nurse triage as being potentially unstable and ineligible for discharge home? 1. a toddler w/mild irritability and temperature 101 F of unknown origin 2. a middle-age adult dx w/sciatica and chronic back pain. the client rates pain as "6 out of 10" 3. an adolescent dx w/sickle cell disease who appears well-hydrated and reports pain as being 6, w/a goal of 5 4. an older adult w/a hx of COPD and current PaO2 of 83

1 A temperature greater than 100.4 F w/no known etiology in this age group requires additional workup A situation that is possibly systemic (vs. local) and acute (vs. chronic) creates a higher acuity level than other chronic, lower acuity conditions

The nurse provides care for a client who had a hypophysectomy. The nurse observes clear drainage coming from the client's nostril. Which action does the nurse take *immediately*? 1. test the drainage for glucose 2. document the drainage 3. lower the HOB 4. obtain a culture of the drainage

1 A possible complication of a hypophysectomy is a CSF leak CSF contains glucose This test will determine if the drainage is CSF

The nurse in the ambulatory care clinic prepares to perform a venipuncture on a client dx w/Crohn disease. The client suddenly becomes upset and asks, "What are you really going to be injecting into my veins?" Which is the *best* responses by the nurse? 1. nothing. I'm just going to draw some blood 2. what makes you think I'm going to inject anything into your vein 3. it sounds like you had a bad experience w/venipunctures before 4. you sound frightened. what are your specific concerns?

4 This response reflects feelings of the client, and allows the client to verbalize feelings and concerns

A client is prescribed methotrexate 15 mg by mouth once a day. The medication is available in 2.5 mg/tablet. Which number of tablets will the nurse provide for each dose?

6 tablets

The nurse administers potassium chloride 25 mEq IV piggyback to a client. The concentrated potassium chloride solution is labeled 40 mEq in 10 mL. How many milliliters of potassium chloride does the nurse add to the IV solution for the piggyback? *record answer using two decimal places*

6.25 mL

The nurse provides care for a client after surgery for a total knee replacement. The HCP prescribes a continuous passive motion (CPM) machine. How will the nurse set up the CPM machine?

Preventing the CPM machine from moving while in use ensures client safety The CPM machine must be plugged in to work properly; the cord should be moved under the bed to prevent falls The knee immobilizer, which is placed directly after surgery, needs to be removed so that the CPM machine straps are secured around the leg The correct placement of the knee allows for correct ROM and circulation; the CPM machine constantly moves the affected knee and provides ROM for a period of time while the client relaxes Positioning the foot against the footpad ensures proper ROM of the knee The leg must be secured w/the CPM machine's straps to ensure safety and proper ROM

The nurse teaches a client newly dx w/DM about proper foot care. Which instructions will the nurse include in the teaching plan? *select all that apply* 1. wash and dry feet every day 2. soak feet in hot water twice daily 3. have a podiatrist cut the toenails 4. check the feet daily for injuries 5. never walk barefoot

1, 3, 4, 5 Those dx w/DM should wash their feet daily and dry them carefully, especially between the toes A client w/DM should have a podiatrist cut their toenails Individuals w/DM should inspect their feet for red spots, cuts, swelling, and blisters This will protect the feet from injury

The nurse provides care for a client on the second day postpartum. The client begins to experience breast engorgement. Which actions are appropriate for the nurse to implement? *select all that apply* 1. instruct the client to express some milk to relieve the distention 2. remove the client's bra to relieve pressure from the sensitive breasts 3. apply ice packs to the breasts between feedings 4. decrease fluid intake for 24 hours 5. increase the frequency of breastfeedings

1, 3, 5 The mother can express milk to get the milk flow started and soften the areola; the client may use a breast pump or manually express milk Cold applications between feedings and heat just before feedings may help to reduce discomfort and engorgement The client should feed more often --> every 1-2 hours

The nurse provides care to a client dx w/a blunt injury to the right temple. Which observation is *most* important for the nurse to make in this client? 1. diarrhea 2. slowing of speech 3. n/v 4. vertigo and insomnia

2 Slowing of speech is an early indication of increasing ICP Other indications include changes in LOC, restlessness, and confusion

The nurse provides care for clients in the ED. Four clients come in at the same time. Which client does the nurse see *first*? 1. a 6 month old w/vomiting and diarrhea 2. a 2 year old w/a temperature of 101 F 3. a 20 year old at 8 weeks' gestation reporting vaginal spotting 4. a 32 year old reporting n/v for several hours

1 This client is at significant risk for dehydration and electrolyte imbalances due to the small body mass, inability to compensate effectively, and loss from both upper and lower GI sources This client is the priority

The charge nurse evaluates client assignments made by a new nurse. The charge nurse determines that client assignments are appropriate if the LPN/LVN is given which assignment? 1. provide initial teaching to a client about proper ostomy care 2. perform stoma care for a client w/a well-functioning ostomy 3. assess a newly created ileostomy to determine if it is functioning as expected 4. provide care for a client recently admitted w/a complicated double-barrel colostomy

2 This is a stable client w/predictable outcomes and is w/in the scope of practice of an LPN/LVN

The nurse receives a hand-off report. Which client should the nurse assess *first*? 1. the client w/a. fib who has an apical pulse 130 bpm and denies pain 2. the client w/a. fib who has an apical pulse of 90 bpm and requests to get up in chair 3. the client w/paroxysmal a. fib who reports palpitations 4. the client w/a. flutter who has a magnesium level of 2

1 This client is in a. fib w/a rapid ventricular rate and needs to be assessed If the client is receiving a medication to control HR, the dose may need to be increased Cardiac output can decrease as a result of the rapid ventricular rate

The nurse provides care for a postpartum client 4 days after delivery. Which finding *most* concerns the nurse? 1. the uterine fundus has descended 2 cm 2. the vaginal walls are edematous 3. lacerations are noted to the perineum 4. brown-tinged discharge is noted on the peripad

1 This is an abnormal finding The uterine fundus descends by approximately 1 cm, or one fingerbreadth, per day Subinvolution occurs when process of involution does not occur properly and can lead to postpartum hemorrhage By 14th day, the fundus has normally descended into the pelvic cavity and cannot be palpated abdominally The descent is documented in relation to the umbilicus

The nurse instructs a client on how to collect a 24 hour urine specimen for a creatinine clearance test. Which statement by the client would cause the nurse to intervene? 1. I will have to have my blood drawn during the test 2. I will go to the lab after I work out in the gym 3. I will drink at least 1 cup of water hourly 4. I will void and discard the urine before the test begins

2 Creatinine is a waste product of muscle breakdown A client should not engage in strenuous exercise during, or just before, the test

A client who received an IV dose of penicillin G develops restlessness, wheezing, and swelling of the lips and tongue. After applying O2 via nonrebreather face mask, which action will the nurse take *next*? 1. initiate an IV infusion of warmed 0.9% sodium chloride 2. administer epinephrine 1:1000 SQ 3. give SQ diphenhydramine 4. insert an indwelling urinary catheter

2 The client is exhibiting symptoms of an anaphylactic reaction While the SQ route is preferred, epinephrine can also be administered by the IV and IM routes Epinephrine is the medication of choice for anaphylaxis as it can activate three types of adrenergic receptors and reverse the reaction to the antigen This leads to increased BP, decreased epiglottal edema, and decreased bronchoconstriction

The nurse prepares a client dx w/epilepsy for a positron emission tomography (PET) scan. Which direction to the client is *most* important for the nurse to include? 1. be prepared to feel a warm sensation when the dye is injected 2. you will want to empty your bladder before the test 3. be sure to remove all your jewelry before you enter the testing area 4. you will be asked to think in different ways during the test

2 This ensures that the client will be comfortable and able to lie still throughout the procedure, which may last as long as 2 hours After radioisotope administration, the client waits 30-45 minutes on stretcher or table so the substance can circulate to the brain After this waiting period, the scan is performed

The nurse precepts a novice nurse and reviews practices intended to reduce the incidence of accidental needlestick injuries. The nurse recognizes which statement by the novice nurse as an indication that additional training is needed? 1. I'll use the unassisted one-hand technique to manually recap an exposed needle 2. it is important to maintain a sharps injury log of all needlestick injuries 3. I'll dispose of the needle in a sharps container 4. I'll immediately get rid of the used needle after use

1 It is not recommended that exposed needles be recapped

The nurse provides care for clients in the diabetic clinic. Which client does the nurse assess *first*? 1. the client w/sunken eyeballs and a fruity breath odor 2. the client reporting pain in both calves when exercising 3. the client drinking copious water w/constant hunger 4. the client w/difficulty sleeping and frequent crying

1 Sunken eyes and fruity breath indicate DKA, which is treated w/NS and regular insulin

The nurse provides care for a client 24 hours after a thyroidectomy. Which client statement to the nurse requires an *immediate* intervention? 1. I have been having some muscle spasms in my legs and my lips are tingling 2. I think I am getting a cold because I have been coughing and sneezing all night 3. I am still having pain around the incision 4. my voice is still very hoarse

1 The client is at risk for hypocalcemia, which may be manifested by tetany and result in airway obstruction, respiratory arrest, cardiac dysrhythmias, and cardia arrest

The nurse provides care to a client who is being prepared to receive an epidural patch for a postlumbar puncture HA. In which position will the nurse place the client? 1. side-lying position 2. dorsal recumbent position 3. lithotomy position 4. upright position

1 The client should be in the side-lying position for epidural patch placement This position allows the HCP access to the region for the procedure

The nurse assesses a group of clients for risk of developing psoriasis. The nurse identifies which client as being low risk for developing psoriasis? 1. a young adult African American 2. a client w/a family hx of the condition 3. a client reporting prolonged emotional stress 4. an older adult experiencing menopause

1 The incidence of psoriasis is lower among darker-skinned races

The nurse observes a student nurse preparing to insert an indwelling urinary catheter. Which action by the student indicates the nurse needs to provide additional teaching? * 1. applies sterile gloves prior to positioning client 2. transfers of catheter from dominant to non-dominant hand after cleansing the urethral meatus 3. applies sterile lubricant to the catheter tip prior to insertion into the urethra 4. opens cleansing swabs included in the insertion kit while wearing sterile gloves 5. attaches prefilled syringe to the balloon port after placing sterile gloves

1, 2 Sterile gloves should be used to set up the sterile field and to insert the urinary catheter; the student nurse needs to reposition the client before placing sterile gloves; this action requires additional education by the nurse When prepping the insertion site, the dominant hand remains sterile while the non-dominant hand does not; this action will contaminate the catheter and requires additional education by the nurse

An adolescent client insists that wearing protective necklaces can help cure the client's illness. The client explains that these practices are part of their religious beliefs. Which nursing action is appropriate for the care of this client? *select all that apply* 1. support the use of the necklaces, provided they are safe for the client 2. report this incident to the HCP 3. recognize that the client's actions are important to the client's coping w/the illness 4. assess if other religious and spiritual beliefs are important for the client and include those in the plan of care 5. inform the client and the client's parent that protective necklaces are not part of the client's tx plan

1, 3, 4 Allowing the use of religious objects is part of respecting the client's religious beliefs and practices Clients who are dx w/an illness have various ways of coping w/the dx; part of coping is being able to practice religious beliefs that the client believes have an impact on their health and wellness Religious beliefs and practices play a big role in the client's coping; these beliefs and practices should be included in the plan of care as long as they are safe for the client

The nurse provides care for clients in the ED. Which client situation *most* benefits from having a case manager assigned to the care plan team? *select all that apply* 1. a middle-age adult dx w/COPD 2. toddler dx w/otitis media 3. a school-aged child w/an anaphylaxis reaction to an unknown allergen 4. an adolescent dx w/T1DKA 5. a young adult w/symptoms of a STI 6. an infant dx w/an acute upper airway respiratory infection

1, 4 Nurses and designated case managers understand that chronic and advanced stages of chronic illnesses require close monitoring, medication management, and exacerbation prevention; this is often done for known disease processes such as COPD to prevent ED visits and hospitalizations In this case, the growing emotional, developmental, and hormonal changes in an adolescent can make them at risk for frequent blood glucose fluctuations; a nurse case manager can assist in educating for prevention of exacerbation of diseases such as diabetes and asthma; they also can help clients understand how to cope w/their disease and provide symptom management to help clients manage the disease and reduce or prevent the occurrence of ED visits

While ambulating to the bathroom, a client becomes dizzy and loses consciousness. Which intervention should the nurse initiate *first* if no one is available to assist? 1. move the client back into bed 2. use the gait belt to lower the client to the floor 3. initiate the rapid response team 4. check the client for an irregular or absent pulse

2 This is the priority nursing intervention The nurse should first lower the client to the floor in a safe manner In this situation, the goal is to keep the client safe, along w/the nurse

The nurse visits the home of a client prescribed phenytoin 8 weeks ago for tonic-clonic seizure control. Which client statement requires *immediate* intervention by the nurse? *select all that apply* 1. I need to tell my HCP if I decide to try to get pregnant 2. I noticed a rash on my stomach last week 3. lately, I find myself thinking about driving off a cliff 4. if I start having adverse effects, I should stop taking the phenytoin immediately 5. I take my phenytoin once a day at bedtime

2, 3, 4 A rash is a symptom of phenytoin hypersensitivity; the medication may need to be changed Phenytoin can increase suicidal tendencies; intervention is required for this finding Abruptly discontinuing phenytoin can cause seizures; adverse effects should be reported; the HCP will determine what medication change is required

The charge nurse on a cardiac care unit makes assignments. Which client is appropriate to assign to a float nurse from the med-surg unit? *select all that apply* 1. a client w/an IV infusion of epinephrine for HF 2. a client scheduled for insertion of an implantable cardioverter-defibrillator device 3. a client receiving albumin and blood transfusions for hypotension 4. a client receiving intermittent IV cefazolin for endocarditis 5. a client newly admitted w/kidney failure secondary to HF

2, 3, 4 This is a stable client who is scheduled for a routine procedure and will require typical preoperative care These skills are transferable and used in any nursing area; the float nurse can transfuse blood and infuse albumin This client is stable and requires routine nursing care, such as antibiotic infusion

A client who is reporting persistent lower back pain requests a pain medication. After reviewing the client's medication administration record, the nurse informs the client that the next dose of pain medication is not due for several hours. Which non-pharmacological intervention is appropriate for the nurse to offer? *select all that apply* 1. a lidocaine patch to place on the painful area 2. a heating pad to place on the painful area 3. a gentle massage w/a muscle-relaxing cream on the painful area 4. repositioning in bed to relieve pressure from the painful area 5. aromatherapy to provide a distraction from the pain

2, 4, 5 Offering the client a heating pad, repositioning the client to relieve pressure, and offering the client aromatherapy to provide a distraction from pain is an appropriate non-pharmacological intervention

The nurse provides care to a client who is vomiting brown material that has a fecal odor. Which condition does the nurse suspect is causing this type of vomitus? 1. gastric outlet obstruction 2. obstruction below the pylorus 3. intestinal obstruction 4. excessive hydrochloric acid in the gastric area

3 A bowel obstruction is indicated w/vomitus that is brown w/a fecal odor as described

The nurse provides care for a client who receives frequent opioid analgesics for pain. The client's spouse states to the nurse, "I think my spouse is receiving too many pain medications. Next time, please administer a placebo." Which action by the nurse is *best*? 1. inform the client of the spouse's request 2. administer a placebo instead of the narcotic 3. inform the spouse that the action is unethical 4. notify the HCP immeidately

3 The nurse has an ethical and legal duty to protect the competent client's rights In this case, the client has a right to receive prescribed medications w/o outside interference if the client reports pain The nurse has a duty to advocate for the client

The school nurse assesses several school-age clients who were brought to the clinic while having an asthma attack. Which client does the nurse attend to *first*? 1. the client who is coughing copious amounts of sputum 2. the client using abdominal muscles in an effort to breathe better 3. the client w/wheezing no longer heard in one lobe 4. the client having prolonged expiration w/each breath and coughing

3 Wheezing that has stopped in one or both lobes can be an indication of total occlusion of the airway and needs to be assessed as soon as possible

The nurse works under the supervision of a democratic nurse leader planning to institute a new policy for the unit. Which step is the nurse leader likely to take? 1. encourage staff leadership by generating commitment to the development of a new policy 2. institute a policy based solely on the nurse leader's preference and experience 3. delay developing a policy until the administrator makes the policy a mandatory requirement 4. schedule a meeting w/the entire team to gain their input on developing a new policy

4 A democratic nurse leader shares leadership and makes important decisions w/the team

Which assessment by the nurse indicates that a client's NG tube may be malpositioned? 1. the NG tube aspirate is cloudy and green 2. the pH of the NG tube aspirate is 3 3. air injected through tube is auscultated over the epigastrium 4. the external length of the NG tube has increased

4 Increased length of the NG tube may indicate outward migration, and the NG tube tip may be malpositioned in the esophagus instead of the stomach

The nurse provides care for infants in the pediatric clinic. When teaching parents about developmental milestones, in which order does the nurse present the information?

First: the infant loses the doll's eye reflex at 2-3 months of age and can follow a moving object briefly At about 4 months of age, the infant begins drooling as the gums swell and teeth erupt The infant responds to name by 6-8 months of age The infant will take deliberate steps when held up or after pulling self up to a standing position at 9-10 months of age Last: an infant will pick up bite-size pieces of cereal at 11 months and deliberately put them in the mouth

The nurse schedules a client for a myelogram. Which teaching will the nurse provide to prepare the client for this test? *select all that apply* 1. a trained radiology technician will perform the procedure 2. jewelry and metal objects will need to be removed 3. an informed consent form will need to be signed 4. food and fluids will be restricted for 4-8 hours before the procedure 5. the procedure will take about 45 minutes

2, 3, 4, 5 Jewelry and metal objects from the chest area need to be removed An informed consent is required because the procedure is invasive Preparation for a myelogram includes restricting food and fluids for 4-8 hours before the procedure The procedure takes about 45 minutes to complete

The nurse provides discharge teaching to a client dx w/a stage 2 pressure injury. The nurse instructs the client to perform prescribed wound care twice daily by cleansing the wound w/wound cleanser, covering the wound w/an abdominal pad, and securing the dressing w/paper tape. The client is to follow up w/the HCP in three days. Which nursing action is *most* appropriate to ensure the client can perform the needed wound care? 1. ask the client, "do you understand the wound care instructions?" 2. tell the client to keep the current dressing in place until the follow-up appointment 3. contact the case manager to ensure the client can obtain needed wound care supplies 4. request the client stay as an inpt in the hospital unitl until the follow-up appointment

3

An LPN/LVN works under the supervision of a nurse in the medical unit. Which client should the nurse delegate to the LPN/LVN? 1. a client w/acute flank pain r/t a dx of acute pyelonephritis 2. a client experiencing urinary incontinence who needs bladder retraining prior to discharge 3. a client dx w/cystitis who is currently on scheduled oral antibiotic therapy 4. a client w/a new prescription for lithotripsy following a dx of renal calculi

3 Administering oral antibiotics for a stable client is w/in the scope of practice of an LPN/LVN

The nurse receives report from the previous shift. Which client does the nurse see *first*? 1. a client w/MI whose monitoring shows four to six premature ventricular beats per hour 2. a client w/dementia who is confused, agitated, and incontinent of urine and feces 3. a client w/pneumonia who is increasingly confused and has a temperature of 104 F 4. a client w/diabetes who is restless during the night and whose fasting blood glucose is 170

3 An elevated temperature indicates pneumonia is worse, but by itself is not concerning Confusion can indicate hypoxia Fever increases metabolic and O2 demand, and combined w/increasing confusion indicates this client's condition may worsen quickly

A client dx w/active TB is placed in a negative pressure room. The client is scheduled for a CT scan of the chest in the radiology department. Which action does the nurse take? 1. inform the HCP that the client cannot leave the negative pressure room 2. place an N95 mask on the client and begin transportation to the radiology department 3. request that the CT scan prescription be switched to a portable chest radiograph 4. place a surgical mask on the client and alert the radiology technician of the client's dx

4 If a client dx w/active TB requires transport for medically-essential procedures, the client must wear a surgical mask during transport to cover the mouth and nose The radiology technician should be notified of the client's dx so appropriate PPE can be donned prior to the client's arrival

The nurse provides care to a client who is prescribed an IV infusion of LR solution for tx of dehydration. The client appears restless and reports difficulty breathing. Auscultation of the client's lungs reveals bibasilar crackles. Which intervention does the nurse perform *first*? 1. notify the HCP 2. lower the head of the client's bed 3. administer furosemide as prescribed 4. discontinue the client's infusion

4 Manifestations of fluid volume overload include restlessness, dyspnea, and development of crackles (rales) in the lung bases Priority interventions for the client who demonstrates s/s of fluid overload include discontinuing the infusion of IV fluids

The nurse provides care for a 2 week old neonate during a wellness visit. Which instruction does the nurse provide to the parents in relation to the neonate's sleep? 1. establish a bedtime routine by age 4 weeks 2. place the newborn on a soft mattress to promote comfort 3. use bumper pads in the crib to protect the newborn during movement 4. do not rock the newborn to sleep

4 Parents should be encouraged to place the newborn in the crib to fall asleep instead of rocking the baby to sleep

The nurse provides care to a client who reports pain at an IV site. The nurse notes tenderness and redness at the insertion site and redness proximally along the vein. Which intervention does the nurse implement? 1. slow the infusion rate and monitor the client's response 2. discontinue the infusion and notify the HCP 3. remove the IV and apply a pressure dressing to the site 4. remove the IV and apply a warm, moist compress

4 S/S of phlebitis include pain and tenderness at the IV insertion site and redness along the affected vein Management of phlebitis includes removal of the IV catheter and application of a warm, moist compress to the affected area

The nurse plans care for a client dx w/dementia. Which nursing intervention is the *priority*? 1. encourage the family to perform ADLs for the client 2. provide a flexible schedule for the client 3. limit reminiscing by the client 4. assume a face-to-face position when speaking to the client

4 By speaking face-to-face, the nurse maximizes verbal and nonverbal cues The nurse should use short, simple words and phrases, and speak slowly to give the client time to process information

The nurse manager reviews the unit's emergency response plan for a fire w/the staff. Which statement by a staff member indicates a need for further education? *select all that apply* 1. keep the doors to the unit open at all times so staff, clients, and visitors can evacuate more easily 2. clients in immediate danger should be evacuated first 3. the nurse should extinguish the fire and then activate the fire alarms 4. the nurse should aim the fire extinguisher at the top of the fire 5. critically ill clients should have the doors to their rooms closed until ambulatory clients have been evacuated

1, 3, 4 Doors to the unit should be closed; closing doors and windows helps contain the fire and prevent the spread to other areas of the hospital The fire alarm should be activated first to alert others of the fire threat A fire extinguisher is most effective when pointed at the base of the fire

A nurse teaches a client who is being discharged home. The client has a T-tube after an open cholecystectomy. Which statement made by the client requires clarification by the nurse? 1. the T-tube allows the bile to flow into my intestnes 2. I will measure and record the amount of drainage twice a day 3. I will be careful to protect the skin around the T-tube site 4. my T-tube should drain about 3 cups of bile per day

4 The expected daily output from T-tubes is approximately 400 mL, or a little more than 1.5 cups More than 3 cups, or 800 mL, per day is too much and requires the attention of the HCP The client needs to have this information reviewed

The client is dx w/HF. The nurse receives a new prescription to administer IV chlorothiazide. The nurse questions this prescription based on which lab value? *select all that apply* 1. serum sodium = 128 2. serum calcium = 12 3. serum potassium = 5.3 4. serum pH = 7.48 5. BUN = 15 6. urine specific gravity = 1.022

1, 2, 4 Thiazide diuretics are prone to produce hyponatremia because they increase sodium excretion w/o affecting the kidney's ability to concentrate urine; this client's sodium is decreased; the nurse questions this prescription Thiazide diuretics decrease excretion of calcium; this client's calcium level is elevated Thiazide and loop diuretics produce metabolic alkalosis because of urinary loss of hydrogen

The nurse prepares to insert an indwelling urinary catheter into a male client. Which actions will the nurse implement? *select all that apply* 1. select an 18 French size catheter 2. retract and maintain retraction of foreskin 3. hold penis perpendicular to body 4. use sterile technique on insertion 5. insert catheter 2-3 inches into urethra

1, 3, 4 The general size of an indwelling catheter for men is between 16-18 French Holding the penis perpendicular to the body straightens the urethra for easier insertion Sterile technique should be used to prevent an infection

The nurse provides care for a client who reports flank pain. The HCP wrties a client prescription that states, "CT scan to r/o CVA." Which action does the nurse take *first*? 1. assess if the client has metal implants 2. determine if the client has peripheral IV access 3. ask if the client has an allergy to contrast media 4. contact the provider for clarification

4 The nurse should question the HCP about the prescription Flank pain does not support a CT scan to r/o CVA The prescription will likely need to be rewritten

The clinic nurse has taught parents about safe sleep for their young infants. Which statement by a parent indicates teaching is successful? *select all that apply* 1. our baby sleeps most comfortably on his tummy 2. our baby's thick, soft comforter will help him sleep 3. we will place our baby on his back for naps and at bedtime 4. our baby's bassinette will stay in our bedroom for a few more months 5. we will add rice cereal to the bedtime bottle to help him sleep

3, 4 Infant supine sleeping is associated w/a decreased risk of SIDS The safest place for infants to sleep is in their own bed

A client comes to the clinic reporting muscle weakness, breathlessness, and bone pain. The nurse notes that the client takes phenytoin 100 mg three times a day. When providing nutritional counseling, which food grouping *best* meets this client's needs? 1. bananas, mushrooms, yams 2. oranges, broccoli, papayas 3. milk, cantaloupe, kale 4. soybeans, spinach, pumpkin seeds

3 Anticonvulsants can cause folate and vitamin D deficiencies The client has symptoms reflective of anemia and bone resorption Folate deficiency can cause anemia Good sources of folate are green leafy vegetables, legumes, tomatoes, and various fruits such as oranges and cantaloupe Good sources of vitamin D include fortified milk Because vitamin D promotes calcium absorption, foods rich in this vitamin (kale) are also recommended

The nurse assesses a newborn and notes a sac-like lesion bulging from a newborn's lower back. The HCP is notified, diagnostic tests are prescribed, and the newborn is dx w/myelomeningocele. Which action does the nurse take *first*? 1. position the neonate in the supine position 2. prepare the neonate for immediate surgery 3. cover the neonate's lesion w/a moist sterile dressing 4. test the neonate's Moro reflex

3 Covering the lesion w/a moist sterile dressing is the nurse's priority Meticulous care is taken to prevent sac rupture, because any opening greatly increases the risk of infection to the CNS The neonate is usually placed in an incubator or radiant warmer so the temperature can be maintained w/o clothing and blankets to prevent irritation of the lesion

An older adult client dx w/DM is at risk for amputation. Which outcome does the nurse establish for this client? 1. maintain a normal cholesterol blood level 2. wear a protective helmet when riding a bike 3. maintain optimal blood glucose control 4. use e-cigarettes instead of regular cigarettes

3 Peripheral vascular disease (PVD) secondary to DM among older adults is the most common cause of amputation Maintaining glycemic control is essential in preventing amputation

The nurse in the ED conducts the initial assessment of a school-age client reporting severe upper arm pain. When the nurse asks the client how the injury occurred, the client looks at the parent and the parent states that the child fell off the couch. Which action should the nurse take *first* when the x-ray result reveals a spiral fracture of the humerus? 1. document the inconsistency between the injury and the hx provided by the parent 2. explain to the parent that the injury does not match the hx 3. communicate the details of the situation to the nurse's immediate supervisor 4. tell the parent to allow the client to answer the nurse's questions

3 Reporting of suspected child abuse is mandatory in North America Using the vertical chain of command, the nurse should notify the nurse's immediate supervisor, who will contact local authorities for further assessment of the situation

The nurse supervises a novice nurse providing care to a client w/new symptoms of a CVA. Which actions by the novice nurse cause the seasoned nurse to intervene? *select all that apply* 1. administers to the client aspirin 325 mg by mouth 2. prepares the client for a CT scan 3. assigns the client a 0 score on the National Institute of Health stroke scale screen 4. measures the client's BP 5. compiles a list of the client's home medications 6. reassures the client that all symptoms will resolve

1, 3, 6 The client should have a CT scan first to determine whether the symptoms of the CVA are caused by ischemic changes or a cerebral hemorrhage; if the symptoms are caused by a hemorrhage, aspirin is contraindicated; fibrinolytic therapy, and not aspirin therapy, should be considered if the stroke is not hemorrhagic in origin If the client is demonstrating symptoms of a CVA, the National Institute of Health stroke scale screen cannot be 0 The nurse cannot guarantee that all of the symptoms of the CVA will completely resolve

The nurse provides dietary teaching to a client w/advanced stage liver cirrhosis. Which client statements require intervention by the nurse? *select all that apply* 1. I will increase the number of calories in my diet 2. I will increase the amount of fat in my diet 3. I will increase the amount of sodium in my diet 4. I will increase the number of B complex vitamins in my diet 5. I will increase the amount of fluids in my diet

2, 3, 5 A client w/liver cirrhosis should decrease the amount of fat, and increase the amount of carbohydrates, in the diet; decrease the amount of sodium in the diet to prevent or manage ascites; should decrease the amount of fluids in the diet to help prevent or manage ascites

The nurse receives report on a group of clients at the beginning of the shift. Which client does the nurse assess *first*? 1. a client drinking contrast for an abdominal CT scan who reports nausea and abdominal pain 2. a client w/a RR of 24 breaths per minute and on O2 saturation of 93% on RA 3. a client reporting frequent small amounts of watery diarrhea w/abdominal cramping and nausea 4. a client whose family member threatened to sue the hospital if the nurse does not talk w/the family immediately

3 Frequent and small amounts of diarrhea may indicate a possible bowel obstruction that can be life-threatening if the bowel perforates The nurse needs to assess this client so interventions can be implemented quickly

The nurse provides care for a client dx w/a right distal ulna and right distal radius fracture resulting from a skateboarding accident. A cast has been applied. Which assessment finding takes *priority*? 1. the fingers of the right hand are minimally edematous 2. while sitting, the casted arm is supported by the client's lap 3. the client states pain and pressure seem to be increasing 4. the client notes pain while freely moving all fingers on the right hand

3 Increasing pressure and pain may be indicative of compartment syndrome and can be a medical emergency

The nurse interacts w/a client who has just accepted a job in an office located on the 36th floor of a building. The client reports experiencing severe anxiety in elevators and enclosed spaces. Which interventions is *most* important for the nurse to recommend? 1. psychopharmacological intervention 2. group therapy 3. systematic desensitization 4. biofeedback

3 Systematic desensitization is a form of behavior modification It is used in conjunction w/deep muscle relaxation designed to decrease the extreme response to anxiety-producing situations This technique is most effective for clients w/phobic disorders

The nurse provides care to a hospitalized client who has just begun receiving low-dose radiation (LDR) via seed implants for tx of prostate cancer. To ensure safety of the client's visitors and health care team members, the nurse implements which intervention? 1. limiting visitors to spending no more than 60 minutes per visit w/the client 2. requiring pregnant staff members to wear a lead apron when providing client care 3. planning the client's care to minimize staff members' exposure to radiation 4. ensuring visitors remain at least 2 feet from the radiation source

3 To minimize the health care team's exposure to radiation, client care should be planned to allow the least amount of exposure to the client

The nurse provides care for a postoperative client reporting pain. The nurse removes an opioid medication from the electronic medication dispensing system. Prior to administering the medication, the nurse notices that another nurse medicated the client w/the same medication 5 minutes earlier. Which action is appropriate for the nurse to take? *select all that apply* 1. return the medication to the electronic medication dispensing system 2. document the near miss medication error in the client's record 3. notify the nursing supervisor 4. notify the client of the near miss medication error 5. notify the HCP 6. measure the client's VS

1 The unused medication in the original packaging should be returned to the electronic medication dispensing system; if the medication was removed from the original packaging (an IV dose was drawn up), two nurses must witness the discarding and the wasting being recorded in the system

Which information is essential to report when communicating client information at the change of shift? *select all that apply* 1. the client is newly dx w/T1DM and needs follow-up teaching about insulin administration 2. the client is seemingly more confused and has been attempting to get out of bed w/o assistance 3. the attending HCP prescribed lorazepam PRN for restlessness 4. the client has a 20 year hx of smoking 5. the client receives carvedilol, benztropine mesylate, and losartan on a daily basis

1, 2, 3 Client teaching needs r/t discharge are important in the continuum of care, and should be communicated during the change of shift report A behavior change and/or new symptom is essential to report during the change of shift All HCP prescriptions that are new are essential to communicate during the change of shift report

An older adult client dx w/glaucoma is being discharged to home. Which statement, if made by a family member, indicates additional teaching is needed regarding home safety? *select all that apply* 1. I recognize that my mom won't be able to drive 2. I removed throw rugs from hallways 3. I changed the kitchen lights to lower wattage bulbs 4. I requested that labels on my mom's eye drops be in large print 5. I marked steps w/yellow strips of tape

3 Due to reduced visual acuity, high wattage bulbs are recommended for increased brightness This statement indicates that additional teaching is needed

The nurse provides care for a client dx w/ peripheral artery disease (PAD). The client reports leg pain occurs frequently when walking. Which action does the nurse advise the client to take? 1. lie down w/feet elevated above the heart when experiencing pain 2. apply a heating pad to the legs for 15 minutes before walking 3. walk until client experiences pain, rest, and then resume walking 4. perform stretching exercises 20 minutes before starting to walk

3 Exercise increases collateral circulation and should be encouraged Stopping and resting will usually relieve the pain, and then the client can continue to walk

An older adult client tells the nurse, "I do not want to be resuscitated if my heart stops." The client's family interjects and tells the nurse to ignore the client's request and do everything possible to keep the client alive. The client is awake but drowsy and oriented. Which action by the nurse is appropriate when responding to this situation? *select all that apply* 1. assure the client they will get better soon 2. suggest the client think about things overnight and make a final decision in the morning 3. prepare a DNR form for the client and HCP to sign 4. acknowledge the family, but inform them it is the right of the client to make this decision 5. refuse the client's wishes due to their drowsiness

3, 4 It is appropriate for the nurse to prepare a DNR form for the client and HCP to sign; this action by the nurse recognizes and shows respect for the client's right to make this decision It is appropriate for the nurse to acknowledge the family's concern and inform them it is the client's right to make this decision; this action by the nurse recognizes and shows respect for the client's rights to make this decision as well as the family's concern and fear of loss

The nurse prepares a transdermal fentanyl patch for a client w/cancer pain. Which action does the nurse take when applying the patch on the client? *select all that apply* 1. avoid a skin area that has abrasions 2. select an area of the skin that has no hair 3. apply gloves before preparing the medication 4. cleanse the skin of the previously applied patch 5. discard the previously removed patch in the sharps container 6. remove the previous patch and fold it w/the medication side in

1, 2, 3, 4, 6 The patch should not be applied to areas w/cuts, burns, or abrasions since the medication may irritate these areas The site to apply a transdermal patch should be clean, dry, and free of hair Gloves should be applied before preparing the medication to prevent accidental exposure to the medication through the skin The site of the previous patch should be cleansed to remove any traces of the medication The previous patch should be removed and folded w/the medication side in to prevent accidental exposure to residual medication on the patch

The risk management nurse conducts an audit of a client's medical record and determines a potential for a medication error based on which transcribed prescription? *select all that apply* 1. MS 4 mg IVP q 6 hours PRN 2. irrigate coccyx wound w/Dakin solution HS 3. hydromorphone 0.5 mg IVP x 1 4. hydralazine hydrochloride 20 mg IVP PRN SBP > 180 5. metformin 500 mg PO qd

1, 2, 5 Because MS may be interpreted as morphine sulfate or magnesium sulfate, the words must be spelled out; this prescription is also incomplete in that it does not include PRN parameters such as "PRN severe pain of >7/10" The intended prescription for this wound is to use Dakin solution, half-strength; "HS" is no longer an approved abbreviation for "half-strength" or "bedtime"; the words must be written out QD is not approved abbreviation; it should be written as "daily"

A nurse interviews a South Asian client. The nurse observes that the client and the young child w/the client are wearing long skirts and cloth coverings over their heads, even though it is very warm. The client speaks in short responses and in a soft tone of voice. Which conclusion does the nurse draw? 1. the client requires further assessment for abuse 2. the client exhibits expected practices from the client's religion 3. the client needs help w/cultural adaptation 4. the client exhibits expected cultural characteristics from the client's background

4 Clients from a South Asian culture (India, Pakistan, Bangladesh, Nepal, Sri Lanka, Fiji, and East Africa) usually speak in a soft tone of voice, as speaking in a more direct and louder manner may be perceived as disrespectful Their traditional clothing often consists of long pieces of clothing, w/or w/o a head cover Such attire and speaking in a soft tone are part of the shared practices of people from that area Sharing common beliefs and practices is one of the characteristics of culture

The ED triage nurse has a limited number of open beds. Which client does the nurse place in an emergency bed? *select all that apply* 1. 17 year old client who intentionally ingested 15 acetaminophen tablets prior to arrival 2. 24 year old client who reports dental pain, rating pain 10/10 on pain scale 3. 63 year old client who reports a severe, localized HA w/no hx of HAs 4. 77 year old client who has had generalized weakness for the past day 5. 88 year old client who has a rash, and whose spouse is being treated w/permethrin cream 6.92 year old client who is requesting suture removal, w/dehiscence noted at site

1, 3, 4 This client requires activated charcoal and possible administration of acetylcysteine; the nurse places this client in an emergency bed This client requires a head CT to r/o hemorrhage This client requires assessment and diagnostic work-up to exclude MI, electrolyte imbalance, and stroke

The nurse manager reviews the medical records for clients receiving care on the unit. Which documentation entries require the completion of an incident report? *select all that apply* 1. client fell at 0900 while getting out of bed. client denied pain. no injuries noted 2. client reports 8/10 pain after receiving pain medication. HCP notified 3. levofloxacin 500 mg PO prescribed. levofloxacin 750 mg PO administered 4. vesicant medication infusing. client's IV site warm to touch, reddened, and swollen 5. client left facility before signing a leaving against medical advice form

1, 3, 4, 5 Falls, regardless of injury, require an incident report Medication errors, all medical/legal occurrences require incident reporting IV infiltration requires incident reporting; vesicant medications can severely damage the client's tissues

The evening shift nurse reviews the client care activities performed by the LPN/LVN during the day shift. Which activities draw the nurse's concern when performed by the LPN/LVN? *select all that apply* 1. administered oral broad-spectrum antibiotics to a client dx w/lower UTI 2. obtained a medical hx on a new admission 3. provided care to a client dx w/partial-thickness and full-thickness burns 4. modified a client's plan of care 5. provided care to a client dx w/plumbism 6. titrated an IV infusion under the direction of a pharmacist

3, 4, 5, 6 The nurse should care for this client, as this client is at a high risk for electrolyte imbalances and will require IV pain medications Only the nurse should develop and modify a client's plan of care; the LPN/LVN should contribute information to the client's plan of care A client dx w/plumbism (lead toxicity) requires close observation by the nurse, who should monitor for increased ICP; lead can also block formation of hemoglobin and become toxic to the kidney tubules IV therapy is not initiated, managed, or delivered by LPN/LVNs; this activity is appropriate for the nurse

The nurse provides care for a client who had a subtotal thyroidectomy 12 hours ago. Which finding does the nurse report to the HCP? 1. the client reports numbness around the mouth and fingertips 2. the client has a hoarse voice when speaking to the nurse 3. the client reports incisional pain as a 7 on a scale of 0-10 4. the client has a pulse oximetry reading of 96% on RA

1 Hypocalcemia and tetany may occur if the parathyroid glands are removed, damaged, or if their blood supply is impaired during thyroid surgery These occurrences can result in decreased parathyroid hormone levels Ask the client hourly about tingling around the mouth or the toes and fingers Assess for muscle twitching as a sign of calcium deficiency Calcium gluconate or calcium chloride for IV use must be available for administration in an emergency situation

The nurse overhears the UAP discuss a client who is hospitalized under an alias after being injured while committing a crime. Which statement will the nurse make to the UAP? *select all that apply* 1. as long as we don't talk to anyone else, it's fine to gossip among ourselves 2. we treat all of our clients the same, regardless of what they may have done 3. we can discuss the client's situation only w/others involved in the care 4. I will tell you what crime was committed after I ask the client 5. the discussion violates the client's confidentiality. please stop the conversation immediately

2, 3, 5 Ethical client care means that all clients are treated the same, regardless of the illness or circumstances; this supports the client's right to ethical care The UAP should only discuss the client's care needs w/those who are involved w/the care The HIPAA includes information about client confidentiality; the UAP talking about the client violates HIPAA and should be stopped immediately