RN Question Trainer Test 4 Missed Questions

Which statement should the nurse make to a client who is going to self-administer continuous ambulatory peritoneal dialysis at home? 1. "Check your weight at the same time daily" 2. "Maintain clean technique at all times during the procedure" 3. "Milk the catheter to encourage extra fluid removal from the abdomen" 4. "Eat a well-balanced, low-protein diet"

1. "Check your weight at the same time daily" Assessment; daily weight is necessary w/peritoneum empty to assess fluid volume status, guidelines for weight gain/loss set by HCP

The nurse completes client assignments for the day. The nurse should assign an LPN/LVN to which client? 1. A client who had a total hip replacement and requires assistance w/ambulation 2. A client w/type 1 diabetes mellitus who has bilateral 4+ pitting edema of the feet 3. A client w/cholelithiasis scheduled for a cholecystectomy and receiving IV morphine 4. A client 6 hours postoperative after cystoscopy to remove a mass in the bladder

1. A client who had a total hip replacement and requires assistance w/ambulation Stable client w/an expected outcome

The multidisciplinary team decides to implement behavior modification with a client. Which nursing action is of PRIMARY importance during this time? 1. Confirm that all staff members understand and comply w/the treatment plan 2. Establish mutually agreed upon, realistic goals 3. Ensure that the potent reinforcers (rewards) are important to the client 4. Establish a fixed interval schedule for reinforcement

1. Confirm that all staff members understand and comply w/the treatment plan To implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program

The client is admitted w/a diagnosis of subdural hematoma and cerebral edema after a motorcycle accident. Which symptoms should the nurse expect to see INITIALLY? SELECT ALL THAT APPLY. 1. Decreasing LOC 2. Fine tremors of the extremities 3. Decerebrate posturing 4. Ipsilateral pupil dilation 5. HA 6. Tonic/Clonic seizures

1. Decreasing LOC 4. Ipsilateral pupil dilation 5. HA - As pressure increases, the LOC decreases - This is pupil dilation on the same side as the hematoma - HA is the first symptom

The client returns to the room following a myelogram. The nursing care plan should include which interventions? SELECT ALL THAT APPLY. 1. Encourage oral fluid intake 2. Maintain the prone position for 12 hours 3. Lie flat for several hours 4. Monitor vital and neurological signs 5. Encourage the client to ambulate after the procedure 6. Evaluate the client's distal pulses on the affected side

1. Encourage oral fluid intake 3. Lie flat for several hours 4. Monitor vital and neurological signs - Implementation; fluids should be encouraged to facilitate dye excretion and to maintain normal spinal fluid - Implementation; helps prevent HAs - Assessment, identifies abnormalities early

The extremely agitated client receives haloperidol while in the psychiatric ER. It is MOST important for the nurse to take which action? 1. Monitor BP every 30 minutes 2. Remain at the client's side to provide reassurance 3. Tell the client the name of the medication and its effects 4. Assess for anticholinergic effects of the medication

1. Monitor BP every 30 minutes Assessment, monitoring VS is of utmost importance to ensure client safety and physiological integrity; rapid neuroleptization is a pharmacological intervention used to rapidly diminish severe symptoms that accompany acute psychosis; alpha-adrenergic blockade of peripheral vascular system lowers BP and causes postural hypotension

The nurse cares for a client placed in balance suspension traction w/a Thomas splint and Pearson attachment b/c of a fractured right femur. The nurse notes that the client's left leg is externally rotated. The nurse should take which action? 1. Place a trochanter roll on the outer aspect of the thigh 2. Perform resistive ROM of the left leg 3. Adduct and internally rotate the left leg 4. Instruct the client to maintain the left leg in a neutral position

1. Place a trochanter roll on the outer aspect of the thigh Holds hip in a neutral position and leg in normal alignment, entire weight of leg cannot be held by props placed below knee

The client has a history of oliguria, hypertension and peripheral edema. Current lab values are BUN 25 and K+ 4.0 mEq/L. The nurse should restrict which foods in the client's diet? 1. Protein 2. Fats 3. Carbohydrates 4. Magnesium

1. Proteins Decreased production of urea nitrogen can be achieved by restricting protein; metabolic wastes cannot be excreted by the kidneys

During preadmission planning for a client scheduled for a kidney transplant, the client should be educated by the nurse regarding which information? 1. Remind family and friends that there is restricted visiting for at least 72 hours postoperatively 2. Arrange all live plants received postoperatively in one section of the room 3. Continue intermittent peritoneal dialysis for 3 months following surgery 4. Limit consumption of sodium-free liquids for 1 year postoperatively

1. Remind family and friends that there is restricted visiting for at least 72 hours postoperatively Transplant clients require protective isolation following surgery

Which technique is correct for the nurse to use when changing a large abdominal dressing on an incision w/a Penrose drain? 1. Remove the dressing layers one at a time 2. Clean the wound w/povidone-iodine and hydrogen peroxide 3. Clean the drain area first 4. If the dressing adheres to the wound, pull gently and firmly

1. Remove the dressing layers one at a time To avoid dislodging the drain, remove the dressing layers one at a time

The nurse cares for a post-cholecystectomy client who had the T-tube removed this morning. Two hours after removal of the T-tube, the nurse notes that the 4x4 dressing covering the stab site is saturated w/dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which action? 1. Remove the dressing, and replace it w/a more absorbent dressing 2. Collect a culture and sensitivity specimen of drainage 3. Observe the would for dehiscence 4. Reinforce the dressing w/an 8x10 dressing

1. Remove the dressing, and replace it w/a more absorbent dressing Expected that a stab wound will continue to drain until the would seals; nurse should keep wound clean and dry

Which assessment findings indicate to the nurse the need for more sedation for a client withdrawing from alcohol dependence? 1. Steadily increasing VS 2. Mild tremors and irritability 3. Decreased respirations and disorientation 4. Stomach distress and inability to sleep

1. Steadily increasing VS Indication that the client is approaching delirium tremens, which can be avoided w/additional sedation

The nurse cares for a 26-year-old client immediately after the delivery of an 8-lb, 4-oz baby. The client's history indicates a diagnosis of type 1 diabetes at age 12. The nurse expects which change to occur in the client? 1. The blood glucose will fall b/c of sudden decrease in insulin requirements 2. The blood glucose will rise b/c of a rapid decrease in circulating insulin 3. The blood glucose will gradually rise b/c of a decreased level of metabolic stress 4. The blood glucose will gradually fall b/c of a decrease in food intake

1. The blood glucose will fall b/c of sudden decrease in insulin requirements Hormonal interference in glucose metabolism during pregnancy causes insulin requirements to increase then decrease after delivery

A 13-year-old male is diagnosed w/MD develops nocturia. The client wants to know about external catheters. The nurse should base the response on which statement? 1. The catheter can be removed during the day 2. External catheters are uncomfortable 3. The catheter would drain into a bag at the bedside or on the wheelchair 4. The external condom catheter is easy to apply

1. The catheter can be removed during the day Being free from any drain bags during the day would appeal to a 13-year-old

The nurse supervises the staff providing care for the 18-month-old hospitalized with Hepatitis A. The nurse determines that the staff's care is appropriate if which action is observed? 1. The child is placed in a private room 2. The staff removes a toy from the child's bed and takes it to the nurse's station 3. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack 4. The staff uses standard precautions

1. The child is placed in a private room Contact precautions required for diapered or incontinent clients

The visiting nurse instructs a client how to use esophageal speck following a total laryngectomy. Which action, if performed by the client, indicates teaching is effective? 1. The client swallows air and then eructates it while forming words with the mouth 2. The client places a battery-powered device against the side of the neck 3. The client places a finger over the tracheostomy, forcing air up through the vocal cords 4. The client covers the stoma in the tracheoesophageal fistula and moves the lips

1. The client swallows air and then eructates it while forming words with the mouth Describes esophageal speech

The nurse cares for clients on a med/surg unit. The nurse determines several situations need to be addressed. In which order will the nurse address the situation? PLACE THE ANSWERS IN ORDER OF PRIOIRTY. 1. The client's spouse reports the client's nose is bleeding 2. The HCP asks the nurse to obtain the client's latest serum electrolyte 3. The NAP is 30 minutes late for the third time 4. An angry adult child is threatening to sue the hospital b/c the confused parent fell out of bed.

1. The client's spouse reports the client's nose is bleeding 4. An angry adult child is threatening to sue the hospital b/c the confused parent fell out of bed. 2. The HCP asks the nurse to obtain the client's latest serum electrolyte 3. The NAP is 30 minutes late for the third time - Important to assess client to determine amount and cause of bleeding - Important issue that needs to be addressed after tending to the client who is bleeding - Last client issue to address or can be delegated to another staff member - Clients take priority over personal issues

Which nursing intervention is a priority in preventing complications after a cesarean birth? 1. Turn, cough, and deep breathe 2. Limit fluid intake 3. Supply a high-carbohydrate diet 4. Evaluate skin integrity

1. Turn, cough, and deep breathe Represents preventive care for respiratory congestion resulting from anesthesia and shallow respirations d/t abdominal incision

The nurse cares for a young adult admitted to the hospital with a severe head injury. How should the nurse position the client? 1. With the clients neck in a midline position and the HOB elevated 30 degrees 2. Side-lying w/the client's head extended and the bed flat 3. In high Fowler's position w/the client's head maintained in a neutral position 4. In semi-Fowler's position w/the clients head turned to the side

1. With the clients neck in a midline position and the HOB elevated 30 degrees Decreases ICP

The nurse prepares to administer terbutaline to the client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. What action should the nurse take FIRST? 1. Withhold the medication 2. Decrease the dose by half 3. Administer the medication 4. Wait 15 minutes, and then recheck the rate

1. Withhold the medication Maternal tachycardia is a SE of terbutaline; other maternal SE include nervousness, tremors, HA, and possible pulmonary edema; fetal SE include tachycardia and hypoglycemia; terbutaline is usually preferred over ritodrine b/c it has minimal effects on BP

A client has recently been diagnosed with systemic lupus (SLE) and shares with the nurse, "I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy b/c I have lupus." Which response by the nurse is BEST? 1. "Most clients find that they feel better when they are pregnant" 2. "How long have you been in remission?" 3. "Clients w/lupus frequently have slightly longer gestations" 4. "It is best to become pregnant within the first 6 months of diagnosis"

2. "How long have you been in remission?" Should be in remission for at least 5 months prior to conceiving

A client returns from surgery after a hysterectomy d/t cancer, and there is an order for antiembolism stockings. Which information should the nurse include when instructing the client about wearing the support stockings? 1. "Wear the stockings when your legs cramp" 2. "Wear the stockings during your hospitalization" 3. "Put the stockings on prior to going to bed" 4. "Put the stockings on after you get out of bed in the morning"

2. "Wear the stockings during your hospitalization" Stockings should be worn the entire time that the client is in the hospital; should be removed for baths and preplaced after the skin is dry, and before the client gets out of bed

A client diagnosed w/MS is at 39 weeks gestation. The client is admitted to the labor and delivery unit in active labor. The client's VS are BP 127/72; Pulse 72 bpm; cervix is 3 cm dilated; FHT 124 bpm; moderate contractions are 4 minutes apart. The nurse should anticipate the need for which intervention? 1. Prepare to administer IV oxytocin to the client 2. A reduction in the amount of pain medication administered 3. Check the client's BP every 5 minutes 4. Prepare isolette for the infant

2. A reduction in the amount of pain medication administered Less pain medication is required b/c of overall decrease in pain perception d/t MS

An adult client has regular insulin ordered before breakfast. The nurse notes that the client's blood glucose level is 68 mg/dL and the client is nauseated. Which action should the nurse take? 1. Immediately give the client orange juice to drink 2. Administer the insulin on time 3. Withhold the insulin and notify the HCP 4. Return the breakfast tray to the kitchen

2. Administer the insulin on time Take insulin or oral agent as ordered; encourage client to eat soft foods and liquids on breakfast meal tray; recheck blood glucose again in 30-60 minutes; because illness can raise the blood glucose level with the regularly prescribed insulin regime, blood glucose and/or urine ketones should be monitored every 3 to 4 hours; sip 8 to 12 ounces of liquid per hour to decrease the possibility of dehydration; substitute easily digested soft foods or liquids if solids are not tolerated

The nurse cares for the client who has just returned to the room after a scleral bucking procedure. Which nursing action is MOST important? 1. Remove reading material to decrease eyestrain 2. Ask the client if there is any nausea 3. Assess for color of drainage from the affected eye 4. Maintain sterility during q 3 hour saline eye irrigation

2. Ask the client if there is any nausea Assessment; it is important to prevent N/V, would increase IOP, could cause damage to area repaired

After abdominal surgery, a client has an NG tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in flow of gastric secretions. Which nursing intervention is MOST appropriate? 1. Irrigate the NG tube w/distilled water 2. Aspirate the gastric contents w/a syringe 3. Administer an antiemetic medicine 4. Insert a new NG tube

2. Aspirate the gastric contents w/a syringe To confirm placement, the nurse should aspirate and test the pH of the aspirate; results should be 0 to 4

A client is in cardiogenic shock after a MI. Which is a correctly stated nursing diagnosis for the client? 1. Activity intolerance r/t impaired O2 transport 2. Decreased cardiac tissue perfusion r/t decreased heat-pumping action 3. Altered CO r/t cardiac ischemia 4. Deficient fluid volume r/t decreased fluid intake

2. Decreased cardiac tissue perfusion r/t decreased heat-pumping action Correctly stated, appropriate nursing diagnosis

The older client is seen in the outpatient clinic for treatment of an acute attach of gout. Which nursing intervention is MOST beneficial in decreasing the client's pain during ambulation? 1. Perform passive ROM exercises before walking 2. Encourage partial weight bearing while ambulating 3. Immobilize the extremity between activities 4. Restrict the amount of time and the distance the client walks

2. Encourage partial weight bearing while ambulating Would relieve weight, pressure, and stress on affected leg, may use a walker

A young adult client constantly seeks attention from the nurses, stomping away from the nurses' station and pouting when requests are refused. Which response by the nurse is MOST appropriate? 1. Encourage the client to establish trust w/one staff person w/whom therapeutic interventions should occur 2. Give client unsolicited attention when the client is exhibiting acceptable behaviors 3. Ignore the client when the client exhibits attention-seeking behavior 4. Rotate the staff so that client will learn to relate to more than one nurse

2. Give client unsolicited attention when the client is exhibiting acceptable behaviors Reward non-attention-seeking behaviors by giving the client unsolicited attention

After a client develops left-sided hemiparesis from a stroke, the nurse notes a decrease in muscle tone. The nurse determines which nursing diagnosis is the PRIORITY? 1. Impaired mobility r/t paralysis 2. Impaired skin integrity r/t decrease in tissue oxygenation 3. Impaired skin integrity r/t immobility 4. Impaired verbal communication r/t decrease in thought processes

2. Impaired skin integrity r/t decrease in tissue oxygenation Leading cause of skin breakdown is a decrease in tissue perfusion

The client diagnosed w/AIDS is seen in the ER w/reporting mouth pain, difficulty swallowing, and a white discharge in the back of the throat. The nurse expects the HCP to order which medication? 1. Metronidazole 7.5 mg/kg q 6 hours 2. Ketoconazole 200 mg daily 3. Trimethoprim-sulfamethoxazole 800 mg PO q 12 hours 4. Rifampin PO 10 mg/kg daily

2. Ketoconazole 200 mg daily Drug of choice for treatment of candidiasis

The client receives procainamide slowly by IV push. The nurse should withhold the next dose if which observation is made? 1. Presence of PVCs 2. Occurrence of severe hypotension 3. Recurring paroxysmal atrial tachycardia 4. A sedimentation rate of 10

2. Occurrence of severe hypotension Severe hypotension or bradycardia are signs of an adverse reaction of this medication This med is given to treat PVCs and atrial tachycardia

The home health care nurse cares for the client diagnosed w/ type 1 diabetes. The client is maintained on a regimen of intermediate-acting insulin and short-acting insulin and an 1800 calorie diabetic diet w/normal blood sugar levels. Morning self-monitored blood sugar readings the past 2 days were 205 and 233 mg/dL. The nurse expects the HCP to take which action? 1. Reduce the client's diet to 1500 calorie ADA 2. Order three additional units of intermediate-acting insulin at 2200 3. Order an additional 10 units of short-acting insulin at 2200 4. Eliminate the client's bedtime snack

2. Order three additional units of intermediate-acting insulin at 2200 Dawn phenomena, treatment is to adjust the evening dient, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia

The client develops right-sided HF. The nurse expects to observe which symptoms? SELECT ALL THAT APPLY. 1. Increase respiration w/exertion 2. Peripheral edema and anorexia 3. Polycythemia 4. Cough producing large amounts of thick, yellow mucus 5. Twitching of extremities 6. Distended neck veins

2. Peripheral edema and anorexia 3. Polycythemia 6. Distended neck veins - Edema c/b a decreased heart pumping action and accumulation of fluid; malaise causing anorexia - Increased RBC as compensation for decreased oxygenation - Related to HF

During a first aid class, the nurse instructs clients on the emergency care of partial thickness burns. The nurse identifies which of the following interventions for partial thickness burns of the chest and arms BEST prevents infection? 1. Wash the burn w/an antiseptic soap and water 2. Remove clothing, and wrap the victim in a clean sheet 3. Leave the blisters intact and apply an ointment 4. Take no action until the victim arrives in a burn unit

2. Remove clothing, and wrap the victim in a clean sheet After fire is out, remove clothing and cover victim w/a clean sheet

The nurse instructs a client diagnosed w/MS to perform intermittent self-catheterization at home. The nurse should include which instructions? 1. Use a new, sterile catheter each time the client performs a catheterization 2. Store the catheter in a plastic food storage bag 3. Perform the catheterization procedure every 10 hours 4. Limit oral fluids to reduce the number of times a catheterization is needed

2. Store the catheter in a plastic food storage bag Will reduce the risk of contamination; sterile storage is not necessary

The nurse assesses the development of a 3-month-old child in the well-clinic. Which behavior, if observed by the nurse, is UNEXPECTED? 1. The child holds the head erect when sitting on the examination table 2. The child tries to grasp a toy just out of reach 3. The child turns the head to try and locate a sound 4. The child smiles spontaneously when the parent is seen

2. The child tries to grasp a toy just out of reach Unexpected until 6 months of age

The nurse cares for clients in the skilled nursing facility. In which order will the nurse see the clients? PLACE THE ANSWERS IN ORDER OF PRIOIRTY. 1. The client received IV morphine and is transferred w/an order for acetaminophen w/codeine 2. The client admitted for a stroke whose prescription for warfarin expired 2 days ago 3. The client has dysuria and foul-smelling, cloudy, dark amber urine 4. The client diagnosed w/immunosuppression has not received an influenza immunization

2. The client admitted for a stroke whose prescription for warfarin expired 2 days ago 1. The client received IV morphine and is transferred w/an order for acetaminophen w/codeine 3. The client has dysuria and foul-smelling, cloudy, dark amber urine 4. The client diagnosed w/immunosuppression has not received an influenza immunization - Duration of warfarin is 2 to 5 days, client is at risk for a repeat stroke - Anticoagulant takes priority, client still receiving pain medication but must be addressed b/c of change in medication intensity - Painful urination, may indicate infection; not as urgent as previous two - Anticoagulant takes priority; immunization is last priority of these clients

An elderly client is admitted to the hospital for treatment of a fractured femur. The client's spouse tells the nurse that the client has become very hard of hearing. The nurse might expect the client to exhibit which characteristic? 1. The client prefers to be left alone 2. The client appears suspicious of strangers 3. The client communicates best in writing 4. The client's speech is difficult to understand

2. The client appears suspicious of strangers Suspiciousness r/f interference w/communication

The nurse administers morphine 6 mg IV push to a client for postoperative pain. Following administration of the drug, the nurse observes BP 100/68, pulse 68, respirations 8, client is sleeping quietly. Which nursing action is MOST appropriate? 1. Allow the client to sleep undisturbed 2. Administer O2 via face mask or nasal prongs 3. Administer naloxone 4. Place epinephrine 1:1000 at the bedside

3. Administer naloxone IV naloxone should be given to reverse respiratory depression; respiratory rate of 8 is too low and necessitates a nursing action

Which is a correct instruction by the nurse to the parent of a 4-year-old client regarding collecting a specimen to be tested for pinworms? 1. Collect the specimen 30 minutes after the child falls asleep at night 2. Save a portion of the child's first stool of the day and take it to the clinic immediately 3. Collect the specimen in the early morning with a piece of Scotch tape touching to the child's anus 4. Feed the child a high-fat meal, and then save the first stool following the meal

3. Collect the specimen in the early morning with a piece of Scotch tape touching to the child's anus Pinworms crawl outside the anus early in the morning to lay their eggs They are not routinely found in stool

The nurse teaches a well-baby class to a group of parents with toddlers. The nurse should encourage the parents to perform which intervention? 1. Exercise their children daily 2. Use a playpen whenever possible 3. Provide a safe play area for the children 4. Teach the children noncompetitive activities

3. Provide a safe play area for the children Safety is a fundamental issue with this age group; they are exploratory in their play

A woman is admitted to the L/D unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority? 1. Administer O2 2. Turn her to the right side 3. Provide adequate hydration 4. Start antibiotics

3. Provide adequate hydration Adequate hydration is a priority for any client w/sickle cell crisis

A client is scheduled for a left lower lobectomy. The HCP orders diazepam 2 mg IM for anxiety. The nurse determines that the medication is appropriate if the client displays which symptoms? 1. Agitation and decreased LOC 2. Lethargy and decreased RR 3. Restlessness and increased HR 4. Hostility and increased BP

3. Restlessness and increased HR Observation most indicative for antianxiety medications is restlessness and increased HR d/t circulating catecholamines

What is the nurse's INITIAL priority when managing a physically assaultive client? 1. Restrict the client to the room 2. Place the client under one-to -one supervision 3. Restore the client's self-control and prevent further loss of control 4. Clear the immediate area of other clients to prevent harm

3. Restore the client's self-control and prevent further loss of control Most important priority in the nursing management of an assaultive client is to maintain milleu safety by restoring the client's self-control; a quick assessment of situation, psychological intervention, chemical intervention, and possibly physical control are important when managing the physically assaultive client

The HCP orders sucralfate 1 g PO bid for a client taking digoxin 0.25 mg daily. The client asks the nurse if both pills can be taken together so that the client doesn't forget to take them. The nurse should advise the client to take the medications in which way? 1. Take the sucralfate and digoxin before breakfast 2. Take the digoxin 1 hour before breakfast and the sucralfate 1 hour after breakfast 3. Take the sucralfate 1 hour before breakfast and the digoxin 1 hour after breakfast 4. Take the sucralfate and the digoxin after breakfast

3. Take the sucralfate 1 hour before breakfast and the digoxin 1 hour after breakfast Sucralfate best results on an empty stomach b/c it forms a barrier on the GI mucosa, and would decrease the absorption of other medications. Medications should be separated by 2 hours for maximum absorption

The nurse cares for the client on the nursing unit. Which finding does the nurse recognize as a positive response to fluoxetine HCl? 1. The nurse notes hand tremors and leg twitching 2. The client states is able to sleep for longer periods of time 3. The client has an increased energy level and participates in unit activities 4. The nurse observes the client is hypervigilant and scans the environment

3. The client has an increased energy level and participates in unit activities Fluoxetine HCl is and "energizing" antidepressant, as client begins to demonstrate a positive response, the client has an increased energy level, is able to participate more in millieu

The nurse counsels the elderly client who comes to the outpatient clinic for a routine examination. The history indicates the client takes a laxative tablet twice a day and a laxative suppository once a day. The nurse should suspect which about the client? 1. The client is has an anal fixation resulting from a recent loss of a spouse 2. The client is depressed b/c of alterations in intestinal absorption and excretion 3. The client is experiencing excessive concern w/body function b/c of physical changes 4. The client has regressed b/c of a fear of losing the ability to have bowel movements

3. The client is experiencing excessive concern w/body function b/c of physical changes Physical changes occur in late adulthood causing changes in body image; constipation frequent problem of elderly, but by this client is excessive

The nurse supervises the staff caring for four clients receiving blood transfusions. In which order should the nurse visit each client? PLACE THE ANSWERS IN ORDER OF PRIORTY. 1. The client with neck vein distension 2. The client reporting a HA 3. The client vomiting 4. The client reporting itching

3. The client vomiting 1. The client with neck vein distension 4. The client reporting itching 2. The client reporting a HA - Acute hemolytic reaction; most dangerous type of transfusion reaction, symptoms include: N/V, pain in lower back, hematuria; treatment is to stop blood, obtain urine specimen, and maintain blood volume and kidney perfusion - Circulatory overload; treatment is to adjust rate of infusion, position in an upright position, and administer O2 and possibly diuretics - Allergic reaction; symptoms include urticarial, pruritus, fever; treatment is to stop blood, give antihistamines and restart transfusion slowly - Febrile reaction; symptoms include fever, chills, nausea, HA; treatment is to stop blood and administer antipyretics

An older client undergoes the second exchange of intermittent peritoneal dialysis (IPD). Which action requires an intervention by the nurse? 1. The client reports pain during the inflow of the dialysate 2. The client reports constipation 3. The dialysate outflow is cloudy 4. There is blood-tinged fluid around the intra-abdominal catheter

3. The dialysate outflow is cloudy Indicates peritonitis, also will see N/V, anorexia, abdominal pain, tenderness, and rigidity

The nurse prepares a client for a cesarean birth. The client tells the nurse about having a "shot" before major surgery several years ago and asks if a similar one will be given before this one. What is the nurse's best understanding? 1. The medication given before a cesarean has a lower overall dose of medication than is given before general surgery 2. The medication given before a cesarean has lower amounts of sedatives and hypnotics than are given before general surgery 3. The medication given before a cesarean contains lower amounts of narcotics that are given before general surgery 4. The medication given before a cesarean contains medications similar in type and dosages to those given before general surgery

3. The medication given before a cesarean contains lower amounts of narcotics that are given before general surgery Decreased narcotics so that less narcotic crosses the placental barrier, causing respiratory depression in the infant

The nurse observes care given to the client experiencing severe to panic levels of anxiety. The nurse should intervene in which situation? 1. The staff maintains a calm manner when interacting w/the client 2. The staff attends to client's physical needs as necessary 3. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety 4. The staff assesses the client's need for medication or seclusion if other interventions have failed to reduce anxiety

3. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety At this level of anxiety, client is unable to process thoughts and feelings for problem solving

The client is treated for sexual abuse by one parent. What does the nurse anticipates as an INITIAL positive client outcome of treatment? 1. Acknowledges willing participation in an incestuous relationship 2. Re-establishes a trusting relationship w/the other parent 3. Verbalizes that they are not responsible for sexual abuse 4. Describes feelings of anxiety when speaking about sexual abuse

3. Verbalizes that they are not responsible for sexual abuse Victim needs assistance to challenge "belief of victims" which includes "I am bad and deserve the abuse"

The nurse prepares to perform peritoneal dialysis on an older client. The client states that pain occurred the last time the procedure was done. It is MOST appropriate for the nurse to take which action? 1. Administer a warm drink to the client 2. Administer a warm bath to the client 3. Warm the bag of dialysate solution w/a heating pad 4. Warm the bag of dialysate solution in a microwave oven

3. Warm the bag of dialysate solution w/a heating pad Temperature can be regulated, warming reduces pain caused by cold solution

The nurse observes an LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which behavior, if performed by the LPN/LVN, indicates an understanding of proper technique? 1. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes 2. The incision is packed w/sterile gauze, and then sterile saline is poured over the dressing 3. Wet gauze is packed into the incision w/out overlapping it onto the skin 4. The old dressing is saturated w/sterile saline before it is removed

3. Wet gauze is packed into the incision w/out overlapping it onto the skin If wet dressing touches skin, it could cause skin breakdown

The client who is positive for HIV is to be discharged and will be taking zidovudine at home. Which action by the nurse is best? 1. Review the importance of adhering to a 4-hour schedule 2. Advise the client to buy a timed pill dispenser 3. Write the schedule of when the medicine should be taken 4. Encourage self-medication prior to discharge

3. Write the schedule of when the medicine should be taken Planned and written schedule of administration is more effective for adherence to time frames

The nurse cares for a client just returning to the postsurgical unit following abdominal surgery for cancer of the colon. It is MOST appropriate for the nurse to take which action? 1. Determine the stage of loss and grief 2. Analyze the quality and quantity of pain 3. Instruct the client to cough and deep breathe 4. Ask the client to lift the head off the pillow

4. Ask the client to lift the head off the pillow Should assess whether there are any remaining effects of neuromuscular blocking agents; may block ability to breath deeply

Which nursing intervention is MOST important for a client diagnosed w/rheumatoid arthritis? 1. Provide support to flexed joints w/pillows and pads 2. Position the client on the abdomen several times a day 3. Massage the inflamed joints w/creams and oils 4. Assist the client w/heat application and ROM exercises

4. Assist the client w/heat application and ROM exercises Reduces swelling, increases circulation, diminishes stiffness while preserving joint mobility

The HCP orders ranitidine hydrochloride 150 mg PO daily for the client. The nurse should advise the client that the BEST time to take this medication is when? 1. Prior to breakfast 2. With dinner 3. With food 4. At hour of sleep

4. At hour of sleep Best results when taking once a day

The nurse prepares a 5-year-old child for surgery. The nurse notes that the child's parents are divorced and have joint legal custody. The informed consent for surgery has been signed by one parent. Which action by the nurse is BEST? 1. Notify the HCP 2. Inform surgery 3. Contact the other parent to obtain consent 4. Continue the child's preoperative preparation

4. Continue the child's preoperative preparation Parent or legal guardian required to give informed consent prior to surgical procedure Consent from either divorced parent is sufficient

The client diagnosed w/a peptic ulcer has a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, which statement is the PRIORITY to caution the client about? 1. Sit up for at least 30 minutes after eating 2. Avoid fluids between meals 3. Increase the intake of high-carbohydrate foods 4. Eating large meals that are high in simple sugars and liquids

4. Eating large meals that are high in simple sugars and liquids Basic guidelines to teach a postgastrectomy client are measures to prevent dumping syndrome, which include: lying down for 30 minutes after meals, drinking fluids between meals, and reducing intake of carbohydrates

The nurse plans care for a client on bed rest. To promote evening rest and sleep for this client, it is MOST important for the nurse to take which action? 1. Provide privacy 2. Give back rubs at bedtime 3. Assist w/a bath every day 4. Encourage daytime activities

4. Encourage daytime activities Provides relief from tension, ensures client naps less during the day, helps client relax

The nurse monitors a client's EKG strip and notes coupled premature ventricular contractions greater than 1o per minute. The nurse should expect to administer which medication? 1. Atropine IV 2. Isoproterenol IV 3. Verapamil IV 4. Lidocaine IV

4. Lidocaine IV Lidocaine is the drug of choice for frequent premature ventricular contractions occurring in excess of 6 to 10 per minute; for coupled PVCs or for a consecutive series of PVCs that my r/I ventricular tachycardia

The nurse is assigned to work w/the parents of a child diagnosed w/mental disabilities. Which should the nurse include in the care plan for the parents? 1. Interpret the grieving process for the parents 2. Discuss the reality of institutional placement 3. Assist the parents in making decisions and long-term plans for the child 4. Perform a family assessment to assist in the planning of intervention

4. Perform a family assessment to assist in the planning of intervention Assessment, this will help the nurse to know where the family is in regard to grieving, coping, etc.

Which symptoms are MOST likely to be observed by the nurse when a client is withdrawing from heroin? 1. Severe cravings, depression, fatigue, hypersomnia 2. Depression, disturbed sleep, restlessness, disorientation 3. N/V, tachycardia, coarse tremors, seizures 4. Runny nose, yawning, fever, muscle and joint pain, diarrhea

4. Runny nose, yawning, fever, muscle and joint pain, and diarrhea Narcotic withdrawal is very much like the symptoms of the flu 1. is cocaine withdrawal 2. is amphetamine withdrawal 3. is barbiturate withdrawal

The nurse performs discharge teaching for a client diagnosed with Addison's disease. It is MOST important for the nurse to instruct the client about which information? 1. S/S of infection 2. Fluid and electrolyte balance 3. Seizure precautions 4. Steroid replacement

4. Steroid replacement Steroid replacement is the most important information for the client to know

Which assessment does the nurse expect to make regarding the developmental stage of a 45-year-old male? 1. Cognitive skills are starting to decline 2. A balance is found among work, family, and social life 3. Bone mass begins to increase at this age 4. The client starts to measure life accomplishments against goals

4. The client starts to measure life accomplishments against goals May precipitate a mid-life crisis

The home care nurse instructs a client recently diagnosed with TB. It is MOST important for the nurse to include which as a part of the teaching plan? 1. The client should cover the mouth and nose when coughing or sneezing during the first 2 weeks of treatment 2. It is necessary for the client to wear a mask at all times to prevent transmission of the disease 3. The family should support the client to help reduce feelings of low self-esteem and isolation 4. The client will be required to take prescribed medication for 6 to 9 months

4. The client will be required to take prescribed medication for 6 to 9 months Necessary to take medication for 6 to 9 months

When caring for a client w/a nursing diagnosis of rape trauma syndrome, acute phase, the nurse should consider which as the MOST important INITIAL goal for the client? 1. Within 3 to 5 months, the client will state that the memory of the event is less vivid and distressing 2. The client will indicate a willingness to keep a follow-up appointment w/a rape crisis counselor 3. The client will be able to describe the results of the physical examination that was completed in the ER 4. The client will begin to express the reactions and feelings about the assault before leaving the ER

4. The client will begin to express the reactions and feelings about the assault before leaving the ER This is the initial priority to encourage the client to begin dealing w/what happened by verbalizing feelings and gaining some acceptance and perspective