Random Questions

A pediatric nurse is teaching a group of new parents about what to expect regarding their infants eyes and vision. What points should the nurse include? 1. At 4 weeks of age, the infant should be able to gaze at objects. 2. Infants should have tears by the age of 1 month. 3. Visual acuity is about 20/300 at 4 months of age. 4. During the first 2 months of life, infant's eyes may appear to be crossed. 5. Depth perception begins around the 5th month of age.

1., 3, 4, & 5. These statements are correct. At birth the baby's vision is limited best to 8-10 inches from their face. The eyes are not well coordinated and may appear crossed. 2. Incorrect: Infants do not have tears until about 3 months of age.

What is the most effective method of stroke prevention that the nurse should teach to the public? 1. Administering platelet inhibitors to prevent clot formation. 2. Undergoing transluminal angioplasty to open a stenosed artery and improve blood flow. 3. Maintaining normal weight, exercising, and controlling comorbid conditions. 4. Administering tissue plasminogen activator (tPA).

3. Correct: Although administering platelet inhibitors, tPA, and undergoing transluminal angioplasty may improve cerebral blood flow, the goals of stroke prevention include health promotion for the healthy individual and education and management of modifiable risk factors to prevent a stroke. Health promotion focuses on a healthy diet, weight control, regular excercising, no smoking, limited alcohol consumption and routine health assessments. 1. Incorrect: This is not the most effective method to prevent a stroke. Anti platelet drugs are usually the chosen treatment to prevent stroke in clients who have had a TIA. 2. Incorrect: This is not the most effective method to prevent a stroke. Transluminal angioplasty is an invasive procedure to improve blood flow. 4. Incorrect: This is not the most effective method to prevent a stroke. tPA is administered IV to reestablish blood flow through a blocked artery in a client with acute onset of ischemic stroke symptoms.

The nurse is caring for a client with a closed head injury. Three days after admission, urinary output for 8 hours was 1800 mL. In response to this data, what would be the appropriate nursing action? 1. Hydrate the client with 500 mL of IV fluid in the next hour. 2. Monitor BUN and creatinine. 3. Check urine specific gravity. 4. Recognize this as a side effect of dexamethasone.

3. Correct: For any client with a head injury and abnormally high urinary output, the nurse knows the client is at risk for ADH (anti-diuretic hormone) problems. The pituitary gland is located in the brain. ADH is produced in the pituitary gland. In head injured clients, ADH can get messed up. If the client does not have enough ADH large volumes of water will be lost in the urine. The name of this disease is diabetes insipidus (DI). Large volume losses place the client at risk for shock. The nurse knows to further investigate the problem by checking a urine specific gravity. For clients in DI, the urine specific gravity will be very, very low because they are losing so much water. When you see the letters DI, think of the "D" for diuresis and think SHOCK first. 1. Incorrect: Administration of 500 mL of fluid over one hour is possible if the client were in shock. The stem of the question, however, does not indicate this client is in shock. 2. Incorrect: Monitoring BUN and creatinine does not help identify diabetes insipidus. 4. Incorrect: Decadron can cause fluid retention, not increased urinary output.

Which assessment finding by the nurse is likely to indicate an increased level of stress in a client? 1. Weight at normal level. 2. Daily experience of headaches and other body aches. 3. Use of the problem solving method to handle daily annoyances. 4. Reports of increased creativity in the job situation.

2. Correct: Headaches and other body aches may indicate increased levels of stress. Body aches may even be an indicator of depression. Restlessness and fatigue may also indicate increased levels of stress. 1. Incorrect: Normal weight is not an indicator of increased stress. If stress levels are increased, most people experience weight loss or a gain. 3. Incorrect: This does not indicate an increased level of stress. Use of the problem solving method is an effective way to deal with stress. 4. Incorrect: This does not indicate an increased level of stress. Creativity is usually decreased when stress levels are increased.

The staff nurse is caring for a 3-month old client receiving potassium IV therapy. Which actions indicate to the charge nurse that the staff nurse understands IV management? 1. Uses a 15 gtt factor drip chamber when changing the IV tubing. 2. Applies elbow restraints to prevent dislodgement of the IV catheter. 3. Checks the IV site for blood return hourly. 4. Instructs unlicensed assistive personnel (UAP) to count drip rate hourly. 5. Attaches a volume-controlled IV administration set to IV bag prior to beginning IV therapy.

2., 3. & 5. Correct: Young children and infants usually must be restrained to some degree to prevent accidental dislodging of the needle. Elbow restraints can prevent an infant with a scalp IV from rubbing or touching the IV site. When a foot, leg, or arm is used, limb motion must be limited. IV potassium is an irritant. When the fluid being infused is a known irritant or vesicant, the nurse should check the IV site for blood return and possible infiltration hourly. Infants and young children have a narrow range of normal fluid volume, and the risk for fluid overload is great, especially in an infant. Always use a volume-controlled IV administration set with an infant or small child. These sets hold no more than 100-150 mL of fluid, so the maximum amount that could accidentally be infused is limited. 1. Incorrect: Always use microdrip tubing which is a 60 gtt chamber. Microdrip chambers are used for children and for clients who can not tolerate a fast infusion rate or large volumes. 4. Incorrect: This intervention is beyond the scope of a UAP. The UAP may assist with activities of daily living and bedside care under the supervision of a registered nurse or other healthcare professional. The nurse is responsible for monitoring the IV flow rate.

Which signs/symptoms noted by the nurse would support a client history of chronic emphysema? 1. Atelectasis. 2. Increased anteroposterior (AP) diameter. 3. Breathlessness. 4. Use of accessory muscles with respiration. 5. Leans backwards to breathe. 6. Clubbing of fingernails

2., 3., 4., & 6. Correct: Emphysema is described as a permanent hyperinflation of lung beyond the bronchioles with destruction of alveolar walls. Airway resistance is increased, especially on expiration. Inspection reveals dyspnea on exertion, barrel chest (anteroposterior diameter is equal to transverse diameter), tachypnea, and use of accessory muscles with respiration. Clubbing of fingernails is due to chronically decreased oxygen levels. 1. Incorrect: Atelectasis is collapse of alveolar lung tissue, and findings reflect presence of a small, airless lung. This condition is caused by complete obstruction of a draining bronchus by a tumor, thick secretions, or an aspirated foreign body, or by compression of lung. 5. Incorrect: Client tends to lean forward (orthopnea) and uses accessory muscles of respiration to breathe.

The schizophrenic client tells the nurse, "I am Jesus, and I am here to save the world!" The client is reading from the Bible and warning others of hell and damnation. The other clients on the unit are upset and several are beginning to cry. What nursing intervention is most appropriate? 1. Set verbal limits and have the client return to assigned room. 2. Explain to the client that not all people are Christians. 3. Remove the Bible from the client and explain that the client is not Jesus. 4. Ask the client to share with the group how the client is Jesus.

1. Correct: Yes, the nurse must set limits. This is disrupting others and so the client needs to be redirected to their room for a cool down and then another activity shortly thereafter. This client is experiencing delusions of grandeur, which are not reality based, and require intervention that does not reinforce the behavior. 2. Incorrect: No, this will only reinforce the clients thought process of religion. 3. Incorrect: No, don't argue with the client. This is not therapeutic and does nothing to help resolve the disruption to the other clients. 4. Incorrect: This is ridiculing the client and also inflaming the situation. This is not desirable.

In which situations should the nurse notify the primary healthcare provider of a medication incident? 1. Every occurance. 2. Client is harmed or dies. 3. Medication incident is a near miss. 4. Nurse administers an incorrect dosage. 5. Client questions the medication color.

2. & 4. Correct: The primary healthcare provider should be notified if harm is brought to the client or death occurs as a result of the medication incident. The primary healthcare provider should be notified if the nurse administers an incorrect dosage to the client, and an incident report needs to be completed in this situation. 1. Incorrect: The primary healthcare provider should be notified if harm is brought to the client but not for all events with medications. An incident report should be completed so the hospital can track incident patterns for quality improvement. 3. Incorrect: Near misses do not need to be reported to the primary healthcare provider. Following the rights of medication administration every time ensures medication error prevention. 5. Incorrect: The nurse should answer questions regarding medication color. Depending on the manufacturer, the shape and color of the medication can vary.

Which assessment finding identified in a client diagnosed with Guillain-Barre Syndrome would indicate that the nurse needs to notify the primary healthcare provider? 1. Vital lung capacity of 900 mL. 2. Breathlessness while talking. 3. Heart rate of 98 beats per minute. 4. Respiratory rate of 24 breaths per minute.

2. Correct: Breathlessness while talking indicates respiratory fatigue. Preparation for intubation needs to be made. 1. Incorrect: If the vital lung capacity drops below 800 mL, mechanical ventilation is warranted. 3. Incorrect: Imminent signs of respiratory failure include a heart rate greater than 120 beats per minute or less than 70 beats per minute. 4. Incorrect: Imminent signs of respiratory failure include a respiratory rate greater than 30 breaths per minute.

The out patient surgical unit has admitted multiple clients currently awaiting early morning procedures. What client should the nurse assess first? 1. The client awaiting repair of hiatal hernia reporting chest pain. 2. The client with a torn right rotator cuff reporting shoulder pain. 3. The client with an inguinal hernia repair reporting skin irritation. 4. The client awaiting a hemorrhoidectomy reporting rectal bleeding.

1. Correct: A hiatal hernia occurs when a portion of the stomach pushes up through the esophageal ring (hiatus) of the diaphragm. Surgical intervention is generally a last resort and only when there is evidence of serious complications. Although chest pain could be the result of reflux within the esophagus, it could also indicate a strangulated hiatal hernia. The nurse needs to assess this client immediately. 2. Incorrect: A torn rotator cuff is generally only repaired when other treatment options have been ineffective, such as rest, ice, NSAIDs and even steroid injections. This client has been ordered a surgical repair, indicating other therapies have failed. Shoulder pain on the affected side is to be expected and not an urgent need. 3. Incorrect: An inguinal hernia is the protrusion of intestine through abdominal muscles, creating a painful bulge which worsens with lifting, bending, or straining. Skin irritation usually results from wearing a supportive garment known as a truss. The purpose of this belted device is to apply pressure and provide support to the area of the hernia until surgical repair. Skin irritation is not the nurse's priority. 4. Incorrect: Large or engorged rectal hemorrhoids may require surgical repair because of excessive bleeding, pain, or prolapse. This type of bleeding is not unexpected nor does it present any major concerns about shock. This client would not need to be seen first.

An emergency room nurse is assessing a child with a suspicious spiral fracture to the right arm. The nurse is aware the best evidence to support possible child abuse is what? 1. Inconsistency between injury and explanation of the cause. 2. Child withdraws when the parent tries to hug or comfort. 3. Parents leave the room when questioned about the injury. 4. Lack of parental concern with injury or pending treatment.

1. Correct: The best evidence to support suspicion of child abuse is an inconsistent story between how the injury occurred and the injuries noted in the child. There may be additional signs noted by the nurse, but specific details about what led to the injury, compared to the physical assessment, provides clear evidence for possible abuse. 2. Incorrect: While most children become clingy when an illness or injury occurs, withdrawing from a parent is not clear evidence of abuse. It could be an indication of dysfunctional parenting or incomplete bonding, but not necessarily child abuse. 3. Incorrect: Though most parents seem very concerned and are overly attentive, others may be overcome with grief that the incident happened. When questioned about the cause of the injury, a parent may exit the room, overcome by a sense of guilt and responsibility for the occurrence. This action is not true evidence of child abuse. 4. Incorrect: Parental response to an injured child widely varies and can be inconsistent based on multiple factors, such as sex and age of child, personal perceptions, cultural practices and even the circumstances of the event. Parents can become so overwhelmed by the incident that even non-abusive parents may seem indifferent while trying to remain strong.

When providing instructions, the nurse asks the client to repeat the techniques for crutch walking. The nurse is aware that further teaching is needed when the client makes which statement? 1. "The elbows should be flexed at 10 degrees." 2. "I should not lean on the crutches with my armpit." 3. "When going upstairs, my non-surgical leg goes up first." 4. "Both crutches are held in one hand when sitting down".

1. Correct: The nurse is looking for an incorrect statement from the client. This statement indicates the client will need further instruction prior to discharge. When using crutches, the client's elbows should be flexed at 30 degrees. 2. Incorrect: This is a correct statement by the client. The weight of the body is placed on the hands and handgrips rather than being supported by the armpits, which could cause axillary nerve damage. This is a correct statement by the client; however, the question asks for an incorrect statement by the client. 3. Incorrect: The client is aware that the non-surgical "good" leg should be placed on the steps first when going upstairs, while the surgical "bad" leg is placed on the stairs first when coming down steps. This is a correct statement, indicating that the client did understand teaching; however, this question is looking for an indication that the client needs further instructions. 4. Incorrect: When sitting down in a chair, the client would indeed place both crutches in one hand while safely reaching for the chair with the free hand. This is a correct statement and does not indicate the need for further teaching.

The school nurse has educated a group of teens concerned about acquiring the Ebola virus. Which statement by the students would indicate to the nurse that further teaching is necessary? 1. "I can get a vaccine to prevent getting the Ebola virus." 2. "Ebola is not spread through casual contact, so my risk of getting the virus is low." 3. "The Ebola virus is passed from person to person through blood and body fluid." 4. "Ebola viruses are mainly found in primates in Africa."

1. Correct: This is an incorrect statement. At present, there is no vaccine to prevent Ebola. 2. Incorrect: This is a correct statement about the Ebola virus. Ebola is not spread through casual contact. 3. Incorrect: This is a correct statement about the Ebola virus. Ebola virus is passed from person to person through blood and body fluid. 4. Incorrect: This is a correct statement about the Ebola virus. Ebola viruses are mainly found in primates in Africa.

What actions should the nurse take when administering fentanyl? 1. Remove old fentanyl patch prior to applying new patch. 2. Cleanse area of old fentanyl patch. 3. Shave hair where fentanyl patch will be applied. 4. Place fentanyl patch over dry skin. 5. Apply adhesive dressing over the fentanyl patch. 6. Dispose of fentanyl patch in trash.

1., 2., & 4. Correct: These are correct actions. Apply patch to dry, hairless area of subcutaneous tissue, preferably the chest, abdomen, or upper back. The old patch should be removed prior to applying a new patch so that too much medication is not given. This is also why the old site should be cleaned. The patch should be placed on dry skin. Do not place over emaciated skin, irritated or broken skin, or edematous skin. 3. Incorrect: Do not shave area where patch will be applied and do not apply over dense hair areas. If there is hair on the skin, clip the hair as close to the skin as possible, but do not shave. 5. Incorrect: Do not apply adhesive dressing over patch. It can interfere with absorption. If the patch comes loose, you may tape the edges and remove and apply a new patch. 6. Incorrect: Dispose of fentanyl patch in sharps container. Fentanyl patches that have been worn 3 days still contain enough medication to cause serious harm to adults and children.

The nurse is teaching the family of a homebound client about ways to increase the client's safety while bathing independently. Which strategies should the nurse include? 1. Install grab bars in the tub or shower. 2. Install hand bars on sides of tub. 3. Use tub/shower seat for bathing. 4. Provide a long handled bath scrubbie for bathing. 5. Schedule bathing routines three times per week.

1., 2., 3. & 4. Correct: Grab bars will assist the client in getting into or out of the tub or shower, thus reducing the chance for falls. Hand bars are very helpful as one enters or exits the tub. The increased stability offered by these devices reduces risk of falls. Using a shower seat will allow the client to remain independent in terms of entering or exiting the tub or shower. The use of handled scrubbies or sponges allows the client to reach lower extremities or back with greater ease. 5. Incorrect: The bathing routine may need to be more often than three times per week depending on the client. The bathing schedule does not relate to a client's independence.

Which signs/symptoms does the nurse expect to note when caring for a client with a suspected cystitis? 1. Incontinence 2. Urgency 3. Frequency 4. Hematuria 5. Nocturia 6. Flank pain

1., 2., 3., 4. & 5. Correct: Signs and symptoms of cystitis include burning on urination, nocturia, incontinence, suprapubic or pelvic pain, hematuria, and back pain. 6. Incorrect: Flank pain is seen when the urinary tract infection progresses to the kidneys.

Which food items, if chosen by a client diagnosed with diverticulosis, would indicate to the nurse that the client understands the prescribed diet? 1. Avocados 2. Acorn squash 3. Applesauce 4. Lima beans 5. Raspberries 6. Cottage cheese

1., 2., 4., & 5. Correct: High fiber foods include raw fruits, legumes, vegetables, whole breads, and cereals. Avocados have 10.5 grams of fiber per cup. Acorn squash has 9 grams of fiber per cup. Lima beans 13.2 grams of fiber per cup. Raspberries have 8 grams of fiber per cup. 3. Incorrect: Raw fruits have more fiber than cooked or processed fruits. A raw apple would provide more fiber than applesauce. 6. Incorrect: Milk and foods made from milk: such as yogurt, pudding, ice cream, cheeses, cottage cheese and sour cream are low fiber.

A client with distended and tortuous veins along the inner aspects of both legs asks the nurse how to decrease the development of these veins. What should the nurse advise? 1. Exercise 2. Follow a low protein diet 3. Wear low heeled shoes 4. Elevate legs above heart several times per day 5. Do not cross legs

1., 3., 4., & 5. Correct: These are varicose veins. Get moving. Walking is a great way to encourage blood circulation to the legs. Low-heeled shoes work calf muscles more, which is better for veins. To improve circulation in legs, take several short breaks daily to elevate legs above the level of the heart. Do not cross legs as it decreases circulation distally. 2. Incorrect: Low sodium diet will prevent swelling caused from water retention. A diet low in protein will not decrease the development of these veins. The key is to keep swelling down so that pressure on the veins is reduced.

What discharge instructions should the nurse include for a client following a transsphenoidal hypophysectomy? 1. Sleep with head of bed at 35 degrees. 2. Notify the primary healthcare provider for an increased urinary output. 3. Brush the teeth three times a day followed by rinsing with a commercial mouthwash. 4. Nasal packing will need to be removed in 48 hours. 5. Use a humidifier in the room. 6. Stay on a clear liquid diet for two days.

1.,2., 5. Correct. Sleeping with the head of the bed elevated will promote drainage of cerebrospinal fluid. An increased UOP could indicate diabetes insipidus, an adverse reaction to this surgical procedure. Humidified air prevents drying of nasal passages. 3. Incorrect. Because the incision for this surgery is just above the gumline, the client should not brush the front teeth. Oral care should be performed with a sponge until the incision heals. 4. Incorrect. There is no nasal packing. The incision is located just above the gumline of the upper teeth. 6. Incorrect. The client can eat a regular diet.

How would a tendency toward stereotyping and countertransference affect the nurse's ability to complete a client's cultural assessment? 1. Facilitate the care planning process 2. Promote decisions based on the nurses value system 3. Utilize an open honest approach while responding to the client's concerns 4. Develop an unbiased approach to care.

2. Correct: Both stereotyping and countertransference will decrease the nurse's sensitivity to the client's needs and the culture they represent. Nurses who impose these values upon clients will make decisions based on their attitudes, values and beliefs and not those of the culturally different client. 1. Incorrect: Both stereotyping and countertransference also interfere with the treatment process you can't base your care plan on your general views toward a client's culture. Care plans, must be individualized and not based on stereotypes. 3. Incorrect: The nurse will make automatic responses based on preconceived ideas and expectations. The nurse is unable to be open and honest about client concerns. Remember, stereotyped behavior is based on the assumption that all people in a similar cultural, racial or ethical group think and act alike. 4. Incorrect: The nurse's need to maintain an unbiased care is important because the client's needs remain unmet. Value clarification by the nurse will assist in preventing stereotyping and countertransference to other clients. The nurse will never have an unbiased approach to care for clients unless the nurse understands and removes unhealthy values affecting the assessment process.

A client has been admitted to the labor and delivery unit with a diagnosis of preeclampsia. During afternoon rounds, which assessment finding by the nurse should be reported to the primary healthcare provider immediately? 1. Deep tendon reflexes of plus three. 2. Urine output of 80 mL over four hours. 3. Respiratory rate of 24 breaths/minute. 4. Severe headache with blurred vision.

2. Correct: Preeclampsia is a condition in which the client's blood pressure is consistently elevated, with a systolic greater than 140 mm Hg and a diastolic above 90 mm Hg. The greatest main concern is decreased perfusion to the placenta, endangering mother and fetus, potentially accompanied by seizures, kidney or liver failure. This client has had only 80 mL of urine in four hours, indicating an output less than the minimum required of 30 mL per hour. This indication of possible kidney failure should be reported to the primary healthcare provider immediately. 1. Incorrect: Deep tendon reflexes (DTR'S) range from 0 to +5 and are used to assess the neurologic integrity of the body. Normal reflexes for the body range around +2 but become elevated in preeclampsia. The possibility of seizures increases as DTR's increase over the normal range. This symptom is serious but expected in a client with preeclampsia. The nurse should continue monitoring this. 3.Incorrect: As blood pressure increases in the preeclampsic client, both respirations and heart rate would also begin to elevate. The client may display excessive swelling of hands and feet, occasionally accompanied by facial swelling. Although a respiratory rate of 24 is a bit elevated, it is nothing the nurse needs to report immediately. 4. Incorrect: The combination of increased blood pressure and swelling in preeclampsia frequently results in severe headaches and blurred vision. If the blood pressure reaches life-threatening levels, clients have been known to develop blindness because of retinal response to the decreased body perfusion. Although headache and blurred vision are serious symptoms, this is not completely unexpected and therefore does not need to be reported to the primary healthcare provider immediately.

Which action by two unlicensed nursing personnel (UAPs), while moving the client back up in bed, would require intervention by the nurse? 1. Lowers the side rails closest to them. 2. Places hands under client's axilla. 3. Lowers the head of bed. 4. Raises the height of the bed.

2. Correct: This action is not appropriate and requires intervention by the nurse. This could damage the brachial plexus nerves under the axilla. Use a draw sheet to prevent this from occurring. 1. Incorrect: This is a correct action. The UAPs will need to lower the side rails closest to them to safely move the client up in bed. Not lowering the rails could injury the UAPs back. 3. Incorrect: This action is correct. Moving the client upward with the head of the bed raised works against gravity, requires more force and can cause back strain. 4. Incorrect: This action is appropriate and would not require intervention by the nurse. Raising the height of the bed brings the client close to the UAPs center of gravity and decreases the chance of back injury.

A nurse is planning to teach a group of adult males in their 40's about health care promotion recommendations. Which recommendations should the nurse include? 1. Do bi-annual skin self-exam to check for new moles or changes in moles. 2. Comprehensive eye exam every 5 years starting at age 45. 3. Limit alcohol intake to no more than two drinks per day. 4. Yearly physical exam from a health care provider. 5. Get at least 30 minutes of moderate physical exercise on most days of the week.

3, & 5. Correct: If a client must drink alcohol, they should do so only in moderation. For men, that means up to two drinks a day for men age 65 or younger and one drink a day for men over age 65. The risk of various types of cancer, such as liver cancer, appears to increase with the amount of alcohol ingested and the length of time that one has regularly been drinking. Too much alcohol can also raise blood pressure. Physical exercise can go a long way toward managing stress and controlling weight. Controlling stress and obesity can decrease the risk of many health risks such as heart disease, diabetes, and stroke. 1. Incorrect: Do monthly skin self-exam to check for new moles or changes in moles. 2. Incorrect: Comprehensive eye exam every 2 years is recommended. Changes in vision is a relatively common problem for people in their 40s. They may find that glasses are needed for the first time in their life. They may need glasses to see at a distance or for reading. 4. Incorrect: Physical exam every 2-3 years when no health issues exist including height, weight, and BMI. Routine blood tests, urinalysis and mental health screening is conducted at this time.

The nurse in the pediatric intensive care unit (PICU) is caring for a preschool child three days after open heart surgery. What assessment finding should the nurse report immediately to the primary healthcare provider? 1. Increased episodes of fussy crying. 2. A hacking, non-productive cough. 3. Oral temperature of 100.9°F (38.3°C). 4. Chest tube draining 30 mL per shift.

3. CORRECT: An oral temperature of 100.9°F (38.3°C) is considered too elevated for 3 days post-op. An oral body temperature greater than 100.5°F (38.1°C) indicates the potential for infection. Although no other vital signs are given in the scenario, a temperature this elevated would need to be reported immediately by the nurse to the primary healthcare provider. 1. INCORRECT: Increasing episodes of crying could indicate many things in a preschool child, including pain, fear, loneliness, or even elevated body temperature. While this change in the client's status will need to be investigated further, the nurse would not need to report this behavior at this time. 2. INCORRECT: A hacking, non-productive cough, even several days after open heart surgery, could be attributed to the effects of intubation, anesthesia, or even certain cardiac medications. Clients are always encouraged to cough and deep breathe in order to prevent pulmonary complications. If the cough becomes productive or breathing becomes labored, the nurse would need to report this to the primary healthcare provider. This is not an urgent concern for the nurse. 4. INCORRECT: Chest tube drainage is common following open-heart surgery, even three days later. It is impossible to evaluate whether 30 mL in one shift is a change since there are no parameters to compare the previous shift's output. The nurse would not need to report this drainage at this time.

An adolescent is being instructed on the proper way to use crutches following knee surgery. The nurse knows that teaching has been successful when the client makes what statement? 1. "The weight of the crutches should be on my shoulders." 2. "It's ok to lean against the crutches if I am standing still." 3. "If going up the stairs, my non-operative leg goes up first." 4. "When sitting down, first lean crutches against the wall."

3. CORRECT: It is evident that the client has understood the nurse's instructions with this statement. When going up stairs with crutches, the unaffected (non-operative) leg goes up first. The strong leg bears the body weight and therefore provides a solid base while the client lifts up the weaker leg. 1. INCORRECT: The correct position for crutches should be about 2 inches below the axilla and never directly up into the arm pit. Body weight is carried by the hands on the hand-grips, which means the force to push comes from the forearms and biceps, not the shoulders. Bearing weight in the axilla can cause severe damage to the axillary nerves and muscles. 2. INCORRECT: Crutches are an ambulatory aid only and, if not used correctly, can actually be a safety hazard. Even if the client is standing still, it is unsafe to use crutches as a leaning support. Additionally, even resting on the crutches can cause trauma to the axillary area. 4. INCORRECT: When sitting in a chair, the client should back up to the chair until the back of the knees gently touches the chair seat. The client should then reach back and grab the arm of the chair while holding both crutches in the other hand. Once seated, the client can then lean the crutches upright nearby. They will balance better if stood upside down.

After drawing up insulin for subcutaneous administration, the nurse receives a return phone call from a primary healthcare provider who wants to give prescription orders on a new admit. The nurse asks a new nurse to administer the insulin dose. What action should the new nurse take? 1. Administer the insulin dose to the client. 2. Consult with the charge nurse about administering the insulin dose to the client. 3. Tell the nurse that whoever draws up the medication has to administer that medication. 4. Offer to take the call from the primary healthcare provider so the nurse can administer the insulin.

3. Correct: A nurse can only administer medication that has been drawn up by that nurse. It is not acceptable practice to administer a medication drawn up by another nurse. 1. Incorrect: The nurse who gives this medication does not really know what was drawn up. It could be the wrong medication, the wrong dose, the wrong time. A nurse can only administer medication that has been drawn up by that nurse. 2. Incorrect: There is no need to consult the charge nurse because the new nurse should not administer the medication that has been drawn up by another nurse. 4. Incorrect: The nurse should first take the return phone call from the primary healthcare provider and then administer the insulin yourself.

A client has been admitted to the emergency department after repeated food binging and purging by vomiting and laxative abuse. The client reports leg pains and weakness. ECG reveals a depressed ST segment and flattened T wave. Based on this data, what does the nurse anticipate that this client will need to receive first? 1. Oral fluids 2. Kayexalate enemas 3. Intravenous potassium (KCL) 4. An antidiarrheal medication

3. Correct: Look at the clues in the stem: vomiting, laxative abuse, symptoms of hypokalemia including weakness, muscle cramps, and arrhythmias. Due to repeated laxative abuse and vomiting, the client has lost potassium. Normal potassium is 3.5-5.0 mEq/L. IV potassium is required for a severely low potassium. 1. Incorrect: Oral fluids are needed, but with symptoms this severe, IV resuscitation is needed with potassium. The client is exhibiting symptoms of severe hypokalemia. The potassium is prescribed to correct this imbalance. 2. Incorrect: Kayexalate is given for high potassium. This client's potassium is low. The therapeutic effect of kayexalate is to reduce the serum potassium level. 4. Incorrect: We are worried about low potassium here. This won't solve the problem. An antidiarrheal medication may be prescribed, but the client is exhibiting symptoms of hypokalemia. The client should be administered the IV potassium first to correct the low potassium level.

A full term infant is being assessed 12 hours after birth. The infant's respiratory rate is 50 and shallow, with periods of apnea. What action by the nurse takes priority? 1. Apply oxygen by mask at 1 liter. 2. Prepare for emergency intubation. 3. Continue monitoring every 15 minutes. 4. Notify the primary healthcare provider stat.

3. Correct: Normal respirations in the healthy neonate are generally shallow and expected to be between 30 and 50 times per minute with short periods of apnea up to 5 seconds. This infant is displaying a normal respiratory status for the newborn. The nurse should continue to monitor the infant. 1. Incorrect: This infant is showing normal adaptation to extrauterine life. The rate of 50, even with short periods of apnea, is within expected limits for a newborn. No need for oxygen at this time. 2. Incorrect:There is no indication that this infant is experiencing respiratory distress which would require intubation. Shallow respirations at the rate of 30 to 50 times per minute are expected, even with short apneic periods of 5 seconds. 4. Incorrect: There is no need to contact the primary healthcare provider. The respiratory status of this infant, even with short periods of apnea, is normal for a full term infant 12 hours after birth. Continued monitoring is all that is needed at this time.

A female client considers using spermicidal agents because she wants both birth control and protection from sexually transmitted infections (STIs). What information should the nurse provide the client about spermicidal agents? 1. Effectively reduces vaginal fungal infections such as Candida albicans. 2. Eliminates bacterial and viral sexually transmitted infections. 3. Most effective when used in conjunction with barrier methods, such as a diaphragm. 4. Causes few side effects.

3. Correct: Spermicidal agents have an approximately 25% failure rate in preventing pregnancy. These agents kill sperm by destroying the protective surface of sperm and preventing metabolic activities necessary for survival. 1. Incorrect: They do not kill fungi such as Candida albicans, even in high concentrations. 4. Incorrect: Spermicidal agents are used only when sexual intercourse is expected, but side effects include vaginal and penile irritation, lesions, and ulcerations due to the detergent effect. Disruption of normal protective vaginal flora results in an increased risk of opportunistic vaginal infections and urinary tract infections. 2. Incorrect: Spermicidal agents do not eliminate bacterial and viral STIs.

The nurse is teaching a community education class on alternative therapies. Which alternative therapy that uses substances found in nature should the nurse include? 1. Energy therapies. 2. Mind-body interventions. 3. Body-based methods. 4. Biologically-based therapies.

4. Correct: Biologically-based therapies use substances found in nature such as herbs, foods, and vitamins. 1. Incorrect: Energy therapies use energy fields. Substances found in nature are biologically-based therapies. 2. Incorrect: Mind-body interventions use the mind to help affect the function of the body. Substances found in nature are biologically-based therapies. 3. Incorrect: Body-based methods use movement of the body. Substances found in nature are biologically-based therapies.

Which intervention should the nurse recommend to the adult child who is caring for an elderly parent diagnosed with Alzheimer's disease (AD)? 1. Give parent a small dog for company and comfort. 2. Reset the water heater to 125 degrees Fahrenheit (51.67 degree Celsius) to prevent burns. 3. Place mirrors in multiple locations so parent sees images of self. 4. Make floors and walls different colors.

4. Correct: People with Alzheimer's disease (AD) get more confused over time. They also may not see, smell, touch, hear and/or taste things they once did. By creating a contrast in color between the floors and walls makes it easier for the person with AD to see. 1. Incorrect: Be careful with small pets. The person with AD may not see the pet and trip over it. This is a safety issue. A fall could cause a major injury to the client. 2. Incorrect: The water heater should be set below 120 degrees Fahrenheit (48.8 degrees Celsius) to prevent burns. 3. Incorrect: Limit the size and number of mirrors in the home. Mirror images may confuse the person with AD. They may not recognize self and may see the person as a stranger.

What room assignment would be best for the nurse to make for a primigravida with gestational diabetes who was admitted for glycemic control? 1. A private room near the nurses' station. 2. A room with a client admitted with a placenta previa. 3. A room with a client in preterm labor. 4. A room with a client admitted with pregestational diabetes.

4. Correct: Placing clients with similar diagnoses together can result in information sharing and emotional support. It is ok to put these two clients together. 1. Incorrect: A private room is not required since the client has no emotional or infection control issues. Also, it is not necessary to place them near the nursing station because they do not need monitoring on that close of a level. 2. Incorrect: A client with placenta previa is in an unstable state and can have emotional issues concerning this diagnosis. The client would be best in a private room. 3. Incorrect: The client in preterm labor needs a private room that is quiet with limited visitors, she is having issues herself and concerned about her unborn child.

While preparing an information sheet for a client diagnosed with a vancomycin-resistant enterococcus (VRE) urinary tract infection (UTI), the home health nurse should include which instructions? 1. Wash hands with hot water and soap when hands are soiled. 2. Gloves are not needed in the home since contamination with VRE has already occurred. 3. Wash hands before using the bathroom and after preparing food. 4. Clean the bathroom and kitchen with warm water and bleach.

4. Correct: The bathroom and kitchen should be cleaned with warm water and bleach to decrease contamination. The client should wash hands after using the bathroom and before preparing food. 1. Incorrect: Instructing the client and family to wash with hot water can cause drying and cracking of the skin. Hands should be washed with all contacts. Washing hands is the single most important thing to do to prevent infection. 2. Incorrect: Gloves are needed with VRE to prevent spread of infection. Gloves are especially needed if contact with blood or other infectious materials is anticipated. 3. Incorrect: Hands should be washed after using the bathroom and prior to handling or preparing food.

The nurse notices the primary healthcare provider removes gloves after performing an invasive procedure on a client. The healthcare provider then enters another client's room without washing hands. What is the initial action by the nurse? 1. Ignore it since the primary healthcare provider knows best. 2. Contact the nursing supervisor. 3. Notify the chief of medical staff. 4. Remind the primary healthcare provider of the importance of standard precautions.

4. Correct: The nurse is the client's advocate and can remind the primary healthcare provider of the importance of washing hands before entering a client's room. Hand washing should be performed when going from one room to another. 1. Incorrect: Nurses are to be client advocates and resolve a problem that they see. The primary healthcare provider should wash their hands prior to entering another client's room. 2. Incorrect: The nursing supervisor is not the first step, the nurse is. This incident may be reported to the charge nurse at a later time but the client's safety is priority. 3. Incorrect: This is not the first step. The nurse should address the problem when it is witnessed. The nurse should follow the chain of command when reporting a problem but speaking to the chief of medical staff is not the best action at this time.

A client diagnosed with advanced cirrhosis is admitted with dehydration and elevated ammonia levels. While discussing dietary issues, the client requests larger portions of meat with meals. Which response by the nurse provides the most accurate information to the client? 1. I will ask the dietician to add more meat with dinner. 2. Protein must be limited because of elevated ammonia levels. 3. You need to drink more fluids because of your dehydration. 4. We can ask for between meal snacks with more carbohydrates.

2. Correct: Normally, protein is broken down into ammonia, which the liver converts into urea, and the kidneys then easily excrete. However, in a diseased liver, this conversion is not possible, and ammonia continues to build up in the body, ultimately affecting the brain. The nurse would be aware that additional protein would be harmful for this client. 1. Incorrect: Increasing meat at mealtimes would be detrimental to the client's health. When protein is taken into the body, a healthy liver will convert this into urea that is then excreted by the kidneys. However, this client's impaired liver is not able to make that conversion; therefore, the ammonia levels would continue to increase. The nurse can discuss with the client other foods that might safely be added to meals. 3. Incorrect: While it is true this client is dehydrated, the issue is that the client wants to increase the amount of meat at mealtimes. This response does not address the client's request nor does it provide any teaching that would help the client once discharged. 4. Incorrect: Although this response indicates that the nurse is focusing on the client's issue with food, this reply does not address the request for more meat with meals. This would be the appropriate opportunity to educate the client on the need to limit daily protein in the diet.

Which assigned client should the nurse see first? 1. Diagnosed with urinary tract infection 2 days ago who is to be discharged. 2. Admitted last night with a diagnosis of severe pneumonia. 3. 45 year old who had a hernia repair 24 hours ago. 4. Scheduled for an endoscopy in two hours.

2. Correct: The client with severe pneumonia is at greatest risk for respiratory difficulty and should be seen first. Clients with severe pneumonia may develop the following complications: bacteremia, septic shock, lung abscesses, pleural effusion, empyema, pleurisy, renal failure, and respiratory failure. 1. Incorrect: The client who is being discharged is considered to be stable. A client who was diagnosed with a urinary tract infection is considered to be stable. This client is not exhibiting signs of potential airway complications. 3. Incorrect: This postoperative client of 24 hours is considered stable. The client's age of 45 also does not suggest that the client was a surgical risk. 4. Incorrect: The client admitted for an endoscopy is considered to be stable at this point. There is no data listed to support the client needing to be assessed first.

A client at 34 weeks gestation with pregnancy induced hypertension (PIH) reports "heartburn." Which action by the nurse has priority? 1. Administer an antacid per standing orders. 2. Check client's blood pressure. 3. Call the primary healthcare provider immediately. 4. Assure client this is a normal discomfort of pregnancy.

3. Correct: Epigastric discomfort is commonly described as "heartburn" by pregnant clients, but epigastric discomfort is a symptom of impending rupture of the liver capsule and seizures associated with worsening PIH and eclampsia. As a new nurse we need to assume the worst. Call the primary healthcare provider. 1. Incorrect: Not a concern as much as impending seizure symptoms. Administering an antacid will not fix the problem if PIH is worsing. This is delaying care. 2. Incorrect: Not a concern as much as impending seizure symptoms. Checking the client's blood pressure is not the priority in this situation. It will not fix the problem. 4. Incorrect: Not in this situation. Heartburn is a normal discomfort or right upper quadrant pain in a client with PIH may indicate impending rupture of the liver capsule which is a life threatening complication.

Which risk factor should the nurse include when planning to educate a group of women about breast cancer? 1. Menopause before the age of 50 2. Drinking one glass of wine daily 3. Multiparity 4. Early menarche

4. Correct: Early menarche before age 12 is a known risk factor for breast cancer. The increased risk of breast cancer linked to a younger age at first period is likely due, at least in part, to the amount of estrogen a woman is exposed to in her life. A higher lifetime exposure to estrogen is linked to an increase in breast cancer risk. The earlier a woman starts having periods, the longer her breast tissue is exposed to estrogens released during the menstrual cycle and the greater her lifetime exposure to estrogen. 1. Incorrect: Studies show women who go through menopause after age 50 have increased risk of breast cancer. The risk for breast cancer increases as time period between menarche and menopause increases. 2. Incorrect: Small increase in risk with moderate alcohol consumption, not one glass of wine daily. Drinking low to moderate amounts of alcohol, however, may lower the risks of heart disease, high blood pressure and death. But, drinking more than one drink per day (for women) and more than two drinks per day (for men) has no health benefits and many serious health risks, including breast cancer. Alcohol can change the way a woman's body metabolizes estrogen (how estrogen works in the body). This can cause blood estrogen levels to rise. Estrogen levels are higher in women who drink alcohol than in non-drinkers. These higher estrogen levels may in turn, increase the risk of breast cancer. 3. Incorrect: Nulliparity (no pregnancies) is a known risk factor for breast cancer. Factors that increase the number of menstrual cycles also increase the risk of breast cancer, probably due to increased endogenous estrogen exposure.