qreview #2

The nurse is caring for a client with myasthenia gravis. What is essential for the nurse to teach this client regarding treatment? 1. Frequent low-calorie snacks. 2. Strict monitoring of intake and output. 3. Use of sweeping gaze when walking. 4. Setting the alarm clock for medication times.

4. Setting the alarm clock for medication times. (I chose 3) 4. Correct: Yes! Medication must be taken on time. Too early can cause weakness and too late can cause extreme weakness to point of paralysis. 3. Incorrect: No, this is done when the client has homonymous hemianopsia.

A new mother brings her infant to the clinic for a well-baby checkup. While at the clinic, the mother asks the nurse if there are any reasons why her infant should not have the measles, mumps, rubella (MMR) vaccine. The nurse's response is based on evidence that the MMR vaccine is contraindicated under which condition? 1. A known allergy to gelatin. 2. A family history of autism. 3. In infants with diarrhea. 4. A known allergy to sulfonamides.

1. A known allergy to gelatin. (I chose 4) 1. Correct: The MMR vaccine is grown using chicken embryos and manufactured with the use of gelatin. Known allergies to gelatin would be a contraindication for administration. 4. Incorrect: Sulfonamides are not used in the development of the MMR vaccine. Neomycin is used in the development of the MMR vaccine. Neomycin is the only antibiotic allergy that would contraindicate the administration of the MMR vaccine.

A nurse is planning to provide an education class on preconception health care to a group of young women wishing to become pregnant. What points should the nurse include in this class? SATA 1. Attain a healthy weight. 2. Make sure immunizations are up to date. 3. Avoid drinking alcohol. 4. Learn family health history. 5. Maintain folic acid intake at 200 micrograms/day.

1. Attain a healthy weight. 2. Make sure immunizations are up to date. 3. Avoid drinking alcohol. 4. Learn family health history. ( i chose 235) 1., 2., 3., & 4. Correct: All of these actions are needed to promote the birth of a healthy baby. A preconception care visit or class can help women take steps for a safe and healthy pregnancy before they get pregnant. 5. Incorrect: Folic acid intake should be 400 micrograms per day in order to reduce neural tube defects by 70%.

A nurse has just inserted an indwelling urinary catheter in a client scheduled for surgery. What should the nurse document? SATA 1. Perineal skin assessment 2. Client teaching 3. Color of urine 4. Date and time of insertion 5. Type catheter inserted 6. Infusing rate of IV fluid

1. Perineal skin assessment 2. Client teaching 3. Color of urine 4. Date and time of insertion 5. Type catheter inserted (I chose 345) 1., 2., 3., 4., & 5. Correct: Perineal skin assessment should be assessed prior to insertion of the indwelling catheter. The following documentation is appropriate after inserting an indwelling catheter: Client teaching, color of the urine, date and time of the insertion and the type of catheter inserted.

The nurse is teaching a client regarding buspirone. The nurse recognizes that teaching has been effective when the client makes which statements? SATA 1. "I should start feeling better in two or three days." 2. "I should not drink alcohol while taking this medication." 3. "I will rise slowly from lying to sitting or standing." 4. "I will notify my primary healthcare provider of any unusal facial movements." 5. "I need to keep the medication in a closed container in the refrigerator."

2. "I should not drink alcohol while taking this medication." 3. "I will rise slowly from lying to sitting or standing." 4. "I will notify my primary healthcare provider of any unusal facial movements." (I chose 23) 2., 3., & 4. Correct: These are correct statements that indicate that the client understands the teaching about this medication. Combined with alcohol use, the client may develop dizziness or drowsiness. Buspirone may cause orthostatic hypotension, so position changes are made slowly. The primary healthcare provider should be notified of any abnormal facial movements. The therapeutic effect occurs in 3-4 weeks.

The nurse is caring for a client in the emergency department. The primary healthcare provider prescribed 1000 mL of D5 ½ NS. The IV is infusing at 25 gtts/min. (Drop factor is 60 gtts/mL). What is the infusion time in hours? Round your answer to the nearest whole number.

I put 25. Correct answer is 40 hours. I thought it was asking for mL/hr

What statements by a client diagnosed with a hiatal hernia would indicate to the nurse that the discharge teaching was effective? SATA 1. "I should eat six small meals a day." 2. "Sitting up for an hour after I eat will decrease symptoms." 3. "Eating a grapefruit for breakfast will help digest the rest of my food." 4. "Ten inch blocks need to be placed under the head of my bed." 5. "I will get assistance for lifting heavy objects." 6. "I will avoid using laxatives."

1. "I should eat six small meals a day." 2. "Sitting up for an hour after I eat will decrease symptoms." 4. "Ten inch blocks need to be placed under the head of my bed." 5. "I will get assistance for lifting heavy objects." (I chose 145) 1., 2., 4., & 5. Correct: Clients with a hiatal hernia should eat small frequent meals, because large meals cause them to be symptomatic with heartburn and other symptoms. Sitting up after eating will keep the stomach down as much as possible. If they lie down, the stomach will go upward and cause regurgitation, heartburn, nausea, and fullness. Placing blocks under the bed also helps keep the stomach downward and reduces symptoms when the client sleeps. One of the major causes and aggravating actions for a hiatal hernia is straining. Therefore, the clients do not need to be lifting heavy objects.

A client arrives at the emergency department after sustaining partial and full-thickness burns over the anterior neck, chest, and right arm. Which interventions will the nurse initiate? SATA 1. Administer oxygen 2. Start two intravenous lines 3. Remove necklace 4. Elevate right arm 5. Debride wounds

1. Administer oxygen 2. Start two intravenous lines 3. Remove necklace 4. Elevate right arm (I chose 123, i unclicked 4) 1., 2., 3., & 4. Correct: Burns over the anterior neck and chest mean that the client is likely to have inhalation burns, putting him/her at high risk for impaired gas exchange. The inhalation will cause edema of the airway. It goes back to Maslow's Hierarchy of Needs. Administer oxygen and start two IVs so that fluid resuscitation can begin. Metal continues to burn and swelling will occur, so remove the necklace or any jewelry. Elevate the arm to decrease swelling.

While performing a vaginal examination on a client in labor, the nurse feels soft, squishy tissue instead of a head. What conclusion should the nurse make based on this assessment finding? 1. Breech presentation 2. Edema of cervix 3. Closed cervix 4. Bulging membranes

1. Breech presentation (I chose 4) 1. Correct: The nurse is palpating the buttocks of the fetus. The buttocks would be assessed as soft, squishy tissue. This is evidence of a breech presentation. 4. Incorrect: Bulging membranes will be taunt, not soft and squishy.

The occupational health nurse is leading a group discussion about addiction. What should the nurse include as the primary barrier to the client with alcohol addiction seeking treatment? 1. Co-dependency 2. Denial 3. Depression 4. Stigma

2. Denial (I chose 3, i changed my answer) 2. Correct: They reject that they have a drinking problem and will argue with you if you suggest it. The client with an addiction may also use denial to lessen the impact of their addiction. 3. Incorrect: No depression associated with substance abuse. The primary reason a person does not seek treatment is denial of their addiction.

Which client must the nurse assign to a private room? 1. Primiparous client who delivered twins at 28 weeks gestation two days ago 2. Postpartum client on IV Ampicillin and Gentamicin for chorioamnionitis 3. Postpartum client whose 2 hour old infant is being worked up for sepsis 4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C)

4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C) (I chose 2) 4. Correct: A temperature of 100.5° F (38.05° C) or greater in a client more than 24 hours postpartum is likely an indication of infection. This client should be kept separate from other mothers and babies. 2. Incorrect: Chorioamnionitis is not contagious.

Which actions by the nurse, working in the recovery room, should be performed to prevent injury from a needle stick? SATA 1. Recap the needle after use to prevent injury. 2. Reinsert the sylet if it becomes loose in the vascular assess device. 3. After drawing up saline to flush an intravenous (IV) line, place the syringe in a pocket to prevent possible injury. 4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible.

4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible. (I chose 245. i was not sure about 2, but chose it anyways) 4. & 5. Correct: Puncture resistant biohazard containers should be replaced when three-quarters full to prevent hand injury when disposing of sharps. Use of "needleless" devices reduces the risk of needle stick injuries. 2. Incorrect: Reinserting the stylet may cause injury to the nurse and client.

What should the nurse teach a pregnant client who comes to the clinic reporting hemorrhoids and constipation? SATA 1. Increased rectal pressure from the gravid uterus may result in hemorrhoids. 2. Hormones decrease maternal GI motility, resulting in constipation. 3. The client needs more fiber in the diet. 4. A mild laxative is recommended to alleviate constipation. 5. The client needs to increase fluid intake.

1. Increased rectal pressure from the gravid uterus may result in hemorrhoids. 2. Hormones decrease maternal GI motility, resulting in constipation. 3. The client needs more fiber in the diet. 5. The client needs to increase fluid intake. (I chose 235) 1., 2., 3. & 5. Correct: As pregnancy progresses, the enlarging uterus increases abdominal and rectal pressure. GI motility slows due to hormonal influences. Pregnant clients may benefit significantly from dietary changes including adequate hydration and increased fiber intake.

The nurse is caring for a client in an outpatient clinic. The client is being treated with warfarin for prevention of a stroke due to atrial fibrillation. The international normalized ratio (INR) was noted to be 4.6. What should the nurse do? SATA 1. Inform the primary healthcare provider immediately. 2. Instruct the client to continue medication as ordered. 3. Inform the client to watch for signs of bleeding. 4. Inform the client to return to the clinic per routine monitoring schedule. 5. Take no action as this value is within target range.

1. Inform the primary healthcare provider immediately. 3. Inform the client to watch for signs of bleeding. (I chose 134) 1. & 3. Correct: The primary healthcare provider should be notified. The value of 4 is above the usual target range of 2-3. The client has a potential for decreased clotting and bleeding. The client should be told to watch for signs of bleeding. 4. Incorrect: The client should not leave the clinic until the primary healthcare provider has been notified. Further action is indicated and may include changing the usual warfarin dosage.

The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider? 1. "When I was 8 years old I had chickenpox." 2. "I had rheumatic fever when I was 10 years old." 3. "There is a strong history of gastric cancer in my family." 4. "I have pain in my hip with any movement."

2. "I had rheumatic fever when I was 10 years old." (I chose 4) 2. Correct: After having rheumatic fever, a client would need to be pre-medicated with antibiotics prior to any surgical or dental procedure to prevent a recurrence. 4. Incorrect: Pain in the hip is likely the reason for the surgery.

A nurse is calling the primary healthcare provider about a client who is experiencing dyspnea and chest pain two days post total knee replacement. Which statements by the nurse are appropriate according to the communication tool SBAR (Situation, Background, Assessment and Recommendation)? SATA 1. "Hello Dr, I am calling about one of your clients." 2. "Jane Doe is having increasing dyspnea and is reporting chest pain." 3. "Jane Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Resp 32. She is restless." 4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism." 5. "I recommend that you see the client immediately and that we start oxygen stat. Do you agree?"

2. "Jane Doe is having increasing dyspnea and is reporting chest pain." 3. "Jane Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Resp 32. She is restless." 4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism." 5. "I recommend that you see the client immediately and that we start oxygen stat. Do you agree?" (I chose 345, left out 2) 2., 3., 4., & 5. Correct: First, the nurse should identify self, agency, and client calling about. Then deliver SBAR. The Situation, Background, Assessment and Recommendation (SBAR) technique has become the Joint Commission's stated industry best practice for standardized communication in healthcare, effortlessly structuring critical information primarily for spoken delivery. Each of these statements fulfills appropriate SBAR requirements.

The nurse is working at the triage station. Which client should the nurse triage first? 1. A client with hepatitis A who states, "My arms and legs are itching." 2. A client with a cast on the right leg who states, "My right leg is killing me and nothing I do makes it stop hurting. " 3. A client with nausea and vomiting for two days states, "I am very weak and can't eat." 4. A client with hematuria and reports left flank pain.

2. A client with a cast on the right leg who states, "My right leg is killing me and nothing I do makes it stop hurting. " (i chose 3) 2. Correct: The client who has a cast with unrelieved severe pain indicates compartment syndrome and requires immediate action. This client is at greatest risk for harm because untreated compartment syndrome can cause irreparable nerve, and muscle damage and can lead to amputation. 3. Incorrect: This client would need to be seen and evaluated for dehydration. Of the clients listed here, this is not the triage nurse's highest priority.

What should a nurse teach a client who has been diagnosed with hepatitis A? 1. Hepatitis A is spread through blood and body fluid. 2. Chronic liver disease is a common complication of hepatitis A. 3. Symptoms of hepatitis A include malaise, dark colored urine, and jaundice. 4. Treatment includes alpha-interferon and ribavirin.

3. Symptoms of hepatitis A include malaise, dark colored urine, and jaundice. (I chose 2) 3. Correct: Symptoms of hepatitis A include fever, malaise, loss of appetite, diarrhea, nausea, abdominal discomfort, dark-colored urine, and jaundice. 2. Incorrect: Hepatitis A infection does not cause chronic liver disease and is rarely fatal, but it can cause debilitating symptoms and fulminant hepatitis, which is associated with high mortality.

The primary healthcare provider suspects the client has tuberculosis (TB) and prescribes a Mantoux test. What precautions should the nurse take when administering the Mantoux test? SATA 1. Don sterile gloves. 2. Place the client on reverse isolation. 3. Wear a particulate respirator 4. Obtain a consent form. 5. Initiate airborne precautions.

3. Wear a particulate respirator 5. Initiate airborne precautions. (I chose 2345) 3. & 5. Correct: A disposable particulate respirator that fits snugly around the face is needed. The client needs to be on acid-fast bacilli (AFB) isolation precautions, not reverse isolation. Airborne precautions include a private room with negative pressure and a minimum of 6 air exchanges per hour. Ultraviolet lamps and high efficiency particulate air filters are also needed. 2. Incorrect: The client needs to be on airborne isolation precautions, not reverse isolation. Airborne precautions include a private room with negative pressure and a minimum of 6 air exchanges per hour. Ultraviolet lamps and high efficiency particulate air filters are also needed. 4. Incorrect: A consent is not necessary.

The nurse is teaching a newly diagnosed diabetic about proper foot care. Which statements by the nurse are correct? SATA 1. Cut the toenails in a rounded fashion. 2. Wash the feet with warm water and betadine. 3. Wear appropriate fitting shoes at all times. 4. View the bottom of the feet daily. 5. Protect feet from hot and cold.

3. Wear appropriate fitting shoes at all times. 4. View the bottom of the feet daily. 5. Protect feet from hot and cold. (I chose 1345) 3., 4., & 5. Correct: Shoes should be worn at all times to prevent injury. The client may step on something and not know that the foot has been injured. Inspection should be done daily, since many diabetics cannot feel if their feet have been injured. Feet may not be sensitive to hot and cold, which could cause injury. 1. Incorrect: Toe nails should be cut straight across to avoid an ingrown toenail. Additionally any skin cuts on the toes may result in infection.

A client admitted with a myocardial infarction has developed crackles in bilateral lung bases. Which prescription written by the primary healthcare provider should the nurse complete first? 1. Draw blood for arterial blood gases. 2. Place compression hose on legs. 3. Insert indwelling catheter for hourly urinary output. 4. Administer furosemide 20 mg intravenous push (IVP).

4. Administer furosemide 20 mg intravenous push (IVP). (I chose 1) 4. Correct: The client is developing pulmonary edema or heart failure and needs to be diuresed to remove excess fluid. The question stem tells you that you have prescriptions for these four options so what are you going to do first. All prescriptions are possible but furosemide will fix the problem. 1. Incorrect: You may need to draw these to evaluate the effect of the fluid on oxygenation but this option will not be priority over removing the fluid.

The nurse will be admitting a client from the operating room following a left total pneumonectomy for adenocarcinoma. Which type of chest drainage should the nurse anticipate that the client will have? 1. Bilateral chest tubes. 2. One chest tube on the operative side 3. Two chest tubes on the operative side 4. No chest drainage will be necessary.

4. No chest drainage will be necessary. (I chose 2) 4. Correct: A total pneumonectomy means the excision of the entire lung. A drainage tube is not inserted, since the fluid and air must accumulate in the thoracic space. This is to prevent mediastinal shift to the left. 2. Incorrect: The entire lung is removed. The left thoracic space should fill with fluid and air to prevent mediastinal shift. The insertion of a chest tube is not warranted.

A client diagnosed with pancreatitis becomes increasingly restless, confused and has pulled out the NG tube and IV catheter. HR-128/min, BP 96/62. Oxygen saturation = 90%. Skin is cool and clammy to touch. Prioritize the actions that the nurse should take. Obtain blood sugar level. Initiate oxygen. Insert another IV line. Insert NG tube. Repeat vital sign checks

Initiate oxygen. Insert another IV line. Obtain blood sugar level. Insert NG tube. Repeat vital sign checks (I chose the order on the front) First, initiate oxygen. The client is anxious and has tachycardia, signs of hypoxia. The BP is also low, so the client might be bleeding internally. If there is a decreased circulating blood volume then there is less hemoglobin to carry oxygen, so increasing the available oxygen will help the client until the problem is corrected. Second, get the IV started so fluid resuscitation can continue.This increased volume will improve the blood pressure. More volume, more pressure. The IV will also provide a port for needed medications. Third, check the client's blood sugar. Since the pancreas is sick, insulin production can be decreased so glucose can go up. This is next in the priority line of the available options. You have addressed air and circulation, so blood glucose would be next. Fourth, insert the NG tube so that the client can be kept empty and dry and you can prevent aspiration if the client starts vomiting. Last, recheck vital signs to assess effectiveness of your nursing actions.

The nurse is caring for a client with hyperparathyroidism. The nurse will monitor the client for which complications? SATA 1. Kidney stones 2. Diarrhea 3. Osteoporosis 4. Tetany 5. Fluid volume deficit

1. Kidney stones 3. Osteoporosis (I chose 134) 1. & 3. Correct: Yes, because too much calcium in the blood equals too much calcium in the urine and increased risk of kidney stones. Increased parathyroid hormone (PTH) is pulling the calcium from the bones, leaving them weak. 4. Incorrect: Tetany is a clinical manifestation of hypoparathyroidism.

A homebound client lives alone, has a history of poorly controlled diabetes, and has an open wound on the left heel. The home health nurse is concerned about the client's condition and the possible need for a referral. Which intervention should the nurse initiate for this client? 1. Ask the primary healthcare provider to prescribe a diabetes educator consult. 2. Increase home health visits to monitor the healing process of the open wound. 3. Suggest nursing home placement to the family until wound has healed. 4. Suggest that the client's family hire sitters to assist with hygiene care.

1. Ask the primary healthcare provider to prescribe a diabetes educator consult. (I chose 2) 1. Correct: Referrals to appropriate agencies or departments are often made by the home care nurse. Client needs must be met in the most efficient way while utilizing appropriate expertise. This client has poorly controlled diabetes resulting in a wound. A diabetes educator can help develop a plan to prevent further complications of diabetes. 2. Incorrect: The home care nurse has identified an immediate need which must be met. Increasing the number of visits may be part of the nurse educators plan but the total care of this client needs to be assessed. Healing is not the primary problem, poorly controlled diabetes is the problem.

Which tasks would be appropriate for the nurse to assign to an LPN/VN? SATA 1. Changing a colostomy bag. 2. Administer antibiotic via intravenous piggyback (IVPB). 3. Teach insulin self administration to a diabetic client. 4. Administer IV pain medication to a two day post op client. 5. Check for urinary retention. 6. Remove wound sutures.

1. Changing a colostomy bag. 2. Administer antibiotic via intravenous piggyback (IVPB). 5. Check for urinary retention. 6. Remove wound sutures. (I chose 1,5) 1., 2., 5., & 6. Correct. These tasks are within the PNs practice scope. The PN can change a colostomy bag, administer antibiotics by IVPB, monitor for urinary retention and remove wound sutures

A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions for at risk clients. What steps should the QA manager include in this evaluation? 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Poll staff to identify what fall precautions are implemented for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.

1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance. (I chose all) 1., 2., 4 & 5. Correct: The QA manager is responsible for evaluating performance improvement plans to ensure that staff are providing appropriate care. The QA manager can do chart reviews to see if staff are documenting fall precaution for a client. Direct observation of unit staff will let the QA manager know if staff are performing proper precautions while caring for clients. The first step is to identify what clients are at risk for falls and then see if the staff have identified these clients as at risk as well. Monitoring should be at unpredictable intervals, so staff do not comply just for a scheduled evaluation. 3. Incorrect: Asking the staff does not ensure that they follow through.

A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first to assure that the client's request is respected? 1. Ensure a do-not-resuscitate prescription has been provided. 2. Report client wishes during the end-of-shift report. 3. Have the client sign an advanced directive. 4. Ask the client who holds the durable power of attorney for health care decisions.

1. Ensure a do-not-resuscitate prescription has been provided. (I chose 3, changed my answer..) 1. Correct: The nurse should check the medical record for a DNR order. By law, a person who does not have a do-not-resuscitate (DNR) prescription, must be provided CPR in the event of a cardiac/respiratory arrest. This action will ensure the client's end-of-life wishes have been communicated and will honor the client's wishes. 3. Incorrect: If the client has advance directives, a copy should be placed in the medical record. However, a DNR prescription must also be in place to ensure the client is not resuscitated.

A nurse is instructing a client who had a cesarean birth 2 days ago about adverse signs that should be reported to the primary health care provider. Which signs should the nurse include? SATA 1. Fever greater than 100.4° F (38° C) for 2 or more days. 2. Change in lochia from rubra to serosa. 3. Calves with localized pain, redness, and swelling. 4. Burning with urination. 5. Feeling of apathy toward newborn. 6. Able to provide self care.

1. Fever greater than 100.4° F (38° C) for 2 or more days. 3. Calves with localized pain, redness, and swelling. 4. Burning with urination. 5. Feeling of apathy toward newborn. (I chose 134) 1., 3., 4., & 5. Correct: Fever for 2 or more days can indicate infection. Calf pain, redness, and swelling could indicate thrombophlebitis. Burning on urination could indicate urinary tract infection (UTI). Feeling of apathy about the newborn could mean postpartum depression. All should be reported to the primary healthcare provider.

The nurse is caring for a client suffering from major depression. The client spends all day in bed. Which nursing action is appropriate? 1. Frequently initiate contact with client. 2. Frequently round at regular intervals. 3. Patiently wait for the client to come out of the room. 4. Question the client about reason for not getting out of the bed.

1. Frequently initiate contact with client. ( I chose 4) 1. Correct: Be accepting of, and spend time with the client. The client may exhibit pessimism and negativism. The nurse should focus on strengths and accomplishments, and minimize failures. 4. Incorrect: Do not confront the client about lack of activity. This will not promote trust. The client may not know why. The client may also have decreased ability to comprehend the question and formulate an answer.

The nurse is teaching the client about benzodiazepines. Which comments by the client indicate adequate understanding of the drug effects/side effects? SATA 1. I should not drive my car until I see how the medication affects me. 2. I can expect my reaction time to be slowed in the beginning. 3. I may need to double the dose if I continue to be anxious. 4. I must be careful to take the medication for a limited time. 5. There is a risk for dependence on this medication.

1. I should not drive my car until I see how the medication affects me. 2. I can expect my reaction time to be slowed in the beginning. 4. I must be careful to take the medication for a limited time. 5. There is a risk for dependence on this medication. (I chose 12) 1., 2., 4. & 5. Correct: Benzodiazepines slow reaction time and may affect general alertness. The client should not operate machinery until effects of the medication are observed, and client can drive safely. Benzodiazepine medications are usually prescribed for short periods of time. Benzodiazepines are frequently abused. Clients develop tolerance and dependence on the drugs.

A nurse is preparing to conduct a presentation on barriers to therapeutic communication with clients from a culture other than the nurse's culture. Which points should the nurse include in the presentation? SATA 1. Lack of knowledge about a client's culture is a major barrier to therapeutic communication. 2. Follow cultural beliefs when caring for all clients of that particular culture. 3. Ethnocentrism facilitates therapeutic communication. 4. Do not touch the client until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and preferences.

1. Lack of knowledge about a client's culture is a major barrier to therapeutic communication. 4. Do not touch the client until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and preferences. (I chose 135) 1., 4. & 5. Correct: Nurses must understand and take into consideration the cultural differences of their clients. Some cultures do not approve of touching or shaking hands. By assessing the client's culture preference, the nurse is able to provide individualized care. 3. Incorrect: Ethnocentrism is the belief that one's own culture and traditions are better than those of another. It blocks therapeutic communication by allowing the nurse's biases and prejudices to negatively influence the nursing care of the client.

What should the nurse include in the post-op care of a client following the removal of the posterior pituitary gland? SATA 1. Monitor intake and output. 2. Restrict fluids to no more than 1500 ml/day. 3. Weigh daily. 4. Monitor urine specific gravity. 5. Assess the level of consciousness (LOC). 6. Instruct client to avoid blowing the nose forcefully.

1. Monitor intake and output. 3. Weigh daily. 4. Monitor urine specific gravity. 5. Assess the level of consciousness (LOC). 6. Instruct client to avoid blowing the nose forcefully. (I chose 1345) 1., 3., 4., 5., & 6. Correct: Removal of the pituitary gland can lead to diabetes insipidus (DI) as a result of the reduced production of antidiuretic hormone (ADH). The nurse should monitor I & O closely and watch for an increase in output which would indicate diuresis as part of DI. Daily weights are an important part of monitoring the client's fluid status. Monitoring the urine specific gravity is another good way of assessing the fluid status because, as the urinary output increases, the client's urine is becoming more dilute, which would result in a lower urine specific gravity. If the client's serum volume is decreasing from the excessive diuresis, the client can go into shock. The nurse should monitor for early signs of changes in the level of consciousness. To avoid disrupting the surgical site, the client should not blow the nose forcefully for at least one week post-op.

Which assignment would be most appropriate for the charge nurse to assign to the LPN/VN in the Labor, Delivery, Recovery and Postpartum Unit (LDRP)? SATA 1. Primipara needing assistance with breastfeeding. 2. Multipara reporting a headache and epigastric discomfort. 3. Primipara who is two days post op cesarean section. 4. Primipara who is preeclamptic in active labor. 5. Multipara post op cesarean section with a PCA pump.

1. Primipara needing assistance with breastfeeding. 3. Primipara who is two days post op cesarean section. (I chose 23) 1. & 3. Correct: These are stable clients whose care is within the scope of practice of an LPN/VN. 2. Incorrect: This client is high risk because she is exhibiting symptoms of postpartum onset preeclampsia.

An elderly client arrives in the emergency department (ED) after a fall. What assessment findings would lead the nurse to suspect that the client has a fractured right hip? SATA 1. Severe pain in the right hip and groin. 2. Inability to bear weight on the right leg. 3. Right leg slightly longer in length than the left leg. 4. External rotation of right lower leg. 5. Bruising and swelling around the right hip.

1. Severe pain in the right hip and groin. 2. Inability to bear weight on the right leg. 4. External rotation of right lower leg. 5. Bruising and swelling around the right hip. (I chose 125) 1., 2., 4., & 5. Correct: Pain in the affected hip, often severe, is one of the main signs of a hip fracture. This pain may radiate to the groin area. The pain and bone injury generally prevent the client from being able to bear weight on the affected leg. The client will often assume a position in which the leg on the injured side is held in a still and externally rotated position (the foot and knee turns outward). Discoloration and swelling can be an indication of a hip fracture in some clients.

The nurse is planning health promotion strategies for a single parent of young children who is trying to increase personal physical activity level but expresses a lack of time. Which interventions would help the client get more regular physical activity into the day? SATA 1. Suggest walking up and down steps at home several times each morning and evening. 2. Suggest parking further away from the grocery store and work. 3. Walk with the children in the evening instead of watching TV with them. 4. Suggest waking one hour earlier in the morning to go to the gym. 5. Suggest walking for 30 minutes with a buddy each afternoon before leaving work.

1. Suggest walking up and down steps at home several times each morning and evening. 2. Suggest parking further away from the grocery store and work. 3. Walk with the children in the evening instead of watching TV with them. (I chose 23) 1., 2. & 3. Correct: This plan will allow the parent to stay home without adding further time demands to the day. Parking farther away is one plan to get more steps into the day without increasing time demands drastically. Walking with the children allows the parent to spend quality time with the children as well as offers them a good example.

A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client should the charge nurse assign to the neonatal nurse? 1. Undergoing surgery for placement of a central venous catheter. 2. Diagnosed with leukemia, hospitalized for induction of high-dose chemotherapy. 3. Receiving IV heparin for left leg thrombosis. 4. Admitted with a cerebrovascular accident.

1. Undergoing surgery for placement of a central venous catheter. (I chose 3) 1. Correct: This is the most stable client to give to the nurse who was transferred from the neonatal unit. A neonatal nurse cares for central lines daily in this specialty area and can transfer this knowledge to the adult client. 3. Incorrect: This is not the best client for a neonatal nurse because thrombosis problems are not commonly seen in the nursery. Monitoring clotting factors and being aware of signs and symptoms of pulmonary emboli are essential for safe care of this client.

The nurse is administering the prescribed Mantoux tuberculin skin test to a client. The nurse does not observe the tense blister-like formation at the injection site. Which action should the nurse take? 1. Chart the injection site response as the only action. 2. Administer another Mantoux tuberculin skin test at a different site. 3. Circle the area, wait 48 to 72 hours, and assess for a reaction. 4. Call the primary healthcare provider.

2. Administer another Mantoux tuberculin skin test at a different site. (I chose 4) 2. Correct: If there is not a wheal of at least 6 mm in diameter after the solution is injected , the test should be administered again. The nurse would need to administer another Mantoux tuberculin skin test in another area about 5-6 cm from the original injection site. 4. Incorrect: There is no need to call the primary healthcare provider. The primary healthcare provider prescribed the test. The injection should be administered to create a 5-6 cm wheal.

A client has been admitted with a diagnosis of septic shock and has been successfully intubated. The nurse performs and documents a rapid assessment. Which information from the assessment requires the most immediate action by the nurse? Blood pressure 90/40 mm Hg Heart rate 112 beats/min Respiratory rate 32 breaths/min Temperature 103deg;F (39.4deg;C) axillary O2 saturation 94% Nurses notes: Heart rate irregular. Face flushed and warm. Extremities cool and mottled. Radial pulses faintly palpable. Pedal pulses non-palpable. Denies chest pain. Breath sounds audible bilaterally with adventitious sounds noted to left lung base. Grimaces with light abdominal palpation over pelvic bone. Urine amber and cloudy with red streaks. 100 mL urine output in urinary drainage system. Opens eyes and moves to command. Pupils equal, round, and react to light. 1. Lung assessment finding. 2. Blood pressure reading. 3. Elevated temperature 4. Urine description and output.

2. Blood pressure reading (I chose 1) 2. Correct: The low blood pressure indicates that systemic tissue perfusion will not be adequate. The blood pressure needs to be improved rapidly. 1. Incorrect: The oxygen sat is 94%, so the adventitious lung sounds do not need immediate intervention.

Post thyroidectomy, the nurse assesses the client for complications by performing which assessment? SATA 1. Perform blood glucose monitoring every 6 hours 2. Check for a positive Chvostek's 3. Assess swallowing reflex 4. Monitor neck dressings for change in fit and comfort 5. Administer desmopressin per nasal spray for urinary output (UOP) greater than 200 mL/hr

2. Check for a positive Chvostek's 3. Assess swallowing reflex 4. Monitor neck dressings for change in fit and comfort (I chose 2345) 2., 3., & 4. Correct: A positive Chvostek's and Trousseau's is indicative of tetany (low calcium). This can occur when one or more of the parathyroids are accidently removed when the thyroid is removed. A weak, raspy voice, swallowing difficulty, and impaired respiratory status can be caused by nerve injury. Change in fit and comfort of the dressing can indicate possible neck swelling, which can affect the airway. 5. Incorrect: The action of desmopressin is to increase the reabsorption of water in the kidney. A decrease in vasopressin, (antidiuretic hormone) is not a complication of a thyroidectomy.

An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse respond to this? 1. Encourage the family to accept nursing home placement as the best option for their loved one. 2. Listen to the family's concerns and report those to the primary healthcare provider. 3. Ask the client what she wants and tell the family to abide by the client's wishes. 4. Realize that the nurse does not need to be involved in this decision.

2. Listen to the family's concerns and report those to the primary healthcare provider. (I chose 3) 2. Correct: The nurse should listen to the concerns of the family. The Asian culture tends to be opposed to nursing home placement and see it as their duty to care for their elders in the home. The nurse should listen and serve as an advocate. 3. Incorrect: The client may not be in a position to make this decision.

A nurse is planning a health education seminar for a group of females who are age 45-54. What should the nurse recommend be done annually? SATA 1. Chest xray 2. Mammography 3. Influenza vaccine 4. Tuberculous (TB) skin test 5. Colonoscopy

2. Mammography 3. Influenza vaccine (I chose 235. i knew as soon as i hit submit that 5 was incorrect) 2. & 3. Correct: It is recommended that women age 45-54 should have a mammogram annually. Women 55 or older should have a mammogram every 2 years. The influenza vaccination is recommended annually for persons 6 months and older. 5. Incorrect: Colonoscopy is recommended for clients beginning at age 50, but not annually (every 10 years with no problems) until the age of 75. A colonoscopy should be performed more frequently if there is a change in bowel habits, obvious or occult blood in the stool or abdominal pain.

A client has been prescribed chlorpromazine for the treatment of schizophrenia. The nurse makes afternoon rounds and finds the client's temperature to be 104.7º F/40.4º C. The client has extreme muscle rigidity, and the vital signs have been fluctuating for the last four hours. What should the nurse do first? 1. Provide a tepid sponge bath. 2. Notify the primary healthcare provider immediately. 3. Administer an antipyretic immediately. 4. Administer the chlorpromazine as prescribed.

2. Notify the primary healthcare provider immediately. (I chose 3) 2. Correct: These symptoms are consistent with neuroleptic malignant syndrome (NMS), which is an adverse reaction to antipsychotic drugs. The symptoms of NMS are fever, altered mental state, muscle rigidity, and autonomic dysfunction. This is a medical emergency, and immediate action should be taken. 3. Incorrect: The high temperature should be assessed, but the extreme muscle rigidity and fluctuating vitals are a medical emergency. The client needs further immediate attention.

Which nursing tasks can the RN delegate to an unlicensed assistive personnel (UAP)? SATA 1. Tell a female client who has recurrent urinary tract infections how to wipe after urinating. 2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 3. Collects a urine specimen from an indwelling catheter tubing. 4. Document the intake and output of a client in acute renal failure. 5. Irrigate the foley catheter of a client who has had transurethral resection of the prostate (TURP). 6. Perform perineal care of a client who has urinary incontinence.

2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 4. Document the intake and output of a client in acute renal failure. 6. Perform perineal care of a client who has urinary incontinence. (i chose 2346) 2., 4., & 6. Correct: These are all tasks that can be performed by the UAP. The UAP has received training for completing these tasks. 3. Incorrect: This is out of the scope of practice for the UAP as it is requires entering a sterile system using sterile technique.

A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What statement made by the client indicates that teaching has been effective regarding safe needle disposal? 1. "I should wrap the needle in a paper towel and place in the trash." 2. "I should use a hospital issued biohazard container for all needles." 3. "I may use any hard plastic container with a screw-on cap." 4. "I should take my needles to the nearest hospital for disposal. "

3. "I may use any hard plastic container with a screw-on cap." (I chose 2, i changed my answer) 3. Correct: At home, an FDA approved sharps container is not needed, however, needles, syringes, and sharps may be disposed of in a hard plastic container. Clients should follow their community guidelines for sharps container disposal. This protects the sanitation engineers from injury by the sharps. 2. Incorrect: The hospital is not involved in sharps disposal in the home. A hard plastic container with a screw on cap is an acceptable container to dispose of needles.

A home care nurse is preparing to perform venipuncture to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What should be the nurse's first action? 1. Hug the client to provide support. 2. Take the client to the emergency department for sedation. 3. Decrease stimuli in the room. 4. Teach the client deep breathing exercises.

3. Decrease stimuli in the room. ( I chose 4) 3. Correct: The nurse should remain calm and quiet by the client. A stimulating environment may increase the client's level of anxiety. 4. Incorrect: This is good; however, you need to wait until the panic attack is over. The client must be ready to learn prior to initiating teaching. The nurse should wait until the symptoms resolve for learning to occur.

A hospice nurse is assessing a client reporting chronic pain (5/10 on the pain scale). In addition to the primary healthcare provider and the nurse, what member of the care team will assist in providing comfort therapies for this client? 1. Physical therapist 2. Nutritionist 3. Massage therapist 4. Occupational therapist

3. Massage therapist ( i chose 1) 3. Correct: The massage therapist provides alternative therapies that complement the medical pain control therapies being provided by the primary healthcare provider and the nurse. 1. Incorrect: A physical therapist is trained to improve and restore mobility. Due to the client's terminal status short term reduction of the pain is needed.

A client arrives in the emergency department with fever, nuchal rigidity, and seizures. What action should the nurse take first? 1. Administer Penicillin IVPB. 2. Obtain blood cultures from two sites. 3. Place on droplet precautions. 4. Set up for lumbar puncture.

3. Place on droplet precautions. (I chose 2) 3. Correct. When bacterial meningitis is suspected, the nurse should place the client on droplet precautions at once. Transmission can occur by the droplet/close contact route for up to 24 hours even after starting effective antibiotic therapy. The Centers for Disease Control and Prevention (CDC) recommends droplet precautions in addition to Standard Precautions for bacterial meningitis. 2. Incorrect. Lumbar puncture is done to obtain cultures for diagnosis but would be done after placing in isolation. Blood cultures are obtained from the lumbar puncture and cultures may be obtained from blood, nasopharynx, urine, or skin lesions. The client would be placed in isolation first.

A client was prescribed thioridazine hcl five days ago and presents to the emergency department with a shuffling gait, tremors of the fingers, drooling, and muscle rigidity. Which adverse reaction to this medication does the nurse suspect? 1. Akinesia 2. Neuroleptic malignant syndrome 3. Pseudoparkinsonism 4. Oculogyric crisis

3. Pseudoparkinsonism (I chose 2) 3. Correct: Pseudoparkinsonism may appear 1 to 5 days following initiation of antipsychotic medications: occurs most often in women, the elderly, and dehydrated clients. Symptoms include tremor, shuffling gait, drooling, and rigidity. 2. Incorrect: Neuroleptic malignant syndrome is a rare, but fatal complication of neuroleptic drugs. Symptoms include hyperpyrexia up to 107 degrees, tachycardia, tachypnea, fluctuations in BP, diaphoresis, coma.

Which findings would indicate to the nurse that a client with Addison's disease has received too much glucocorticoid replacement? SATA 1. Dry skin and hair 2. Hypotension 3. Rapid weight gain 4. Decreased blood glucose level 5. Increased cholesterol

3. Rapid weight gain 5. Increased cholesterol (I chose 1235) 3, & 5. Correct: Excessive drug therapy with glucocorticoids will cause rapid weight gain, round face, and fluid retention. Cholesterol and triglycerides in the blood are also increased by glucocorticoids. Long term use of high steroid doses can lead to symptoms such as thinning skin, easy bruising, changes in the shape or location of body fat (especially in your face, neck, back, and waist), increased acne or facial hair, menstrual problems, impotence, or loss of interest in sex. 1. Incorrect: Dry skin and hair would be seen with a decrease in sex hormones, not with a increase in glucocorticoids. An increase in glucocorticoids will result in an increase in oil production in the skin. 2. Incorrect: Hypotension is a sign of Addison's disease. The client loses sodium and water, causing the client's blood pressure to drop. This loss of sodium and water would come from a decrease in mineralocorticoids. This would have nothing to do with glucocorticoids.

The nurse is providing care to a client who has a large abdominal dressing. Which intervention is most likely to reduce the risk of skin irritation due to frequent dressing changes? 1. Use a paper tape for adhering the dressing. 2. Use tape sparingly. 3. Secure the dressing with Montgomery straps. 4. Change the dressing only if it becomes saturated with drainage.

3. Secure the dressing with Montgomery straps. (I chose 1) 3. Correct: Montgomery straps will allow the dressing to be held in place without the use of tape. The adhesive on the ends of the straps is the only adhesive used. 1. Incorrect: Paper tape may be less irritating; however, with repeated changes, skin irritation is more likely. Montgomery straps will decrease the repeated tape changes.

The nurse is planning daily activities for a client who has a diagnosis of schizophrenia. The client tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for this client? 1. Watching TV with two other clients in the day room. 2. Watching TV alone in a conference room. 3. Spending time in brief one on one interactions with the nurse. 4. Sitting in the day-room away from other clients.

3. Spending time in brief one on one interactions with the nurse. ( I chose 1) 3. Correct: The interaction with the nurse can keep the conversation reality based and provide interaction with someone. Clients with schizophrenia may be very withdrawn and need the presence of the nurse. 1. Incorrect: The client is very uncomfortable around the other clients. This action could be appropriate as the client's condition begins to stabilize.

A parent tells the clinic nurse, "My child has just been diagnosed with attention-deficit/hyperactivity disorder (ADHD). What will be done to help my child?" How should the nurse best respond to the parent? 1. The primary healthcare provider will want to start your child on a central nervous system (CNS) depressant in order to decrease hyperactivity and improve attention. 2. You will need to admit your child to the psychiatric behavioral unit so that group therapy can be initiated. 3. Children are often placed on central nervous system stimulants that improve behavior associated with ADHD. 4. The standard of care for children with ADHD includes central nervous system stimulants along with behavior and family therapy.

4. The standard of care for children with ADHD includes central nervous system stimulants along with behavior and family therapy. (I chose 3, i changed my answer) 4. Correct: Multimodal treatment of ADHD is the standard of care for children. There is a lot to be gained by supporting medication treatment with appropriate educational, psychosocial, and family interventions. 3. Incorrect: Central nervous system stimulants are given to children with ADHD. This is a true statement, but the standard of care also includes behavior and family therapy.