Question Bank Quizzes

1) INCORRECT - Theophylline is the drug of choice for acute asthma and is administered as an infusion or as a loading dose. 2) INCORRECT - Tetracycline is a broad spectrum antibiotic and is not contraindicated. 3) INCORRECT - Ipratropium bromide blocks parasympathetic stimulation and decreases mucus and is an important medication in COPD and asthma. 4) CORRECT— Propranolol is a beta-blocker, which means it blocks beta adrenergic impulses to the bronchial tree that cause bronchodilation, resulting in increased bronchoconstriction. If the client's airways are narrowed, the exacerbation will worsen significantly.

A client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The nurse assesses a BP of 162/100 mm Hg, P 78 beats/min, R 30 breaths/min, and labored respiratory effort with wheezing. The nurse questions which prescribed medication? 1. Theophylline 0.7 mg/kg/hr continuous IV infusion.2. Tetracycline hydrochloride 250 mg IM daily.3. Ipratropium bromide 2 inhalations four times daily.4. Propranolol hydrochloride 40 mg PO twice daily.

1) INCORRECT— Antacids are not the treatment of choice for peptic ulcer disease. 2) CORRECT — Volunteering to call the pharmacy demonstrates advocacy in order for the client to receive appropriate treatment for the health problem. 3) CORRECT — Esomeprazole acts to reduce stomach acid, which is the desired mechanism to help heal the ulcer. 4) INCORRECT— Caffeine exacerbates peptic ulcers and should be eliminated from the diet. 5) CORRECT — Nicotine increases stomach acid. Smoking cessation information is appropriate to provide to the client. 6) CORRECT — Black, tarry stools indicate gastrointestinal bleeding. The health care provider should be notified if this occurs.

A client diagnosed with peptic ulcer disease asks if an over-the-counter antacid can be taken instead of esomeprazole because of the cost. Which responses by the nurse are appropriate? (Select all that apply.) 1. "Try the antacids for a few days. If you start to feel worse, call your health care provider."2. "I will call your pharmacy and find out the cost."3. "Esomeprazole helps reduce stomach acid, and you will need to take it for several weeks to achieve healing."4. "Increase your intake of caffeinated liquids to promote healing of the ulcer."5. "Here is information about smoking cessation classes available in your area."6. "Notify your health care provider if you have stools that are black and tarry."

1) INCORRECT - Although the nurse should question the glycerin, as it can cause hyperglycemia, another drug is of more immediate concern. Glycerin is an osmotic agent. By increasing the osmolarity of the blood, it extracts fluid from the extracellular space into the bloodstream. Specifically, it pulls fluid from the aqueous humor and vitreous humor from the anterior chamber of the eye, thus decreasing intraocular pressure. 2) INCORRECT - There is no need to question this prescription. It is a direct-acting cholinergic agent that reduces the intraoccular pressure. 3) CORRECT— This medication is contraindicated. Clients with a sulfa allergy should not take acetazolamide, as an allergic reaction may occur. 4) INCORRECT - The client will require additional blood glucose monitoring, as timolol (like all beta blockers) reduces the client's sensitivity to hypoglycemia symptoms, and the client may not be aware that they are experiencing hypoglycemia. However, there is another drug that may cause immediate harm to the client and is the priority concern.

A client diagnosed with type 2 diabetes mellitus (DM) is treated for hypertension with propanolol. The history reveals that the client is diagnosed with glaucoma and is allergic to sulfa. Which prescribed medication requires an immediateintervention by the nurse? 1. Glycerin.2. Pilocarpine.3. Acetazolamide.4. Timolol maleate.

Correct Answer: 0.5 mL

A client is prescribed a subcutaneous injection of heparin 5000 units every 6 hours. The medication is in a 5 mL multiple-dose vial containing 10,000 units/mL. Which amount of medication in milliliters will the nurse provide for each dose? (Round at the end of the equation. Record your answer using one decimal place.)

ANSWER: 1 milliliter

A client is prescribed intravenous penicillin G potassium 1.2 million units per day in divided doses every 6 hours. The medication vial contains 300,000 units/mL. Which amount of the medication in mL will the nurse provide to the client for a single dose? (Record your answer rounding to the nearest whole number.)

1) INCORRECT - Bending over causes stress on the lumbar region of the back and may contribute to back pain. The client should sit down and bend the knees to put on and tie the shoes. 2) INCORRECT - Standing on the toes to reach a high object places stress on the spine. The client should use a step stool to place the box on the shelf. 3) CORRECT — This allows for lumbar flexion, decreasing pressure on lower spine. 4) INCORRECT - The client should have the feet apart to ensure a wide base of support.

A client is seen in the clinic for back pain. The nurse discusses and demonstrates how to perform activities of daily living to decrease the incidence of back pain. Which action, if performed by the client, indicates to the nurse that teaching is effective? 1. The client bends over to put on tennis shoes and tie laces. 2. The client stands up on toes to place a box on a high shelf.3. The client sits in a recliner with feet elevated to watch TV. 4. The client stands with feet close together and shifts weight.

1) INCORRECT - The client with infected pressure injuries is not considered "clean" and should not be sharing a room with a post-surgical client. 2) INCORRECT - The client with pneumonia has an infection and should not be sharing a room with a post-surgical client. 3) CORRECT - The client recovering from mandibular surgery is considered "clean" and would be appropriate to share a room with the client recovering from a rhinoplasty. 4) INCORRECT - The client with a bone infection should not be sharing a room with a post-surgical client.

A client needs continuing care after rhinoplasty surgery. Which roommate is appropriate for the nurse to place with this client? 1. Client with infected pressure injuries.2. Client with pneumonia. 3. Client with wired jaws because of a mandibular fracture. 4. Client with osteomyelitis.

1) INCORRECT - Aminophylline is a xanthine bronchodilator and can cause rapid pulse and dysrhythmias. 2) INCORRECT - Aminophylline causes nausea and vomiting. 3) CORRECT— Observe client receiving IV administration of medication closely for hypotension, arrhythmias, and convulsions until serum levels stabilize within therapeutic ranges. 4) INCORRECT - An increased urination may occur with toxicity.

A client receives aminophylline 0.7 mg/kg/hr by continuous IV infusion into the left arm. Which adverse effects are important for the nurse to assess during the infusion? 1. Decreased pulse and elevated blood pressure. 2. Constipation and decreased bowel sounds.3. Hypotension and cardiac arrhythmias. 4. Difficulty voiding and oliguria.

1) INCORRECT — This approach does not address the reason the client was nonresponsive to the nurse's greeting. 2) INCORRECT — Although this might be a good action, it does not recognize that assessment is needed because of the medication a client is receiving. 3) INCORRECT — The nurse may take the client's vital signs. However, the issue is why the client didn't hear or respond to the nurse. 4) CORRECT— Ototoxicity is a serious adverse effect of the aminoglycosides such as gentamicin. The client needs to be assessed for hearing loss.

A client receives gentamicin 500 mg every 8 hours IV for a leg infection. The nurse touches the client's shoulder when there is no response to a greeting. The client jumps and acts startled. Which action by the nurse is most important? 1. Ask what the client is thinking.2. Monitor the color and sensation in the client's leg.3. Obtain the client's temperature, pulse, and blood pressure.4. Check the client for tinnitus and hearing loss.

1) INCORRECT - There is no need to remind the staff of their role in client care. It is not necessary to admonish the staff for interpreting the client 's request. 2) INCORRECT - The nurse 's knowledge of the pain process should guide comments made to support personnel. Gossiping about clients is prohibited. The nurse should serve as a role model to other staff. 3) INCORRECT - The purpose of documentation is to communicate needs to other health care professionals. The nurse needs to talk directly to the client about the back pain before documenting. Writing down what others say a client says is hearsay. 4) CORRECT— The body does not respond to significant levels of pain in two different areas of the body at one time. Since the client has a head injury, it is likely that the chronic back pain was not acknowledged by the body or the head injury pain was so severe it overrode the amount of chronic back pain.

A client receiving treatment for a head injury requests pain medication for chronic back pain. Which response is the best for the nurse to make to personnel who question the client 's need for pain medication? 1. "Your job is to report client requests to nursing personnel. Don 't interpret what the client is saying. "2. "I am surprised as well. There was no evidence of back pain when walking to the bathroom earlier this evening. "3. "Tell me exactly what the client said. In cases like this, careful documentation is important. "4. "Anxiety and fatigue are pain distracters. When they are reduced, the back pain returns. "

1) INCORRECT - Eating a heavy meal within 2 hours of bedtime prevents sleep for most people. 2) INCORRECT - Ingesting alcohol 30 minutes before bedtime prevents sleep for most people. 3) CORRECT — Arising at a specific hour every morning promotes sleep by following a set schedule. 4) INCORRECT - Exercise before bedtime prevents sleep by stimulating the body and increasing the metabolism. 5) CORRECT — Warm milk promotes sleep because milk may encourage the release of serotonin, which has a calming effect. 6) CORRECT — A warm bath promotes sleep by helping with relaxation.

A client reports difficulty falling asleep at night. Which activities will the nurse recommend to this client? (Select all that apply.) 1. Eat a heavy meal within 2 hours of bedtime.2. Have a glass of wine 30 minutes before bedtime.3. Arise at a specific hour every morning.4. Exercise 1 hour before bedtime.5. Drink warm milk before bedtime.6. Take a warm bath before bedtime.

1) INCORRECT - The care of the client is a priority. Collecting demographic data can be done at a later time. 2) CORRECT - Bleach is an alkaline substance that can penetrate the scleral membrane and cause permanent eye damage. The alkaline should be immediately removed to limit the amount of damage to the eye. 3) INCORRECT - The client's other systems are not at risk. A comprehensive physical assessment does not need to be done. 4) INCORRECT - There is no need for the client to be placed on a stretcher and covered with a blanket. The client has an eye injury that must be addressed first.

A client seeks medical attention after having bleach splashed in the eyes. Which action will the nurse perform first? 1. Ask the unit secretary to gather demographic data.2. Irrigate the client's face and eyes. 3. Perform a comprehensive physical assessment. 4. Place the client on a stretcher and cover with a blanket.

Answer: 2000 mg/day

A client weighing 10 kg is prescribed ampicillin 200 mg/kg/day. Which amount in milligrams will the nurse administer to this client each day? (Do not round. Record your answer using a whole number.)

1) INCORRECT - Anticonvulsant medication is needed to prevent seizure activity. The client 's renal and liver function should be monitored, along with complete blood count, platelet, and reticulocyte counts. Anticonvulsant medication should never be suddenly discontinued. 2) INCORRECT - Anticonvulsant medication is needed to prevent seizure activity. Another approach is needed to prepare this client for surgery. 3) INCORRECT - The dose does not need to be increased unless seizure activity increases. 4) CORRECT— Anticonvulsant medication is needed to prevent seizure activity. The amount of anesthesia may need to be reduced because the client is taking an anticonvulsant.

A client who is scheduled for surgery takes carbamazepine 100 mg by mouth twice a day. Which action will the nurse expect the health care provider to take because of this medication? 1. Instruct to withhold the medication the morning of surgery.2. Gradually discontinue the medication 24 to 48 hours before surgery. 3. Increase the dosage of the medication before surgery. 4. Inform the anesthesiologist.

Correct Answer: 4.3 mL

A client will receive ondansetron 0.15 mg/kg IV starting 30 minutes prior to chemotherapy. The client weighs 56.8 kg. Ondansetron injectable solution is available in 2 mg per 1 mL. How many milliliters does the nurse administer? (Round at the end of the equation. Record your answer using one decimal place.)

1) CORRECT — The immobility imposed by skeletal traction combined with moist skin from diaphoresis puts this client at risk for a pressure injury. 2) INCORRECT— Skin that blanches does not indicate an ongoing problem with pressure. 3) CORRECT — A preterm neonate does not have sufficient subcutaneous fat stores and is at risk for skin breakdown. The presence of an NG tube increases the neonate's risk, due to pressure from the tube and tape on delicate skin. 4) INCORRECT— After an umbilical hernia repair, this infant should be mobile and not at risk for pressure injuries. 5) INCORRECT— Fever alone does not increase a client's risk of developing a pressure injury. 6) INCORRECT— Intermittent catheterization does not increase a client's risk of developing a pressure injury.

A group of clients are identified as at risk for pressure injury. For which client does the nurse initiate pressure injury prevention measures? (Select all that apply.) 1. A client in skeletal traction who is diaphoretic.2. A client with reddened areas that blanch on both elbows.3. A premature neonate with nasogastric feedings.4. An infant who had surgical repair of an umbilical hernia.5. A client who has a temperature of 103 °F (39.44 oC). 6. A client with urinary retention who self-catheterizes.

1) CORRECT - This addresses safety issues related to a toddler. Some plants are poisonous and/or can cause a variety of symptoms, such as irritation of oropharynx and GI tract; respiratory, kidney, and CNS symptoms; dermatitis; choking; or allergic reactions. The nurse should first address the physical safety concern and then address the parent's psychosocial stressors. 2) INCORRECT - This is a relevant assessment, as it addresses the support system and also conveys the legitimacy of needing a break. However, the nurse should address the safety issues first. 3) INCORRECT - This is a closed-ended (yes/no) question and is non-therapeutic. Furthermore, this is expected behavior for a toddler. 4) INCORRECT - This is an affirmation of the legitimacy of the parent's stressors. However, the nurse should address the safety issues first.

A parent of a toddler reports a gardening hobby to the clinic nurse and discloses the possession of many house plants. The parent states that the toddler is, "into everything all the time and drives me to distraction! " Which response by the nurse is best? 1. "What kind of plants do you have? "2. "Who is available to care for your child when you need a break? "3. "Were you like this at the same age? "4. "It must be hard balancing work and children. "

1) CORRECT - This client is unstable and is currently experiencing breathing concerns. The client is at risk of ineffective airway clearance due to particles in the air from storm debris and damage to the windows. 2) INCORRECT - The client's blood sugar is slightly elevated above normal limits. This client is stable and does not require immediate transfer. 3) INCORRECT - The client has a potential circulation concern. However, there is no indication that the client is currently unstable. There is another client who is a higher priority. 4) INCORRECT - This is the second most unstable client, as the client is experiencing a current circulatory concern and requires frequent monitoring due to the blood transfusion. However, the client with a current breathing concern will take higher priority.

A severe storm has blown out the windows on a 30-bed medical/surgical unit. The nurse determines that clients have to be evacuated to other rooms throughout the hospital. Which client does the nurse transfer first? 1. An adult client admitted with exacerbation of asthma who is receiving nebulizer treatments. 2. An adult client with type 1 diabetes mellitus and a recent blood glucose of 124 mg/dL (6.88 mmol/L). 3. An adult client transferred from cardiac intensive care earlier in the day post-myocardial infarction. 4. An adult client with a peptic ulcer who is receiving a blood transfusion.

1) INCORRECT - There is no need for the parent to discuss the need for pain medication with the health care provider. The nurse is knowledgeable and capable of responding to the parent. 2) INCORRECT - The nurse should focus on the client 's signs and symptoms and not the event that the client wants to attend. 3) CORRECT— A sudden onset of severe pain could indicate tissue injury or rupture of an organ. 4) INCORRECT - The parent is concerned about the tryouts. The nurse should focus on the safety and health of the client.

An adolescent experiences severe left lower quadrant abdominal pain 2 days after the start of a menstrual period. Which response is the best for the nurse to make when the parent asks for pain medication so the client can participate in cheerleading tryouts? 1. "You will need to discuss that with the health care provider. "2. "Your child probably should not be trying out for the cheerleading squad today. "3. "The signs and symptoms sound as if they involve more than the menstrual period. "4. "You appear very concerned about your child 's condition. "

1) INCORRECT - Leaving the unit is unsafe for the clients. A shower is not essential at this time. 2) INCORRECT - While the UAP may need to start a little early to ensure that all clients receive morning care, this is not essential. The priority is to ensure that clients receive the most important treatments and medications. 3) CORRECT - The priority is to determine treatments and medications that are vital to the well-being of the clients. 4) INCORRECT - The nurse should not make as needed medications routine. These medications are not essential.

An ice storm paralyzes a community during the night. The two nurses on a 24-bed medical/surgical unit learn that it will be 12 to 15 hours before they can expect the next shift to arrive. Which action do the nurses take first? 1. Each nurse takes a shower while the other nurse cares for all of the clients. 2. Instruct the unlicensed assistive personnel (UAP) to begin morning care at 0400. 3. Make a list of all of the clients' breathing treatments and intravenous medications for the next 12ndash15 hours. 4. Plan to administer all of the clients' as needed pain medication before they ask for it.

1) CORRECT— This is a priority, as it aids in communication after rescue or recovery. This addresses a pertinent physical need. 2) INCORRECT - The nurse should not leave the children alone. 3) INCORRECT - While this addresses a relevant psychosocial need, ensuring identification of the children takes priority over notification. 4) INCORRECT - While this addresses a relevant psychosocial need, ensuring identification of the children takes priority over comfort provision.

Due to a sudden rise in a nearby river, the nurse at a day camp evacuates the children to an area away from the river. Which action does the nurse take next? 1. Place an identification bracelet on each child.2. Go back for an adequate supply of water. 3. Notify the parents of the children's location. 4. Comfort children who are anxious.

1) INCORRECT - The priority is to determine what the client is doing now to relieve the pain. 2) CORRECT— If the client is in pain, the priority is to determine what the client is doing now to relieve the pain. 3) INCORRECT - Asking about a warm bath is a yes or no question. The nurse should use open-ended questions to assess the client. 4) INCORRECT - Asking if the health care provider is aware of the pain is a yes or no question. The nurse should focus on pain assessment and not ask if the health care provider is aware of the pain.

During a home visit, a client diagnosed with heart failure, hypertension, and osteoarthritis reports experiencing pain. Which question will the nurse ask first? 1. "What has worked to relieve your pain in the past? "2. "What have you taken today to relieve the pain? "3. "Does it help your pain to take a warm bath? "4. "Does your health care provider know you are experiencing pain? "

1) INCORRECT - An infant should not be left unattended on a raised surface. However, the situation does not state the infant is alone. 2) INCORRECT - The doors and screens should be locked, and gates placed at the top and bottom of any stairs for the safety of a toddler. This child could be at risk but is not at the highest risk. 3) CORRECT—This child is at risk putting the raisins, which are foreign objects, into the tracheostomy. This child is at the highest risk for injury. 4) INCORRECT - This is not potentially a risk for injury situation. Teach the child to lock the door. Keep a list of emergency numbers by the phone.

The home health nurse is providing care for several pediatric clients. Which client does the nurse identify as being at the greatest risk for injury? 1. An infant who is in a car seat placed on the coffee table.2. A toddler who is playing alone in the living room. 3. A preschool-age client with a tracheostomy who is eating raisins. 4. A school-age client who stays home alone for half an hour after school.

1) INCORRECT — This would be expected in acute otitis media. 2) INCORRECT — This would be expected in an upper respiratory tract infection. 3) INCORRECT — This would be expected in influenza. 4) CORRECT— Mononucleosis is an infectious disease caused by the Epstein-Barr virus. Besides extreme fatigue, other indications include malaise, fever, headache, epistaxis, and severe sore throat.

The nurse in the pediatric clinic provides care for a school-age client diagnosed with infectious mononucleosis. Which statement does the nurse expect the child to make? 1. "My left ear hurts."2. "I have a cough that won't go away."3. "My nose is runny all the time."4. "I just have no energy to do anything."

1) CORRECT — A hair cap should be worn by the surgical team members to prevent debris from hair and scalp from invading the surgical site. 2) CORRECT— A client's hair should be clipped, as shaving increases the risk of infection. 3) CORRECT — Shirts and waist drawstrings are tucked inside the pants to prevent accidental contact with sterile areas and to contain skin shedding. 4) CORRECT — Staff with upper respiratory infections, sore throat, and skin infections are sources of pathogens and should not be in the surgical area. 5) INCORRECT — A mask should fit tightly. It decreases the risk of post-operative wound infection by containing microorganisms from the oropharynx and nasopharynx. 6) CORRECT — Artificial fingernails harbor microorganisms and can cause nosocomial infections. Nails are to be short and unpolished.

The circulating nurse assesses a client's care during the peri-operative period. Which surgery staff action, observed by the nurse, requires follow-up? (Select all that apply.) 1. Surgical nurse #1 removes the hair cap.2. Surgical nurse #2 shaved the client's hair at the operative site.3. The surgical assistant's shirt is outside the pants.4. Surgical nurse #3 reports a cough.5. The surgeon's face mask fits tightly on the face.6. Surgical nurse #4 has acrylic nails.

1) INCORRECT — While oral hygiene is important, flossing the teeth may lead to bleeding. The client's platelet levels may be low due to myelosuppression. 2) CORRECT — Fresh flowers and potted plants are a medium for bacterial growth and should be avoided, as this client will be high risk for infection due to myelosuppression. 3) INCORRECT — Anemia related to myelosuppression from the high dose methotrexate may cause the client to feel cold. But an afghan from home has the potential to bring in infectious pathogens and should not be brought to the hospital. 4) CORRECT — Electric razors should be used instead of razor blades to decrease the risk of bleeding. The client may experience thrombocytopenia secondary to myelosuppression. 5) INCORRECT — Visitors with infections should not visit the client who is immunocompromised.

The client is on high-dose methotrexate for treatment of non-Hodgkin lymphoma. Which statement made by the client indicates understanding of appropriate precautions?(Select all that apply.) 1. "I should brush and floss my teeth three times a day."2. "I should tell my friends and family not to send flowers."3. "I should plan to bring in a heavy afghan from home because I will probably get cold easily." 4. "I should bring in my electric razor to shave."5. "If my visitor has a cold, they can visit as long as they wear a mask."

1) INCORRECT - Signs and symptoms of infiltration include blanching or pallor of the skin, edema, and pain and tenderness at the IV insertion site. Continued infusion of fluid will worsen the infiltration. Intervention is necessary, including removal of the IV and elevation of the affected extremity. Application of a warm, moist compress to the affected area also may be appropriate. 2) INCORRECT - Manifestations of infiltration include blanching or pallor of the skin, edema, and pain and tenderness at the IV insertion site. The IV catheter should be removed, followed by elevation of the affected extremity. Notification of the health care provider should occur if the client's signs and symptoms are severe, if they persist, or as is indicated by the facility's policy. The client's condition should be appropriately documented and monitored. 3) INCORRECT - Infiltration produces signs and symptoms that may include blanching or pallor of the skin, edema, and pain and tenderness at the IV insertion site. The IV catheter should be removed, followed by elevation of the affected extremity. Application of a warm, moist compress may be indicated. However, heating pad application is not appropriate, as heating pad will cause extreme dilation of the blood vessels and may lead to extravasation, which involves absorption of medication into the surrounding tissues. Direct application of a heating pad to the site also may cause skin and tissue damage. 4) CORRECT - Signs and symptoms of infiltration may include blanching or pallor of the skin, edema, and pain and tenderness at the IV insertion site. Management of infiltration includes removal of the IV catheter and elevation of the affected extremity. Application of a warm, moist compress to the affected area may be indicated.

The client reports pain at an IV site. The nurse observes that the IV insertion site is pale, cool to the touch, and mildly swollen. Which intervention does the nurse implement? 1. Decrease the infusion rate and monitor the client's response.2. Stop the infusion and notify the health care provider. 3. Discontinue the IV and apply a heating pad to the site. 4. Remove the IV and elevate the client's arm on a pillow.

1) INCORRECT - This is an appropriate action because the client is susceptible to illness. However, the priority is to ensure that the caregiver is performing hand hygiene, as this is the largest source of contamination. 2) INCORRECT - This is not necessary. The client should not touch litter boxes, feces, bird droppings, or water in the fish tank. The nurse should encourage the client to wash hands with soap and water after handling the family pet. 3) CORRECT - Hand hygiene is the single best way to kill germs. The caregiver should wash hands after going to the bathroom and before and after fixing food. The caregiver should also wash hands before and after caring for the client. 4) INCORRECT - This is not necessary. All dishes may be washed together.

The home care nurse visits a client diagnosed with acquired immune deficiency syndrome (AIDS). The nurse instructs the client's caregiver about how to prevent infection. Which is the most important instruction the nurse will give to the caregiver? 1. "Cover your nose and mouth when you sneeze or cough."2. "Get rid of all pets in the home."3. "Wash your hands frequently."4. "Wash the client's dishes separately."

1) CORRECT— When going up stairs, the client should lead with the strong extremity and follow with the weaker extremity and the cane. Because the client is experiencing right-sided weakness, the client should first step up with the left leg. This statement indicates that the teaching was effective. 2) INCORRECT— The client should always hold the cane in the hand that is opposite of the affected extremity. This statement indicates that additional teaching is needed. 3) INCORRECT— When going upstairs, the client should lead with the strong extremity and follow with the weaker extremity and the cane. This statement indicates that additional teaching is needed. 4) INCORRECT— The client can go up and down stairs using a cane with proper training. This statement indicates that additional teaching is needed.

The home health nurse instructs a client with right-sided weakness about how to ambulate safely up the stairs using a cane. Which client statement indicates that the teaching was effective? 1. "I should first step up with my left leg."2. "I should hold the cane in my right hand."3. "I should step up with my right leg."4. "I should not go up or down stairs using the cane."

1) CORRECT- The hot bath with oils presents a safety risk. Oils in the bath water can result in a slippery shower or bathtub surface. This is particularly concerning for the client with osteoporosis. Hot bath water can dry or damage the skin. The client with diabetes may have neuropathy, which can decrease the client's ability to perceive pain and recognize an injury. 2) INCORRECT- Increasing interest in activities and events is a positive occurrence and reflects an interest in life. If the client had a recent history of depression and was suddenly more energetic, this might suggest a risk for suicide. 3) INCORRECT- Expressing feelings of guilt may indicate that the adult child is overly focused on the caregiver role. This statement suggests the need to explore the caregiver's feelings and offer options, such as respite care. 4) INCORRECT- The nurse should further assess the child's concern about winter, but this is not of greatest concern.

The home health nurse visits an older adult client with diabetes and osteoporosis. The client lives with an adult child in a two-story home. Which statement by the child most concerns the nurse? 1. "My parent loves taking a hot bath with scented bath oil." 2. "My parent is taking more interest in daily activities." 3. "I feel guilty leaving my parent alone, even for half an hour."4. "I am not sure what we are going to do when winter comes."

1) INCORRECT - This is a true statement, but does not address the workers' concerns. The nurse should first assess and then determine a response. 2) CORRECT - This assessment helps the nurse to identify specific concerns. The nurse needs to find out more information before determining the appropriate course of action. 3) INCORRECT - The nurse should first assess prior to determining a course of action. 4) INCORRECT - This is an inappropriate assessment, as it neither responds to the workers' concerns, nor does it provide information helpful to determining a course of action.

The industrial nurse supervises the health care needs at a local plant. It is announced on the news that a device has exploded in a heavily populated area away from the plant and that individuals near the site have become ill. Several hours later, workers at the plant come to the nurse and demand antibiotics to protect them against potential effects of the device. Which is the best response by the nurse? 1. "I cannot administer medication without a prescription. "2. "Tell me about how you are feeling. "3. "The cause of the illness has not been identified. "4. "Do you have any allergies to medications? "

1) INCORRECT - The novice nurse should begin the assessment with the client in the most supportive position. 2) INCORRECT - To ensure client safety, the assessment should begin with the client lying in bed. Difficulties should be anticipated. 3) CORRECT - To ensure client safety, the assessment should begin with the client in bed. The client 's movement in bed is first assessed, and then progresses by assessing movement to sit at the side of the bed. The client 's mobility and gait can be assessed in the walk to the chair. 4) INCORRECT - Client safety is a priority. The seasoned nurse should intervene immediately and not wait for the findings from the assessment.

The novice nurse asks a client, who is lying in bed, to sit in a chair to complete a mobility assessment. Which action by the seasoned nurse is appropriate? 1. Continue the assessment.2. Report any difficulties the client may have sitting in a chair.3. Begin the assessment while the client is lying in bed. 4. Report the findings at the completion of the assessment.

Correct Answer: 750 mg

The nurse administers amoxicillin 10 mg/kg every 8 hours to a client. The client weighs 55 lb (25 kg). How many milligrams of amoxicillin does the nurse administer in 24 hours? (Record your answer rounding to the nearest whole number. )

1) INCORRECT - A reduction in depression may occur as a result of the diminished pain, but this is not the primary purpose of giving carbamazepine to the client. 2) INCORRECT - Seizures are not associated with trigeminal neuralgia. 3) CORRECT— The agonizing pain of trigeminal neuralgia may result in severe depression and suicide. Carbamazepine inhibits nerve impulses and reduces the pain of the condition. 4) INCORRECT - Sedation may occur as a result of the diminished pain, but this is not the primary purpose of giving carbamazepine.

The nurse administers carbamazepine to a client for trigeminal neuralgia. Which therapeutic effect does the nurse expect after administering this medication? 1. Relieve accompanying depression.2. Reduce the possibility of tonic-clonic seizures. 3. Relieve agonizing pain. 4. Provide sedation.

1) INCORRECT - Both illnesses require precautions, but require different types of precautions. The nurse should not place clients with different infections together. 2) INCORRECT - Both illnesses require precautions, but require different types of precautions. The nurse should not place clients with different infections together. 3) INCORRECT - The client with MRSA requires a private room, but there is no indication that the client requires close monitoring. 4) CORRECT - A private room is best for this client, as a client with MRSA can only room with another client who is also MRSA positive.

The nurse admits a school-age client diagnosed with an open wound that tests positive for methicillin-resistant Staphylococcus aureus (MRSA). Which room assignment is appropriate for this client? 1. A semiprivate room with a toddler diagnosed with respiratory syncytial virus. 2. A semiprivate room with a preschool client diagnosed with acute respiratory virus. 3. A private room that is close to the nurse's station.4. Any private room that is available.

1) INCORRECT - The safety of the clients is the primary concern in this situation. Refusing to work with the sick nurse does not ensure safe client care. 2) INCORRECT - A nurse with group A Streptococcus (strep throat) cannot care for clients until 24 hours after receiving appropriate antibiotic therapy. This suggestion allows the nurse to assent or refuse, and does not protect the clients adequately. 3) INCORRECT - Sending the nurse home will protect the clients from infection, but will result in inadequate staffing. 4) CORRECT— The results of the rapid test can be obtained in 10 minutes. This ensures that both adequate staffing and safety from infection are provided to the clients. If the results of the rapid strep test are negative, then the nurse can care for clients.

The nurse arrives at work stating, "My throat hurts and I have a temperature of 99.5°F (38°C)." This nurse is one of two RNs scheduled to work the shift with no additional support staff. Which action by the healthy nurse is most appropriate? 1. Refuse to work with the nurse who has the sore throat.2. Suggest that the nurse with the sore throat obtain a throat culture before accepting an assignment. 3. Tell the the nurse with the sore throat to go home. 4. Arrange for coverage for the nurse with the sore throat while a rapid strep test is obtained.

1) INCORRECT — Stairs can be eliminated in the client's environment by installing a ramp. 2) INCORRECT — Inability to tie shoes is a modifiable problem with the use of slip-on or alternative fastener shoes. 3) CORRECT— Performing basic hygiene and grooming must be done daily to maintain overall health. If the client cannot do this, it indicates the need for daily home assistance. 4) INCORRECT — Though ideal, walking unassisted is not necessary for independence. A walker or wheelchair may be used.

The nurse assesses a client, diagnosed with rheumatoid arthritis, for self-care readiness. Which activity does the nurse ask the client to perform? 1. Ascend and descend stairs.2. Lace and tie both shoes.3. Comb hair and brush teeth.4. Walk without assistance.

1) INCORRECT - Scissors at the bedside of a client with a Sengstaken-Blakemore tube is an appropriate action. This esophagogastric tube provides balloon tamponade to stop bleeding of esophageal varices. The inflated esophageal balloon can obstruct the airway. In case of an airway obstruction, scissors are to be used to cut the tube's balloon ports. 2) INCORRECT - An Ambu bag should be at the bedside of a client on a ventilator. If the ventilator fails, the Ambu bag is used to maintain ventilation. 3) INCORRECT - A defibrillator on the crash cart and plugged into the wall in the treatment room is an appropriate action. This device should be charged at all times. 4) CORRECT - Nothing should be inserted into the mouth of a client who is having a tonic-clonic seizure. The padded tongue blade should be removed from the client's room.

The nurse assesses clients after receiving hand-off communication. Which observation is most important for the nurse to immediately intervene? 1. Scissors placed on the bedside table of a client with a Sengstaken-Blakemore tube. 2. An ambu bag at the bedside of a client on a ventilator.3. Defibrillator on the crash cart and plugged into the wall in the treatment room. 4. A padded tongue blade taped to the wall above the bed of a client with tonic-clonic seizures.

1) CORRECT - Pernicious anemia is a risk factor for vitamin B12 deficiency because the stomach does not secrete intrinsic factor with this health problem. 2) INCORRECT - Acute lymphocytic anemia is not a risk factor for vitamin B12deficiency. 3) CORRECT - A vegan diet is a risk factor for vitamin B12 deficiency because this vitamin is found in animal muscle meats. 4) INCORRECT - Gastroesophageal reflux disease (GERD) is not a risk factor for vitamin B12 deficiency, however, vitamin B12 deficiency can result if the client is a prescribed a proton pump inhibitor to treat GERD. 5) CORRECT - Metformin is a risk factor for vitamin B12 deficiency because it interferes with the absorption of the vitamin. 6) CORRECT- A gastrectomy is a risk factor for vitamin B12 deficiency because there is no stomach to secrete intrinsic factor.

The nurse at a health fair screens clients for vitamin B12 deficiency. Which client will the nurse determine as needing vitamin B12 supplementation? (Select all that apply.) 1. Recently diagnosed with pernicious anemia. 2. Treated for acute lymphocytic leukemia. 3. Follows a strict vegan diet. 4. Recently diagnosed with gastroesophageal reflux disease. 5. Takes metformin for type 2 diabetes. 6. Had a gastrectomy 2 years ago.

The first step is to remove all jewelry for thorough skin cleaning. Items such as rings present a serious infection risk and cannot be cleaned thoroughly enough to be considered safe. Second, turn on the water using knee or foot controls to eliminate re-contamination of hands. Third, remove debris from under finger nails. Artificial nails are not permitted. Next, apply the antimicrobial scrub agent to the hands and forearms with a soft sponge, and then scrub for 3 to 5 minutes using gentle friction to reduce contaminants. Finally, rinse the hands and forearms, holding the hands above the forearms to prevent water from running back onto cleaned hands. Remove bracelets, rings, and watches. Turn on water using knee or foot control. Clean under the nails of both hands with disposable nail pick. Apply antimicrobial scrub agent to hands and forearms with soft sponge. Time scrub for 3-5 minutes. Rinse hands and forearms, holding hands higher than elbows.

The nurse completes a surgical hand scrub before each procedure. In which order, starting with the first step, does the nurse implement the surgical hand scrub? (Please arrange in order. All options must be used.) Apply antimicrobial scrub agent to hands and forearms with soft sponge. Time scrub for 3-5 minutes. Rinse hands and forearms, holding hands higher than elbows. Remove bracelets, rings, and watches. Turn on water using knee or foot control. Clean under the nails of both hands with disposable nail pick.

The acronym RACE stands for: rescue, alarm, contain, extinguish. This acronym means the nurse rescues or removes the clients in immediate danger, pulls the alarm after removing clients to safety, closes the fire doors to contain the fire, and extinguishes the fire using equipment that is available and evacuates clients as necessary. Move clients away from the fire. Pull the fire alarm. Close all of the fireproof doors. Extinguish the fire.

The nurse discovers a fire in the soiled utility room of a healthcare facility. In which order does the nurse perform the required actions? (Please arrange in order. All options must be used.) Close all of the fireproof doors. Extinguish the fire. Move clients away from the fire. Pull the fire alarm.

1) CORRECT — These are symptoms of tuberculosis. Other signs/symptoms include progressive fatigue, lethargy, nausea, anorexia, and weight loss. 2) INCORRECT — These are symptoms of pheochromocytoma, a tumor that results in hypersecretion of the adrenal medulla. 3) INCORRECT — These are symptoms of pulmonary embolism. 4) INCORRECT — These are symptoms of heart failure.

The nurse in the outpatient clinic provides care for a client diagnosed with tuberculosis. The nurse expects to find which statement in the client record? 1. "Client reports low-grade fever and night sweats."2. "Client reports an increased heart rate and palpitations."3. "Client reports pleuritic chest pain and feelings of doom."4. "Client reports presence of edema and anorexia."

1) INCORRECT — This is non-therapeutic. The nurse should not ask "why" questions, as this may be perceived as judgmental. 2) CORRECT — This provides objective information to the parent. Adolescents may react with anger and depression to the weakness and fatigue. The nurse should encourage the parent to allow the adolescent to vent and reassure the adolescent that activities can be resumed after the acute phase. 3) INCORRECT — There is no need to contact the health care provider. The nurse should respond to the situation. 4) INCORRECT — This response is non-therapeutic, as it shifts the focus to the nurse.

The nurse in the outpatient clinic receives a call from the parent of an adolescent diagnosed with infectious mononucleosis. The parent reports that the adolescent seems angry and depressed since the diagnosis. Which response by the nurse is most appropriate? 1. "Why do you think your child is angry?"2. "Teens become frustrated because of feeling weak and fatigued."3. "Would you like the health care provider to talk with your child?"4. "My child had mono and was crabby all the time."

1) INCORRECT - The spirometer is held upright at eye level so a client can observe the ball rise in the chamber. The purpose is to promote complete lung expansion and to prevent respiratory complications in the postoperative client. 2) INCORRECT - The correct method is to inhale deeply and to hold the breath for 3 seconds. 3) CORRECT— Inhaling deeply and holding for 3 seconds allows for a sustained maximal inspiration to prevent atelectasis. A client is able to see their efforts registered on the spirometer. 4) INCORRECT - Aerosol is not used in a spirometer, although the spirometer is held upright.

The nurse instructs a client about how to use an incentive spirometer. Which instruction does the nurse include? 1. "Hold the spirometer at a 45-degree angle while breathing in. "2. "Exhale into the spirometer for 3 seconds. "3. "Inhale through the mouthpiece and hold your breath for 3 seconds. "4. "Hold the spirometer straight to allow the aerosol to enter lungs. "

1) INCORRECT - The ostomy appliance needs to be changed first thing in the morning or 2 -4 hours after a meal. The client should avoid changing the appliance following a meal, for this stimulates bowel evacuation. 2) INCORRECT - The client needs to avoid using moisturizing soap to clean the skin around the stoma, for it will interfere with the adhesive of the skin barrier. 3) CORRECT— The client should place tissue on the stoma when changing the appliance, for this will absorb stool and prevent stool from contacting the skin. 4) CORRECT— The client needs to cut the skin barrier no more than 1/8 inch larger than the stoma. This will allow the stoma to expand and prevent stool from contacting peristomal skin. 5) CORRECT— The client needs to empty the pouch of stool before removing the appliance. This will prevent contact of stool to the client's skin. 6) CORRECT— The client needs to check the stoma for color, size, and shape. This will ensure adequate blood flow to the stoma.

The nurse instructs a client about the care of a new colostomy. Which information does the nurse include? (Select all that apply.) 1. Change the ostomy appliance following a meal.2. Use a moisturizing soap to clean skin around stoma.3. Place tissue on stoma when changing the appliance.4. Cut the skin barrier 1/8 inch larger than the stoma. 5. Empty the pouch of stool before removing the appliance. 6. Check stoma for color, size, and shape.

1) CORRECT — Taking deep breaths hyper-oxygenates the client's lungs and prevents anoxia during suctioning. 2) INCORRECT — A tonsil tip catheter is used for oral suctioning of mouth. 3) INCORRECT — Suction is applied only as the catheter is withdrawn, not during its insertion. 4) INCORRECT — First, the laryngectomy tube is suctioned and then mouth, in order to prevent introducing bacteria from the mouth into the lungs.

The nurse instructs a client and spouse on how to suction the client's laryngectomy tube. Which observation indicates to the nurse that teaching is effective? 1. The client takes several deep breaths before the suction catheter is inserted. 2. The spouse selects a tonsil tip catheter to suction the laryngectomy tube. 3. The spouse applies suction while introducing the sterile catheter into the stoma. 4. The spouse suctions the mouth and then the laryngectomy tube.

1) CORRECT - Sore throat, fever, increased fatigue, vomiting, and diarrhea are possible adverse effects of imipramine, a tricyclic antidepressant medication. These side effects can be resolved by altering the dosage or changing the medication. 2) INCORRECT - Dry mouth, nasal stuffiness and weight gain are side effects of antidepressants that the client can learn to manage at home without changing the medication. 3) INCORRECT - Rapid heartbeat, frequent headaches, and yellowing of the eye and skin are not adverse effects of imipramine. 4) INCORRECT - Weakness, staggering gait, tremor, and feelings of drunkenness are not adverse effects of imipramine.

The nurse instructs a client on the newly prescribed medication imipramine. Which symptoms will the nurse teach the client to report immediately to the health care provider? 1. Sore throat, fever, increased fatigue, vomiting, diarrhea.2. Dry mouth, nasal stuffiness, weight gain.3. Rapid heartbeat, frequent headaches, yellowing of eyes or skin.4. Weakness, staggering gait, tremor, feelings of drunkenness.

1) INCORRECT - This medication (a loop diuretic) should be taken early in the day so that sleep will not be disturbed by increased urination. 2) INCORRECT - Furosemide is a loop diuretic that may cause orthostatic hypotension. The client should be instructed to rise slowly. 3) INCORRECT - Taking furosemide with meals minimizes gastrointestinal upset. 4) CORRECT— Furosemide is a loop diuretic that is potassium wasting. The client should be encouraged to increase the intake of potassium-rich foods, such as orange juice and bananas.

The nurse instructs a client who is prescribed furosemide. Which client statement indicates that additional teaching is required? 1. "I will take my medicine early in the day."2. "I will contact the doctor if I feel dizzy."3. "I will take my medicine with meals."4. "I will avoid orange juice and bananas."

1) INCORRECT - A client must hold the cane on the side opposite the affected extremity to be effective. 2) INCORRECT - The purpose of the cane it to support the weak side. The cane is advanced at the same time the weak extremity is advanced. 3) CORRECT— The cane acts as support and aids in weight-bearing for the weaker right leg. The elbow should be flexed 30 degrees and the tip of cane should be 15 cm lateral to the base of the fifth toe. 4) INCORRECT - The cane is advanced at the same time the weak extremity advances. The client leans on cane that is in the left hand.

The nurse instructs a client with right-sided weakness how to use a cane. Which client behavior indicates to the nurse that teaching is successful? 1. The client holds the cane in the right hand, moves it forward followed by the right leg, and then the left leg. 2. The client holds the cane in the right hand, moves the cane forward followed by the left leg, and then the right leg. 3. The client holds the cane in the left hand, moves the cane forward followed by the right leg, and then the left leg. 4. The client holds the cane in the left hand, moves the cane forward followed by the left leg, and then the right leg.

First, assemble the necessary equipment to avoid breaks in technique. Second, place the sterile drape on the work surface, holding the drape away from body, lay the bottom half of a drape on the work surface and then the top half of the drape. Third, open wrapper of the sterile item, which is appropriate after assembling necessary equipment and placing sterile drape on the work surface. Fourth, dispose of outer wrapper to prevent accidental contamination of sterile field. Assemble the necessary equipment. Place sterile drape on the work surface. Open wrapper of sterile item. Dispose of outer wrapper.

The nurse is preparing a sterile field for a client care procedure. In which order does the nurse complete the steps associated with setting up a sterile field? (Please arrange in order. All options must be used.) Place sterile drape on the work surface. Assemble the necessary equipment. Open wrapper of sterile item. Dispose of outer wrapper.

1) INCORRECT - While the parents may be glad, the nurse 's priority should be screening and counseling about accident prevention. 2) INCORRECT - The nurse is being non-therapeutic when talking about personal situations. 3) CORRECT— The nurse should assess, before counseling the adolescent about the importance of wearing seat belts and acting appropriately when riding with another adolescent. 4) INCORRECT - The nurse needs to first determine if the adolescent is riding with the friend and then concentrate on appropriate behavior when being a passenger.

The nurse learns that an adolescent client 's best friend has a driver 's license and a new car. Which comment is the most appropriate for the nurse to make? 1. "I bet your parents are glad they don 't have to drive you anymore. "2. "I was so anxious when my teenager started driving. "3. "How often do you ride in the car with your friend? "4. "What kind of driver is your friend? "

1) INCORRECT — The immediate action is to ensure the area is cleaned and disinfected to prevent risk of contamination to other clients or personnel. When reporting, the nurse stays within the chain of command and notifies the nurse's supervisor, not the laboratory supervisor. 2) INCORRECT — The nurse's responsibility is to first ensure the area is properly cleaned and disinfected before communicating the incident to the nurse manager. 3) CORRECT— The priority for the nurse is cleaning up the contaminated area in the client's room by contacting housekeeping to clean and disinfect the area. 4) INCORRECT — Counseling the laboratory technician is the responsibility of the laboratory supervisor. The nurse's first action is to call housekeeping to ensure the contaminated area is cleaned appropriately.

The nurse notes that after a laboratory technician draws a blood specimen from a client there are drops of blood on the floor and the wall next to the needle container. Which action does the nurse take first? 1. Contact the laboratory supervisor to report the incident.2. Contact the nurse manager to report the incident.3. Call housekeeping to clean and disinfect the area.4. Counsel the laboratory technician about appropriate technique.

1) INCORRECT— Tuberculosis requires airborne precautions. Therefore, the client needs to be in a negative air pressure room and individuals entering the room must wear an N-95 respirator mask. 2) INCORRECT— A client with localized herpes zoster requires standard precautions and would not require the family member to stand 4 feet away from the client. 3) INCORRECT— Lyme disease requires standard precautions and would not require the family member to stand 4 feet away from the client. 4) CORRECT— Influenza requires droplet precautions. Therefore, the family member is using proper precautions by standing 4 feet away from the client.

The nurse observes a family member enter a client's room and stand 4 feet from the client. The nurse determines that the family member is using proper precautions because the client is being treated for which diagnosis? 1. Tuberculosis.2. Localized herpes zoster.3. Lyme disease.4. Influenza.

1) INCORRECT - The UAP should bend at the knees to increase body balance and lower center of gravity. 2) INCORRECT - An object should be carried close to body's center of gravity to help balance but should not be carried above the head. 3) CORRECT - By bending the knees, the person maintains a better body balance when lifting. It protects the muscles of the back and moves the center of gravity closer to the object. 4) INCORRECT - Leaning forward would put unnecessary stress on the back. Bend the knees when lifting.

The nurse observes an unlicensed assistive personnel (UAP) preparing to lift an object. Which principle of body mechanics does the nurse recommend to the UAP? 1. "Bend at the waist when you lift objects."2. "Carry objects close to your body or above your head."3. "Bend your knees when you lift objects."4. "Lean forward when you lift objects."

1) INCORRECT - Applying petroleum jelly to the client's lips prevents drying, cracking, and the formation of encrustations. This is an appropriate action and does not require intervention by the nurse. 2) INCORRECT - A solution of hydrogen peroxide and normal saline is used to remove debris and helps keep the mucosa clean and moist. This is an appropriate action and does not require intervention by the nurse. 3) CORRECT - A mouthwash with glycerin causes dehydration and irritation of the oral tissues. The nurse should intervene and provide the UAP and client with a non-glycerin mouthwash. 4) INCORRECT - A soft-bristled toothbrush is used to prevent trauma to the mucosa. This is an appropriate action and does not require intervention by the nurse.

The nurse observes the unlicensed assistive personnel (UAP) perform mouth care on an older adult client admitted to the hospital with fever of unknown origin. Which action performed by the UAP requires an intervention by the nurse? 1. Applying petroleum jelly to the client's lips. 2. Flushing the client's mouth with a 50:50 dilution of hydrogen peroxide and normal saline. 3. Rinsing the client's mouth with a glycerin-based mouthwash. 4. Using a soft bristled toothbrush to clean the client's teeth.

1) INCORRECT — This is an appropriate action, as RSV requires contact precautions. A mask may be worn for standard precautions, which are used when providing care for all clients. 2) INCORRECT — This is an appropriate action. With contact precautions, equipment should be left in the client's room or cleaned thoroughly before use on another client. 3) INCORRECT — This is an appropriate action. Clients who are not infectious should receive care first. Then care should be provided to infectious clients. 4) CORRECT— The UAP should remove gown and gloves before leaving the room, place them in a hamper/trash bin in the room, and wash hands thoroughly.

The nurse observes the unlicensed assistive personnel (UAP) prepare to obtain the vital signs of an infant diagnosed with respiratory syncytial virus (RSV). Which observation requires an intervention by the nurse? 1. The UAP wears a gown, gloves, and mask when entering the room.2. The UAP is using the stethoscope found in the infant's room. 3. The UAP provided care to a post-operative client after a shunt repair before tending to the client with RSV. 4. The UAP removes the gown and gloves and places them in a hamper in the hall.

1) INCORRECT — The chicken leg and broccoli contain protein. The ice pop and lemonade do not provide protein. 2) CORRECT— Protein is found in the cheeseburger, yogurt, and milk. A burn injury requires a high-protein diet for wound healing. 3) INCORRECT — Only cottage cheese contains some protein. There is minimal to no protein in canned peaches, crackers, and apple juice. 4) INCORRECT — Eggs contain protein. Potatoes contain some protein. There are minimal to trace amounts of protein in a banana and orange juice.

The nurse provides nutrition teaching to the parent of a client with deep partial thickness burns on the legs. Which meal does the nurse suggest? 1. Chicken leg, broccoli, ice pop, and lemonade.2. Cheeseburger, fruit-flavored yogurt, carrots, and milk.3. Cottage cheese, canned peaches, crackers, and apple juice.4. Scrambled eggs, hash brown potatoes, banana, and orange juice.

1) INCORRECT — Wearing of gloves by staff during all contact with open wounds is essential. However, a gown, mask, and shoe and hair covers may be required for certain clients with deep and extensive burns, but not for all clients. The evidence on the effectiveness of full personal protective equipment use (gown, gloves, mask, and shoe and hair covers) is mixed. There is another answer choice that is a higher priority. 2) INCORRECT — Disposable and dedicated equipment should be used as much as possible. Equipment certainly should be thoroughly cleaned between rooms. Although important, this is not the most important measure. 3) INCORRECT — Private rooms with negative-pressure air flow are used for airborne precautions such as tuberculosis, not for every client with an infection. 4) CORRECT— Correct and consistent handwashing is the single most effective technique for preventing infection transmission on burn units. This is the priority measure for the nurse to communicate.

The nurse on the burn unit orients new staff to infection control issues. Which measure is most important to emphasize for this particular type of unit? 1. Wear gowns, gloves, masks, as well as shoe and hair covers.2. Ensure that no equipment is shared between clients.3. Assign clients diagnosed with infection to private rooms with negative-pressure air flow.4. Wash hands using a thorough and consistent approach.

1) CORRECT— The nurse needs to determine the reason that the client is not getting up and moving around. Physical activity is important to prevent skin breakdown, respiratory tract infections, and to support client mobility. 2) INCORRECT - While the clutter is a potential issue if it obstructs walking and poses a fall risk, it is more important for the nurse to address the current actual client issue of spending most of the day in bed. 3) INCORRECT - This is a good sign and indicates that the caregiver is able to balance the needs of the children with those of the parent. 4) INCORRECT - This is a good sign, which indicates that the family is sharing responsibility for care.

The nurse performs a home visit for a client diagnosed with Alzheimer disease. Which observation is most concerning to the nurse? 1. The client spends most of the day in bed.2. The home appears cluttered. 3. The daughter attends her children's school activities.4. The son-in-law helps with the client's care.

1) INCORRECT— A client diagnosed with Clostridium difficile must be placed under contact precautions. 2) INCORRECT— A client diagnosed with Clostridium difficile must be placed under contact precautions , not airborne precautions. 3) INCORRECT— A client diagnosed with Clostridium difficile must be placed under contact precautions , not droplet precautions. 4) CORRECT— A client diagnosed with Clostridium difficile must be placed under contact precautions . Initiating contact precautions is essential when the organism can be transmitted by direct contact.

The nurse plans care for a client diagnosed with Clostridium difficile. Which transmission-based precautions should the nurse implement? 1. Standard precautions. 2. Airborne precautions. 3. Droplet precautions. 4. Contact precautions.

Correct Answer: 83 gtts/min

The nurse prepares a 1-liter IV fluid bolus for a client diagnosed with gastroenteritis. The administration set is 20 gtt/mL. The client is to receive the bolus over 4 hours. At what rate in gtts/minute does the nurse adjust the flow? (Do not round. Record your answer using a whole number.)

1) INCORRECT — A home care referral may be appropriate, but the nurse should first determine what type of care the client requires. 2) INCORRECT — This is an appropriate action, but the nurse should first assess. 3) CORRECT— The nurse should first determine the client's needs and then assess whether the parents are able to meet the client's needs. After assessment is complete, the nurse can begin implementation. 4) INCORRECT — This is an appropriate action, but the nurse should first complete the assessment.

The nurse prepares to discharge a client diagnosed with acquired immune deficiency syndrome (AIDS). The client is going to live with the parents so that they can assist with care. Which action does the nurse take first? 1. Refer the client for home care.2. Assess if the client and parents understand the dosing schedule and side effects of the medication. 3. Ask the client about what kind of help is needed from the parents. 4. Encourage the parents to join a support group.

1) INCORRECT - Placing sterile materials close to the edge of the table would break sterile technique. 2) CORRECT— Having the supplies in front of the nurse represents the best technique for a sterile field. 3) INCORRECT - The sterile field is always above the waist of the nurse. Being below would break sterile technique. 4) INCORRECT - All supplies to be used for the insertion of a urinary catheter must be sterile to prevent the transmission of infection. The exception is for a client who self-catheterizes at home.

The nurse prepares to insert an indwelling urinary catheter into a client. Which action is important for the nurse to take? 1. Place all supplies close to the edge of the table.2. Keep the field holding the supplies in front of the nurse. 3. Set up the field below the nurse 's waist level.4. Add only clean supplies to the field.

1) INCORRECT - Clients with MRSA should be placed in contact precautions. Contact precautions require the use of gloves and gown for any contact with the client or equipment. 2) CORRECT— The nurse should wear clean, nonsterile gloves and gown when entering the client's room, if the nurse is going to have any contact with the client or with surfaces that the client touches. 3) INCORRECT - Masks, eye protection, and face shield are only required if client care activity is likely to generate splashes or sprays (such as suctioning). 4) INCORRECT - Contact precautions are required with clients who are diagnosed with MRSA.

The nurse prepares to perform the initial assessment on a school-age client. The client has an open wound infected with methicillin-resistant Staphylococcus aureus(MRSA). Which precaution will the nurse take? 1. Wear gloves only.2. Wear gown and gloves. 3. Wear gown, gloves, and mask. 4. No precautions are necessary.

1) INCORRECT — Mononucleosis, also known as the "kissing disease," is transmitted person to person but only requires standard precautions. 2) INCORRECT — Legionnaire disease is a bacterial pneumonia that requires standard precautions. 3) INCORRECT — HIV and AIDS infections are transmitted by direct contact with blood and body fluids, which requires standard precautions. 4) CORRECT— Disseminated herpes zoster requires airborne and contact precautions. These transmission precautions are observed until the lesions are dry and crusted. This client is not cohorted with other clients.

The nurse receives four new admissions. Which client is placed in a private room? 1. A client diagnosed with infectious mononucleosis.2. A client diagnosed with Legionnaire disease.3. A client diagnosed with human immunodeficiency virus.4. A client diagnosed with disseminated herpes zoster.

1) CORRECT— Bronchodilators can loosen secretions, helping the client expectorate them from the lungs. The nurse expects to observe an increased productive cough after the albuterol nebulizer treatment. 2) INCORRECT — Bronchodilators, such as albuterol, decrease obstruction. Increased, not decreased, obstruction results in wheezing. 3) INCORRECT — Bronchodilators, such as albuterol, do not reduce fluid in lungs. Crackles are auscultated when the client has pulmonary congestion due to fluid overload. 4) CORRECT— Decreased oxygen causes anxiety and the client struggles to obtain enough air. Calmness should occur when the air passages are clearer or more dilated after the nebulized treatment. 5) CORRECT— Tremors are an expected side effect of albuterol and are not concerning.

The nurse provides an albuterol nebulizer treatment to a client recovering from respiratory failure. Which finding does the nurse expect to observe after treatment? (Select all that apply.) 1. Increased productive cough.2. Increased wheezes in upper lobes.3. Decreased crackles in lower lobes.4. Reports of decreased anxiety.5. Bilateral hand tremors.

1) INCORRECT- Skim milk with a powder supplement mix is low in fat and high in carbohydrates and protein. 2) INCORRECT- A baked potato and bread are low in fat and high in carbohydrates, which is a good choice. 3) CORRECT- Pizza and most salad dressings are high in fat and should be avoided by the client with an inflamed gallbladder. 4) INCORRECT- Tapioca fruit gelatin contains no fat and is high in carbohydrates. 5) CORRECT- French onion dip is high in fat and should be avoided 6) CORRECT- Cheese and fried foods are high in fat and should be avoided.

The nurse provides care for a client diagnosed with acute gallbladder inflammation. Which menu selection by the client requires intervention by the nurse? (Select all that apply.) 1. Skim milk with powdered supplement.2. Plain baked potato and bread.3. Pizza with a side salad and ranch dressing.4. Tapioca fruit gelatin and water.5. French onion dip and pita chips.6. Cheese omelet and fried potatoes.

1) INCORRECT — Standard precautions are used when providing care for all clients, regardless of diagnosis or possible infection. When providing care for a client diagnosed with MRSA, the nurse must implement contact precautions along with standard precautions. 2) INCORRECT — MRSA is transmitted through contact. The nurse must implement contact precautions, not airborne precautions. 3) INCORRECT — MRSA is transmitted through contact. The nurse must implement contact precautions, not droplet precautions. 4) CORRECT — MRSA is transmitted through contact. It is essential for the nurse to implement contact precautions to prevent the spread of MRSA.

The nurse provides care for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA). Which transmission-based precautions are essential for the nurse to implement? 1. Standard precautions.2. Airborne precautions.3. Droplet precautions.4. Contact precautions.

1) INCORRECT — Linens that are removed from an isolation room are to be placed in a plastic bag and taken to the area designated for soiled linens. No special handling precautions are required. 2) CORRECT — Lab specimens contain body fluids and need to be marked as hazardous. 3) CORRECT — Used syringes are disposed of in the red sharps container, which is a biohazard container. If the sharps container is being removed from the isolation room, it needs to be placed in the designated biohazard bin on the clinical unit. 4) INCORRECT — Trash that is removed from an isolation room is disposed of in plastic trash bags and does not need to be marked as hazardous. 5) INCORRECT — Equipment that was in the isolation room needs to be cleaned properly before using again. Special precautions are not needed.

The nurse provides care for a client in isolation. Which item must be marked as biohazardous when removing it from the room? (Select all that apply.) 1. Bed linen.2. Lab specimen.3. Discarded syringes.4. Trash.5. Equipment.

Correct Answer: 150 mL

The nurse provides care for a client receiving IV fluids. The health care provider prescribes 600 mL of IV fluids to infuse over 4 hours. The nurse sets the infusion device to infuse how many mL per hour? (Round at the end of the equation. Record your answer using a whole number.)

1) INCORRECT - Because pre-operative medications may interfere with balance, the nurse should have asked the client to void before receiving the medication. This response is not appropriate and non-therapeutic. 2) INCORRECT - Preoperative medications may interfere with balance and create a safety concern. The client should not get up at this time. 3) CORRECT— Preoperative medications may interfere with balance and create a safety concern. The client should remain in bed and be encouraged to use the bedpan. 4) INCORRECT - Seeking a prescription for an indwelling urinary catheter places the client at an increased risk for an infection. The client needs to be encouraged to use the bedpan.

The nurse provides care for a client who has received preoperative medications. The client insists on getting up and going to the bathroom. Which response by the nurse is most appropriate? 1. "You should have gone to the bathroom before receiving the medications."2. "You can walk to the bathroom if you are not feeling groggy."3. "I would suggest that you use the bedpan right now."4. "I will see if your health care provider can prescribe an indwelling urinary catheter."

Correct Answer: 8 drops per minute

The nurse provides care for a client with an infusion of 1200 mL of an IV solution daily. The IV infusion device delivers 10 drops per mL. The nurse adjusts the flow rate so that the client receives how many drops of fluid per minute? (Record your answer rounding to the nearest whole number.)

1) INCORRECT- Sterile technique must be used to apply sterile dressing to the wound. 2) CORRECT- The LPN/LVN removes dressings with clean gloves, removes the clean gloves, and applies sterile gloves to perform sterile dressing change. The LPN/LVN should wash the hands between glove changes. 3) INCORRECT- The LPN/LVN uses sterile gloves to dress the wound. 4) INCORRECT- The supplies must be opened prior to applying the sterile gloves for the dressing change.

The nurse supervises care by an LPN/LVN to a client with an infected, open abdominal wound. The nurse notes a Penrose drain is in place and the wound is draining copious purulent drainage. The nurse determines care is appropriate if which action is observed? 1. The LPN/LVN applies clean gloves, removes the soiled dressing, and performs a clean dressing change.2. The LPN/LVN applies clean gloves, removes the soiled dressing, dons sterile gloves, and performs a sterile dressing change.3. The LPN/LVN applies sterile gloves, removes the soiled dressing, changes to clean gloves, and places clean bandages.4. The LPN/LVN applies sterile gloves, opens needed supplies, and performs a sterile dressing change.

1) INCORRECT- The infant exhibits signs of failure to thrive (FTT). However, this general statement fails to take into account multiple factors. Overfeeding can be harmful, too, resulting in a behavioral feeding aversion. Parents should be encouraged to offer milk frequently. If the infant wants to eat every hour during the day, the parent should not wait until the 2-hour mark, for example. 2) CORRECT - Parents are encouraged to hold and talk to their infants during feedings. Social interactions during feeding encourage the infant to enjoy feedings. 3) CORRECT - Infants with FTT are often fatigued due to malnutrition, causing them to sleep through feedings. Parents need to know the importance of waking them if it is time for a feeding. 4) CORRECT - FTT may have an organic cause such as reflux, so it is important to rule this out by keeping a diary of feeding frequencies, amounts, as well as the amount, frequency, and forcefulness of spit up. 5) INCORRECT- The optimal time to introduce new foods is 4 to 6 months, usually starting with rice cereal. Adding foods increases the energy expended by the infant to learn the new skill. Occasionally health care providers will advise beginning cereal prior to 4 months to help an infant rest longer between feedings, because food is more difficult to digest than milk and keeps the stomach full longer. 6) INCORRECT - It is not necessary for parents to perform these measurements this frequently, especially height. Sometimes parents are advised to weigh infants after a breastfeeding session to gauge how much milk they are getting.

The nurse provides care for an infant client whose weight is at the fifth percentile for the height. At birth the infant was in the 50 th percentile for height and weight. The nurse includes which teaching for the parents? (Select all that apply.) 1. "Feed your baby 6 oz of formula every 2 hours."2. "Hold your baby during each feeding."3. "If your baby sleeps longer than 4 hours, wake to feed."4. "Write down how often and how much your baby spits up."5. "Begin feeding infant foods such as bananas and peaches."6. "Measure your baby's height and weight each day."

1) INCORRECT — There is no direct evidence that Legionnaire disease can be spread between humans. No precautions other than standard precautions are recommended. 2) CORRECT— Legionnaire disease is caused by Legionella pneumophila, which is found in warm, stagnant water such as hot water tanks and is spread by the aerosolized route from the environmental source to the client. Maintenance on the hot water heater is required to eliminate the source. 3) INCORRECT — Legionnaire disease is not spread via saliva. There is no need for this action. 4) INCORRECT — Legionnaire disease is spread by the aerosolized route, such as showers, whirlpools, and air-conditioning cooling towers. Placing filters on the air ducts will not protect the client.

The nurse provides care for clients in a long-term care facility. A client is diagnosed with Legionnaire disease. Which action by the nurse is appropriate? 1. Place the client on droplet precautions.2. Ask for maintenance on the institution's hot water tank.3. Sterilize the utensils used by the client.4. Place filters on the air ducts of the client's room.

1) INCORRECT - Coughing and deep breathing does help prevent pneumonia in hospitalized clients. However, community-acquired pneumonia often follows viral infections or influenza. The best preventative strategy is to ensure the client has received the influenza vaccine. 2) CORRECT - Community-acquired pneumonia (most common form of pneumonia) often follows viral infections or influenza. The nurse should also ask the client about the pneumococcal vaccine. 3) INCORRECT - The nurse should instruct the client to avoid crowds during periods of flu outbreak, but the priority is obtaining the flu vaccine. 4) INCORRECT - The nurse should encourage the client to get enough rest and sleep and eat balanced meals as a general strategy, but this is not specific to pneumonia.

The nurse provides care for clients in a senior citizens center. The client tells the nurse, "I had pneumonia once, and I do not want to get it again." Which question is most important for the nurse to ask? 1. "How often do you cough and deep breathe?"2. "Have you received a flu shot this year?"3. "Do you attempt to avoid crowds?"4. "How much sleep do you receive each night?"

1) CORRECT — Dry mouth is an adverse effect of chlorpromazine, so it is important to maintain good oral hygiene. 2) CORRECT — It can take at least 6 weeks before the client notices improvement in symptoms. 3) INCORRECT— Alcohol should not be mixed with this class of medication. 4) INCORRECT — The client should avoid driving until dosing is stabilized due to potential side effects such as sleepiness. 5) CORRECT — There is a risk of leukopenia in the first 3 months, and this necessitates lab work. 6) CORRECT — Pink urine is an expected side effect of chlorpromazine.

The nurse provides care to a client newly diagnosed with schizophrenia who is prescribed chlorpromazine 25 mg PO tid. Which client statement indicates to the nurse a correct understanding of the medication administration instructions? (Select all that apply.) 1. "It is important that I brush my teeth three times a day."2. "It may take 6 weeks for my medication to work."3. "I can have a glass of wine with dinner each night"4. "I am driving myself home today and to work tomorrow."5. "I need to have blood drawn regularly for a few months."6. "I should not be concerned if my urine turns pink."

1) INCORRECT - For the client diagnosed with leukopenia who requires protective isolation, appropriate precautions include donning a disposable mask, gown, and gloves when entering the client's room. 2) INCORRECT - Use of clean non-disposable eating utensils is acceptable for the client who requires protective isolation precautions. Utensils should not be shared and should be cleaned before reuse. 3) CORRECT— Consumption of fresh fruit is contraindicated for the client who requires isolation precautions due to the potential for ingestion of microorganisms. 4) INCORRECT - Delivery of cards and letters is allowed for the client who requires isolation precautions. However, exposure to fresh flowers is contraindicated due to the potential for introducing microorganisms and contaminants into the client's environment.

The nurse provides care to an adult client diagnosed with leukopenia. The client requires protective isolation due to immunosuppression. Which observation prompts the nurse to intervene? 1. The client's spouse enters the client's room wearing a mask, gown, and gloves. 2. The client's food tray contains non-disposable eating utensils. 3. A basket of fresh fruit is delivered to the client's room. 4. A large card signed by the client's coworkers is delivered to the client's room.

1) INCORRECT— Although the client should be encouraged to ambulate as tolerated, this is not the most important instruction. 2) CORRECT— Overexposure to heat or cold may cause damage related to the changes in sensation. Extremes in temperature can also exacerbate multiple sclerosis symptoms. 3) INCORRECT— The client should be encouraged to participate in an exercise program that includes range-of-motion (ROM), stretching, and strengthening exercises, but this is not the most important instruction. 4) INCORRECT— The client should be encouraged to continue usual activities as much as possible, including social activities. However, this is not the most important instruction.

The nurse provides discharge teaching to a client with multiple sclerosis. Which instruction is most important for the nurse to include? 1. Ambulate as tolerated every day.2. Avoid overexposure to heat or cold.3. Perform stretching and strengthening exercises.4. Participate in social activities.

1) INCORRECT - Passive exercise is carried out by the nurse without help from the client. 2) CORRECT— In active-assistive exercise, the distal part of the limb is supported when the client actively takes the joint through range-of-motion. 3) INCORRECT - Active exercise is carried out by the client without help from the nursing staff. This type of exercise increases muscle strength and increases joint flexibility. 4) INCORRECT - Resistive is a type of active exercise that is carried out independently by the client. The client works against resistance to increase muscle power.

The nurse supports the leg as a client bends and flexes the knee. Which type of therapeutic exercise is the nurse assisting the client to perform? 1. Passive.2. Active-assistive. 3. Active. 4. Resistive.

1) CORRECT - There are no interactions noted between acetaminophen and antihypertensives. 2) INCORRECT - Antihypertensives can cause orthostatic hypotension. The client should get up slowly from sitting or lying down. 3) INCORRECT - Several herbal supplements can interfere with the effectiveness of antihypertensive medications. The client should discuss any herbal supplement use with the health care provider prior to use. 4) CORRECT - Smoking can reduce the effects of antihypertensives as smoking causes vasoconstriction. 5) INCORRECT - Antihypertensive effectiveness needs to be monitored on a regular basis.

The nurse teaches a client about a new medication for hypertension. Which client statement indicates that further teaching is needed? (Select all that apply.) 1. "I should not take acetaminophen with this medication."2. "I will get up slowly from sitting or lying down while taking this medication."3. "I will check with my health care provider before taking herbal supplements."4. "I do not need to stop smoking now that I have this medication."5. "I need to continue to monitor my blood pressure."

1) CORRECT - Bran flakes are low in fat while skim milk contains no fat. 2) INCORRECT- Avocado and peanut butter are both high in fat. 3) CORRECT - Canadian bacon and egg whites are both low in fat. These are good substitutes for regular bacon and whole eggs. 4) CORRECT - Baked tortilla chips and salsa are both low in fat. 5) INCORRECT- Bologna and potato chips are both high in fat. 6) CORRECT - Water-packed tuna is low in fat. While cola is high in carbohydrates, it is not a high-fat food.

The nurse teaches a client who is prescribed a reduced fat diet. The nurse determines that teaching is effective if the client makes which menu selections?(Select all that apply.) 1. Bran flakes and skim milk.2. Avocado and peanut butter sandwich.3. Canadian bacon and egg whites.4. Baked tortilla chips and salsa.5. Bologna sandwich and potato chips.6. Water-packed tuna and a cola.

1) CORRECT— A school-age child who is less than 4 feet 9 inches tall needs to use a booster seat that has both a lap belt and shoulder belts. This parent needs additional instruction. 2) INCORRECT - Children younger than adolescence should not sit in the front passenger seat of a vehicle with an airbag. 3) INCORRECT - A school-age child can sit in a car without a booster seat if the vehicle's seat belt fits properly. The belt should lie low and flat over the child's hip bones and across the shoulder, not the neck or face. 4) INCORRECT - Vehicle seat belts typically fit properly when a child is 4 feet 9 inches or taller.

The nurse teaches parents of school-age children about car safety. Which parental statement indicates to the nurse a need for further teaching? 1. "My child, who is 4 feet 2 inches tall, can sit in a booster seat with only a lap belt."2. "My child does not ride in the front seat of a vehicle with an airbag."3. "My child can use the vehicle seat belt if it lays over the hip bones and across the shoulders."4. "When my child grows to 4 feet 9 inches or taller, a booster seat is not needed."

1) CORRECT - If the client is overweight, a weight loss of 0.5 to 1 lbs (0.23 to 0.5 kg) per week is appropriate. Excessive weight loss may precipitate gouty arthritis. 2) INCORRECT - The client should be drinking eight glasses of liquid per day. 3) INCORRECT - The client should be increasing the intake of whole grains and fresh fruit. 4) INCORRECT - The client with gout should refrain from ingesting alcohol.

The nurse visits the home of a client diagnosed with gout. Which client comment causes the nurse concern during the assessment process? 1. "I am losing three pounds per week."2. "I drink eight glasses of liquid per day."3. "I am eating more whole grains and fresh fruits."4. "I do not drink alcoholic beverages anymore."

1) INCORRECT - The child with a red rash on the cheeks indicates fifth disease. This illness is most contagious before the rash appears. Isolation is not required once the rash appears, and the child can attend school. 2) CORRECT- The child with a fever, headache malaise, anorexia, and ear pain with chewing indicates probable mumps. The child is most communicable immediately before and after the swelling begins. 3) INCORRECT - Allergic conjunctivitis is not contagious. This child does not need to go home from school. 4) INCORRECT - The child with pruritic papules is experiencing eczema. This child does not need to go home from school.

The school nurse assesses four school-age clients. Which client's parents will be contacted to pick up the child from school? 1. Child with a red rash on the cheeks that makes the face look like it has been slapped. 2. Child with a fever reporting headache, malaise, anorexia, and an earache when chewing. 3. Child with allergies whose conjunctiva are inflamed with swollen eyelids and watery drainage. 4. Child with clusters of small, erythematous, intensely pruritic papules in the antecubital space.