Study Questions

What is the diet of choice for a client on hemodialysis? 1. Low fluid, extra protein, low sodium 2. Low protein, fluid restriction, low potassium 3. Low sodium, low potassium, low carbohydrate 4. Low fat, low sodium, complex carbohydrates

2. Low protein, fluid restriction, low potassium Yes, we need to restrict the protein to restrict the waste build up, they only get dialyzed every other day so restrict the fluid, and restrict the sodium and potassium.

The nurse is reinforcing client education about timolol maleate. What should the client know about the newly prescribed timolol maleate eyedrops for glaucoma? 1. The medication works by causing the pupils to constrict. 2. The medication will dilate the canals of Schlemm. 3. This medication decreases the production of aqueous humor. 4. The medication improves ciliary muscle contraction.

3. This medication decreases the production of aqueous humor. Timolol does decrease aqueous humor formation; therefore decreasing intraocular pressure (IOP). 1. Incorrect: Timolol does not constrict pupils​. 2. Incorrect:Timolol does not dilate the canals of Schlemm​. 4. Incorrect: Timolol does not cause ciliary muscle contraction.​

The nurse is providing post-operative care to the craniotomy client. Diabetes insipidus is suspected when the client's urine output suddenly increases significantly. Which action takes highest priority? 1. Continue to monitor urine output 2. Check pulse 3. Check blood pressure 4. Check level of consciousness

3. Check blood pressure This is the best answer because we are "worried" this client is going into SHOCK. So.. you better be checking BP. This is a time where checking the BP is appropriate. (If we "assume the worst" I better check blood pressure. It could have dropped out the bottom.) 1. Incorrect: Continuing to monitor U/O is important but I need to find out if they are already shocky. 2. Incorrect: Checking the pulse is a good thing, but not as important as checking the BP. 4. Incorrect: If my client is going into shock, the highest priority is to assess the BP.

When collecting data for the development of an infection following the application of a plaster cast to the leg, the nurse should reinforcing teaching to the client to observe for the presence of which sign of infection? 1. Hot spots 2. Cold toes 3. Warm toes 4. Paresthesia

1. Hot spots Hot spots is the best answer. Redness and increased warmth are indicators of localized infection. If the cast covers the extremity, redness cannot be visualized, but the client can feel more warmth (a "hot spot") in an area becoming infected. 2,3, & 4 Incorrect: "Cold toes" is a neurovascular check, not an indication of infection. "Warm toes" is a neurovascular check, not an indication of infection. Paresthesia is a neurovascular check, not an indication of infection.

A client was prescribed a monoamine oxidase inhibitor (MAOI) for the treatment of depression. The nurse is reinforcing client education on MAOI medication. Which comment by the client indicates adequate understanding of the tyramine restrictions that apply? 1. I cannot eat avocados or smoked ham. 2. I can eat sausage for breakfast, but not bacon. 3. At least I can still have my beer. 4. I can have blue cheese on my salad but not ranch dressing.

1. I cannot eat avocados or smoked ham. Clients taking MAOIs cannot consume foods containing large amounts of tyramine. MAOIs block monoamine oxidase which breakdown tyramine. Having a MAOI prescribed and eating a diet high in tyramine can cause a severe increase in blood pressure. Smoked ham and avocados are high in tyramine. 2. Incorrect. Clients taking these medications cannot eat the following foods: sausage, salami, liver, or bologna which have high levels of tyramine. 3. Incorrect. Clients taking these medications cannot consume beer, sherry, chianti wines, or ales due to their high tyramine levels. 4. Incorrect. Consuming blue cheese on a salad may result in a hypertensive crisis due to the presence of tyramine.

The nurse has been assigned four clients. Who should the nurse see first? 1. A client with diabetes admitted for debridement of a foot ulcer. 2. A client with epilepsy reporting an odd smell in the room. 3. A client with exacerbation of COPD reporting dyspnea. 4. An adolescent client post appendectomy reporting pain.

2. A client with epilepsy reporting an odd smell in the room. The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. The nurse should immediately assess this client, implement seizure precautions and remain with client for safety.

A client, who has been receiving enteral tube feedings for the past three days, has begun having diarrhea. Which interventions should the nurse employ? 1. Dilute feeding and increase infusion rate. 2. Auscultate for hyperactive bowel sounds. 3. Monitor intake and output. 4. Check for fecal impaction. 5. Keep perianal area clean and dry. 6. Warm tube feeding to 100 degrees.

2. Auscultate for hyperactive bowel sounds. 3. Monitor intake and output. 4. Check for fecal impaction. 5. Keep perianal area clean and dry. Observe for abdominal pain, cramping, frequency, urgency, loose or liquid stools, and hyperactive bowel sounds. Monitor hydration status with input and output. Diarrhea can lead to profound dehydration and electrolyte imbalance, poor skin turgor and dry mucous membrane. Check for fecal impaction by digital examination. Liquid stool may seep past a fecal impaction. Assess condition of perianal skin. Diarrheal stools may be highly corrosive, as a result of increased enzyme content.

A client is admitted following a fall from a bicycle, which resulted in a laceration to the occipital area. Which signs/symptoms noted by the nurse would be of concern? 1. Heart rate 84/min 2. BP 150/60 3. Movement agnosia 4. Reports headache resolved with pain medication 5. Scotoma

2. BP 150/60 3. Movement agnosia 5. Scotoma There are two things going on with this BP. First the systolic pressure is high (1 of 3 signs of Cushing's triad), and second, there is a widened pulse pressure. Movement agnosia is the Inability to recognize the movement of an object. This can be seen when the occipital region of the brain is damaged. Scotoma is an area of visual impairment that can develop from an injury to the occipital region

The primary healthcare provider has prescribed hydromorphone 2 mg intravenously (IV) every 4 hours as needed for pain. When should the nurse plan to administer the medication to the client? 1. Only when requested. 2. Prior to onset of intense pain. 3. With reports of acute pain lasting for at least one hour. 4. Continuously every 4 hours to keep the client pain free.

2. Prior to onset of intense pain. Pain is best managed before acute pain has developed. If the client waits until the pain is intense, the pain medication may not work as effectively or not at all. 4. Incorrect: The order is as needed, not continuously. Also, the goal of being pain free may be unrealistic. The nurse wants to keep the client's pain at a tolerable level. Always measure pain on a pain scale such as 0-10.

A client has recently been diagnosed with rheumatoid arthritis. The nurse anticipates which class of pharmacologic agents will likely be a part of the client's treatment regimen? 1. Mitotic inhibitors 2. Systemic glucocorticoids 3. Antifungals 4. Anticoagulants

2. Systemic glucocorticoids Glucocorticoids (steroids) are an appropriate pharmacologic treatment for rheumatoid arthritis. Other treatment options include the use of NSAIDs, biologic and nonbiologic DMARDs (methotrexate and others). Remember, all the other problems associated with the use of steroids.

How should a nurse prepare to administer a Measles, Mumps, Rubella (MMR) vaccination to a 6 year old child? 1. 3 mL syringe with 23 gauge, 1" needle for IM injection 2. Use a 25 gauge, ¾" needle for subcutaneous (Sub-Q) injection. 3. Prime intranasal spray for administration. 4. Tuberculin (TB) syringe with 28 gauge, 3/8" needle for intradermal injection.

2. Use a 25 gauge, ¾" needle for subcutaneous (Sub-Q) injection. MMR is given Sub-Q. Subcutaneous injections are administered in the fat layer, underneath the skin. When administering SQ injections use a 23-25 gauge needle, needle length for infants (1- 12 months) is 5/8", children 12 months and older 5/8" - ¾".

An elderly client diagnosed with Alzheimer's disease has become combative, restless and wanders at night. The nurse contacts the primary healthcare provider for medication to help the client rest. The nurse knows the best choice for this client is what medication? 1. Chlorpromazine 2. Hydroxyzine 3. Haloperidol 4. Diazepam

3. Haloperidol Haloperidol is a mild antipsychotic used to treat either mental or mood disorders, including uncontrollable movements and emotional outbursts. This drug is relatively safe for elderly clients and can be used at bedtime to enhance rest. 4. INCORRECT: Diazepam is an antianxiety medication but is not appropriate for elderly clients because of the potential for paradoxical response, such as excitation or delirium.

Two days after being prescribed enoxaparin the nurse notes hematemesis. Lab work has been obtained. Based on this data what action is most important for the nurse to take? 1. Administer protamine sulfate. 2. Administer the next dose of enoxaparin. 3. Obtain vital signs. 4. Insert a nasogastric tube.

1. Administer protamine sulfate. This client has a low hgb, hct, and platelet count and is actively bleeding. Protamine sulfate is the antidote for enoxaparin.

The nurse is contributing to a educational program for clients at the community center about influenza. Which risk factors for influenza complications should the nurse recommend? 1. Age over 65 years. 2. History of grand mal seizures 3. Diabetes 4. Renal disease 5. Clients who reside in a nursing home.

1. Age over 65 years. 3. Diabetes 4. Renal disease 5. Clients who reside in a nursing home. Clients who are over the age of 65, have diabetes, have renal disease, or who reside in a nursing home are all at risk for post-influenza complications. 2. Incorrect: A client who has grand mal seizures would not put the client at risk for flu complications. If the client has the other risk factors, then flu complications are more likely.

The nurse is transferring the client from the bed to the wheelchair. Which nursing intervention would the nurse implement after assisting the client to a sitting position on the side of the bed. 1. Assess the client for lightheadedness. 2. Move the wheelchair closer to the bed. 3. Lower the bed to the lowest position. 4. Position the foot of the stronger leg closer to the bed.

1. Assess the client for lightheadedness. Prior to moving the client from the side of the bed to the wheelchair, assess the client for orthostatic hypotension or postural hypotension. The client may experience a sudden decrease in blood pressure after changing the position form lying down to sitting up. 3. Incorrect: The bed should have been lowered to the position prior to moving the client to the side of the bed. The client's feet should rest on the floor. This will assist the client in supporting themselves. 4. Incorrect: Positioning the foot of the stronger leg closer to the bed is a transfer step after assessing the client for orthostatic hypotension. Whether the stronger or weaker leg is positioned closer to the bed will not affect the client's blood pressure status.

A pediatric nurse is reinforcing instructions to 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. At 4 weeks of age, the infant should be able to gaze at objects. 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. 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.

Which tasks could the LPN/VN working on a telemetry unit assign to an unlicensed assistive personnel (UAP)? 1. Bathe the client who is on telemetry. 2. Apply cardiac leads and connect a client to a cardiac monitor. 3. Assist with a portable chest x-ray. 4. Feed a client who is dysphagic. 5. Collect a stool specimen.

1. Bathe the client who is on telemetry. 2. Apply cardiac leads and connect a client to a cardiac monitor. 3. Assist with a portable chest x-ray. 5. Collect a stool specimen. Remember the nurse cannot delegate assessment, teaching, evaluation, medications, or an unstable client to the UAP. The UAP could bathe the client who is on telemetry. This is an appropriate assignment. The UAP can apply cardiac leads and connect the client to a cardiac monitor. The UAP can assist with helping the client sit up for a portable chest x-ray as long as the UAP is not pregnant and wears a shield. The UAP can collect specimens, such as a stool specimen. 4. Incorrect: This client is at risk for choking and is not stable; therefore, the nurse should not allow the UAP to feed this client.

A 3 day post-operative client with a left knee replacement is reporting chills and nausea. Temperature: 100.8ºF/38.2ºC, pulse: 94, respiration: 28 and blood pressure is 146/90. What is the nurse's best action? 1. Call the surgeon immediately. 2. Administer extra strength acetaminophen per prescription. 3. Monitor the surgical site. 4. Offer extra blankets and increase fluids.

1. Call the surgeon immediately. The client's symptoms are indicative of infection, and the primary healthcare provider needs to be notified and may want diagnostic tests performed. The other actions are appropriate to treat the symptoms and provide comfort, but they are not the best action to fix the problem.

What is the best information the nurse can provide when administering acetylsalicylic acid 81 mg to a client experiencing severe, crushing chest pain radiating up the left jaw? 1. Chew the acetylsalicylic acid prior to swallowing. 2. Place the acetylsalicylic acid under the tongue so that it can dissolve. 3. Swallow the acetylsalicylic acid tablet. 4. Insert the acetylsalicylic acid between the cheek and gum for greater absorption.

1. Chew the acetylsalicylic acid prior to swallowing. Acetylsalicylic acid has been shown to decrease mortality and re-infarction rates after MI. The fastest way to get the aspirin into the circulatory system is to have the client chew the acetylsalicylic acid prior to swallowing. 3. Incorrect: If a solid dose pill is prescribed, the pill should be chewed. Faster absorption is obtained from chewing, rather than swallowing acetylsalicylic acid.

A nurse is taking care of a client with major partial thickness burns. Tobramycin 125mg IVPB has been prescribed. What is the priority lab assessment prior to administering this medication? 1. Creatinine 2. Potassium 3. Magnesium 4. Blood urea nitrogen

1. Creatinine 1. Correct: Tobramycin can cause nephrotoxicity. 2. Incorrect: This will not tell us if the kidneys are damaged. 3. Incorrect: This will not tell us if the kidneys are damaged. 4.Incorrect: BUN can elevate for reasons other than renal problems.

A client is taking methylphenidate to treat attention deficit disorder. Which changes are likely to be observed by the nurse when working with this client? 1. Decreased intake of food 2. Calmer demeanor 3. Increased attention span 4. Increased activity level 5. Insomnia

1. Decreased intake of food 2. Calmer demeanor 3. Increased attention span 5. Insomnia The medication may cause anorexia and subsequent weight loss. The client should be calmer if taking the medication as prescribed. The client's ability to focus on the task at hand should be increased. Insomnia is common.

The nurse is contributing to an educational seminar on ophthalmic health. Which risk factors for cataract formation should the nurse recommend? 1. Diabetes mellitus. 2. Cigarette smoking. 3. Family history of glaucoma. 4. Long-term use of corticosteroids. 5. Thin cornea.

1. Diabetes mellitus. 2. Cigarette smoking. 4. Long-term use of corticosteroids. 1., 2. & 4. Correct: All these factors put a client at greater risk for development of cataracts. 3. Incorrect: A family history of glaucoma places a client at risk for the development of glaucoma, not cataracts. 5. Incorrect: Thin cornea is a risk factor for glaucoma, not cataracts.

The nurse notes that a client needs orotracheal suctioning when which signs and symptoms appear? 1. Drooling 2. Bradypnea 3. Apprehension 4. Tachycardia 5. Gurgling

1. Drooling 3. Apprehension 4. Tachycardia 5. Gurgling Signs and symptoms of upper and lower airway obstruction requiring nasotracheal or orotracheal suctioning include increasing respirations, adventitious sounds, nasal secretions, gurgling, drooling, restlessness, gastric secretions or vomitus in mouth, and coughing without clearing secretions from the airway. Signs and symptoms associated with hypoxia include increasing pulse, respirations, apprehension, anxiety, decreased level of consciousness, increased fatigue, dizziness, dysrhythmias, pallor and cyanosis. 2. Incorrect: Respiration will normally increase with hypoxia.

Which signs and symptoms if noted in a male client would lead the nurse to suspect prostate cancer? 1. Dysuria 2. Proteinuria 3. Nocturia 4. Polyuria 5. Lower back pain 6. Pyuria

1. Dysuria 3. Nocturia 4. Polyuria 5. Lower back pain The warning signs of prostate cancer include weak or interrupted urine flow, inability to urinate, difficulty in starting or stopping urine flow, polyuria, nocturia, hematuria, or dysuria. Continuing pain to the lower back, pelvis and upper thigh is also a sign of prostate cancer. 2. Incorrect: Proteinuria is protein in the urine. You would not expect to see protein in the urine unless the glomerulus has been damaged. 6. Incorrect: Pyuria is white blood cells in the urine and would be seen with infection.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Empty the indwelling catheter on the four hour postop client. 2. Instruct a client to soak in a warm bath for 30 minutes when experiencing endometrial discomfort. 3. Monitor the peri-pad count on a client diagnosed with fibroid tumors. 4. Assist client two days post hysterectomy to the bathroom. 5. Encourage a client who is refusing to get out of bed to walk in the hall.

1. Empty the indwelling catheter on the four hour postop client. 4. Assist client two days post hysterectomy to the bathroom. 5. Encourage a client who is refusing to get out of bed to walk in the hall. 1., 4., & 5. Correct: The UAP can empty a client's catheter bag. UAPs can assist with elimination and are taught how to measure output. Ambulating a stable client to the bathroom is also an acceptable task to assign to the UAP. All personnel should encourage a client to ambulate when prescribed. This can be done by the UAP. 2. Incorrect: It is out of the UAP's scope of practice to teach. The RN cannot delegate teaching to anyone other than another RN. 3. Incorrect: The nurse is responsible for assessing and evaluating a client. This would be out of the UAP's scope of practice. The nurse cannot assign assessment and evaluation of the nursing process to the UAP.

The nurse is collecting data from a parent who is seeking treatment for a child in a pediatric clinic suspected of having Fifth disease. What symptoms would the nurse expect associated with this illness? 1. Erythema on the cheeks. 2. Joint pain. 3. Temperature 102°F (38.88°C). 4. Swollen knees. 5. Pruritic rash on soles of feet.

1. Erythema on the cheeks. 2. Joint pain. 4. Swollen knees. 5. Pruritic rash on soles of feet. 1., 2., 4., & 5. Correct: These are common signs/symptoms of Fifth disease. 3. Incorrect: Low grade fever is seen with this disease.

A client with an automated internal cardiac defibrillator (AICD) was successfully defibrillated. The telemetry technician shouts out that the client was in ventricular fibrillation (VF). What should the nurse do first? 1. Go to the client to collect data for signs and symptoms of decreased cardiac output. 2. Call the primary healthcare provider to report that the client had an episode of VF so medication adjustments can be made. 3. Notify the "on call" person in the cath lab to re-charge the ICD in the event that the client has a recurrence. 4. Document the incident on the code report form and follow up regularly.

1. Go to the client to collect data for signs and symptoms of decreased cardiac output. The client comes first. Check to see how they are doing by collecting data related to cardiac output. Make sure to include LOC, vital signs, skin and urinary output. 2. Incorrect: Do not call before you evalute the client who may be unconscious if the arrhythmia has decreased their cardiac output. 3. Incorrect: This is not needed because there is a battery that keeps it charged, so that they don't have to re-charge after each shock. 4. Incorrect: Documentation is not appropriate until the client has been evaluted first.

Which client should the nurse see first after receiving report on assigned clients? 1. Having dyspnea after surgery. 2. Needing vitals signs taken before the administration of blood. 3. Crying with pain after back surgery. 4. Vomiting dark brown, granular material.

1. Having dyspnea after surgery The client may be having a pulmonary embolism after surgery. This client with oxygenation needs takes priority over the other three clients. 2. Incorrect: Needing vitals signs taken before blood administration does not take priority over oxygenation. If blood is needed, tissue perfusion could be altered, so this would need to be addressed in a timely manner after airway issues and other potentially deteriorating situations have been addressed. 4. Incorrect: This client with dark brown emesis may have an upper GI bleed that has slowed or stopped. This is the second client to see but is not a priority over oxygenation. This could potentially return to active GI bleeding and the client's condition could deteriorate rapidly, so the client would need to be seen following the client with dypnea.

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

1. Inform the primary healthcare provider immediately. 3. Inform the client that he should watch for signs of bleeding. The value of 4 is above the usual target range of 2-3. The client should be told to watch for signs of bleeding. Further treatment is indicated. 2. Incorrect: The medication dosage is likely to be reduced. 4. Incorrect: Further action is indicated and may include changing the usual warfarin dosage. 5. Incorrect: The value of 4.6 is greater than the usual target range.

An elderly, bed-bound client receiving G-tube feeding at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway? 1. Initiate seizure precautions 2. Discontinue G-tube feeding 3. Administer oxygen 4. Obtain blood work for troponin level

1. Initiate seizure precautions Feeding tube clients tend to get dehydrated, especially clients on bed rest, because bed rest induces diuresis! If the client is already having neurological signs, a grand mal seizure may be next! Better take seizure precautions while awaiting the serum sodium results. 2. Incorrect: You may do this; however, seizure precautions will take priority. 3. Incorrect: The priority here is seizure precautions. 4. Incorrect: This data should lead to the suspicion of dehydration and hypernatremia, not suspected MI, which would be the reason a troponin level would be obtained.

The nurse has a duty to act as client advocate. What are the consequences of failure to act as a client advocate? 1. Life-threatening complications for the client. 2. Legal action against the nurse and/or health care facility. 3. Suspension of license or loss of license to practice nursing. 4. Suspension of license or loss of license to practice medicine. 5. Loss of client autonomy and right to make decisions.

1. Life-threatening complications for the client. 2. Legal action against the nurse and/or health care facility. 3. Suspension of license or loss of license to practice nursing. 5. Loss of client autonomy and right to make decisions. The role of client advocate is a nurse's responsibility. Failure to act as a client advocate could result in a range of complications for the client, including life-threatening or life-ending complications. Failure to act as client advocate exposes the nurse to liability, potential legal action against the nurse and/or health care facility, and potential suspension or loss of license to practice nursing. The client advocate protects client autonomy and right to make decisions. 4. Incorrect: The nurse does not have a license to practice medicine. The nurse may have suspension of license or loss of license to practice nursing.

A client diagnosed with renal failure has been admitted to the medical unit. An arterial blood gas (ABG) analysis has been prescribed by the primary healthcare provider. Which ABG interpretation by the nurse is appropriate? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis Metabolic acidosis pH - 7.33 (normal value 7.35 - 7.45) less than 7.35 PaCO2 36 mm Hg (normal value 35 - 45 mm Hg) within normal range HCO3 20 mEq/L (normal value 22 - 26 mEq/L) less than 22 mEq/L Metabolic acidosis is reflected in a reduction of the HCO3 and pH levels. Metabolic alkalosis is indicated by an elevated pH and HCO3 levels. The client's HCO3 and the pH are below the normal range. The primary issue with respiratory acidosis is an elevated CO2 level. The CO2 level for this client is within the normal range. With respiratory alkalosis the pH is greater than 7.45. The pH for this client is less than 7.35 and the PaCO2 is within the normal range. The HCO3 value will decrease or elevate depending if the pulmonary process is acute or chronic.

Which referral would the nurse anticipate that the primary healthcare provider would make for a client who has difficulty eating using regular utensils? 1. Occupational therapist 2. Physical therapist 3. Rehabilitation nurse 4. Registered Dietitian

1. Occupational therapist An occupational therapist helps physically disabled clients adapt to physical limitations and is most qualified to help clients improve their ability to perform activities of daily living. OT's help clients learn to approach tasks differently, use assistive devices or equipment, make adaptations to the home or work environments and find ways to assist the client in meeting personal goals.

A client receiving torsemide 20 mg every day reports an onset of cramping in the lower extremities. Based on this report, what current lab finding would the nurse expect? 1. Potassium level of 3.1 mEq/L (3.1 mmol/L) 2. Calcium level of 11 mg/dL (2.75 mmol/L) 3. Sodium level of 140 mEq/L (140 mmol/L) 4. pH level of 7.40

1. Potassium level of 3.1 mEq/L (3.1 mmol/L) Torsemide is a loop diuretic, which causes the excretion of K+. Hypokalemia can result from use of this diuretic. Normal range for potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore the level of 3.1 mEq/L (3.1 mmoL/L) is hypokalemia, and a common sign and symptom includes muscle cramps.

A client returns to the unit after a liver biopsy. Which nursing interventions would the nurse implement? 1. Put a pillow under the costal margin. 2. Place in the right side lying position. 3. Perform passive range of motion exercises to right shoulder. 4. Take vital signs every 10 - 15 minutes for first hour. 5. Instruct the client to avoid strenuous exercise for 1 month.

1. Put a pillow under the costal margin. 2. Place in the right side lying position. 4. Take vital signs every 10 - 15 minutes for first hour. The client is placed on the right side and a pillow placed under the costal margin. The pillow will place additional pressure on the rib cage which will assist with applying pressure to the liver capsule. By positioning the client on the right side, the liver capsule at the site of the biopsy is compressed against the chest wall. If the puncture site is not compressed, there is the possibility that blood or bile will leak from the puncture site. The vital signs are measured at 10 - 15 minute intervals for the first hour. Variations of the vital signs will indicate complications such as bleeding, severe hemorrhage, and bile leakage. 3. Incorrect: Passive range of motion exercises is not correct. The shoulder is not placed in a position during and after the biopsy to warrant passive exercises to the shoulder. 5. Incorrect: The client should be instructed to avoid strenuous exercise for 1 week not 1 month. The strenuous exercise is restricted to 1 week to prevent the possibility of liver bleeding.

After obtaining vital signs, which prescribed medication should the nurse hold when caring for a client on the cardiac unit? 1. Rosuvastatin 2. Enalapril 3. Digoxin 4. Clopidogrel

1. Rosuvastatin Enalapril is an angiotensin converting enzyme (ACE) inhibitor. An ACE inhibitor will lower the client's blood pressure. The blood pressure in the stem's exhibit is low. Lowering the client's blood pressure more could have a negative effect on the client's condition. 1. Incorrect: Rosuvastatin is a lipid lowering medication. The client's blood pressure has no bearing on whether or not to administer the medication. 3. Incorrect: Digoxin is an antiarrhythmic/inotropic agent. It will slow the heart rate and increase the force of myocardial contraction. This action could actually increase the blood pressure. 4. Incorrect: Clopidogrel is an antiplatelet agent. The client's blood pressure would not have a bearing on whether or not to administer the medication.

A client who has been taking phenytoin for several years arrives to the clinic for follow-up care. During the nurse's history and physical of the client, which findings indicate a possible side effect to the phenytoin? 1. Skin rash 2. Reports fatigue 3. Dyspnea on exertion 4. Pale conjunctiva 5. Heart rate 60/min

1. Skin rash 2. Reports fatigue 3. Dyspnea on exertion 4. Pale conjunctiva An adverse effect of phenytoin is aplastic anemia. Phenytoin is an anticonvulsant. Aplastic anemia is a blood disorder where not enough new blood cells are produced in the bone marrow. The blood cells include red blood cells, white blood cells and platelets. The most common symptom of decreased RBC's is fatigue and dyspnea upon exertion because RBC's are responsible for oxygen transport throughout the body. A common sign/symptom of aplastic anemia is also skin rashes. Collectively, these are signs/symptoms of aplastic anemia caused by this medication.

For a client with a major burn, which evaluation criteria best indicates that fluid resuscitation is effective during the first 24 hour of care? 1. Urine output of 30-50 mL per hour 2. Increase in weight from preburn weight 3. Heart rate of 130 beats per minute 4. Central venous pressure of 22 mm

1. Urine output of 30-50 mL per hour 1. Correct: Urine output is the best indicator of adequate fluid replacement during the first 24 hours. 2. Incorrect: The weight is not a good indicator now because of the large volume of fluids being infused. These extra fluids would increase the weight. Edema is a problem because of third spacing. 3. Incorrect: The heart rate should come down with adequate fluid replacement. 4. Incorrect: The CVP reading is too high. This indicates that too many fluids have been given.

Which nursing interventions are appropriate for a client with anorexia nervosa? 1. Weigh daily 2. Allow only 20 minutes of exercise daily 3. Allow the client to bargain for privileges as long as the client eats. 4. Stay with the client during the established time for meals. 5. Maintain visual observation for 1 hour following meals.

1. Weigh daily 4. Stay with the client during the established time for meals. 5. Maintain visual observation for 1 hour following meals. Weigh daily, immediately upon rising and following morning void using same scale if possible. The established time for meals is usually 30 minutes. This takes the focus off of the food and eating and provides the client with attention and reinforcement. The hour following meals may be used to discard food stashed from tray or to engage in self-induced vomiting.

The nurse is reinforcing client education on zolpidem. Which statement by the client indicates to the nurse that the client understands important points about zolpidem? 1. "There is a high potential for tolerance with this medication." 2. "I may do things in my sleep that I will not remember the next day." 3. "Daytime drowsiness is rare when taking this medication." 4. "The most common side effects of this medication are confusion and a bitter aftertaste."

2. "I may do things in my sleep that I will not remember the next day." This is a true statement. The client may sleep drive, make phone calls, prepare food while asleep and have no memory of the activity. 1. Incorrect: This is a schedule 4 substance. There is a low potential for tolerance, dependence, or abuse with this medication. 3. Incorrect: Daytime drowsiness and dizziness are common side effects. 4. Incorrect: Daytime drowsiness and dizziness are the most common side effects. Bitter aftertaste does not occur with this medication.

A client was started on haloperidol 5 days ago, the nurse notes restlessness, muscle weakness, drooling, and a shuffling gait. What should be the nurse's first action? 1. Hold the next haloperidol dose. 2. Administer the prn benztropine mesylate. 3. Notify the primary healthcare provider to discontinue the haloperidol. 4. Draw a blood sample for drug level. Rationale

2. Administer the prn benztropine mesylate. Benztropine mesylate is an anticholinergic that counteracts the extrapyramidal symptoms (EPS) seen with the use of haloperidol. 3. Incorrect: The primary healthcare provider has prescribed benztropine mesylate to combat the side effects of the haloperidol. There is no need to notify the primary healthcare provider, which will delay treatment.

What should the nurse include when reinforcing teaching to a client following a right knee arthroscopy? 1. Apply ice to right knee continuously for the first 24 hours. 2. Elevate the right knee when sitting. 3. Notify the primary healthcare provider of tingling in the right leg. 4. Gradually start an exercise program to prevent scarring. 5. Place a plastic bag over wound when showering.

2. Elevate the right knee when sitting. 3. Notify the primary healthcare provider of tingling in the right leg. 4. Gradually start an exercise program to prevent scarring. 5. Place a plastic bag over wound when showering. 2., 3., 4. & 5. Correct: Elevating the joint for several days will reduce swelling and pain. Tingling to the extremity could mean nerves have been damaged. Exercise is gradually started to strengthen muscles surrounding the joint and prevent scarring of surrounding soft tissues. The client needs to keep the site as clean and dry as possible. 1. Incorrect: Continuous ice can cause tissue damage.

A nurse educator is providing an inservice regarding the Health Insurance Portability and Accountability Act (HIPAA). When explaining this federal act, which provisions should the educator include? 1. HIPAA guarantees individual access to health insurance. 2. Health care agencies must keep a client's personal health information confidential. 3. Clients have the right to request a copy of their personal health information. 4. A client's personal health information may be released to obtain health insurance benefits for the client. 5. All staff members have legal access to a client's medical record while the client is receiving medical care in a facility.

2. Health care agencies must keep a client's personal health information confidential. 3. Clients have the right to request a copy of their personal health information. 4. A client's personal health information may be released to obtain health insurance benefits for the client. HIPAA is federal legislation enacted to protect a client's health information and privacy. Client identifiers and client health information should be kept strictly confidential. Clients have the right to request a copy of their personal health information. A client's personal health information may be released to obtain insurance benefits for the client.

What electrolyte imbalance should the nurse monitor for when caring for a client diagnosed with chronic alcoholism? 1. Hypochloremia 2. Hypokalemia 3. Hypophosphatemia 4. Hypomagnesemia 5. Hypocalcemia

2. Hypokalemia 3. Hypophosphatemia 4. Hypomagnesemia 5. Hypocalcemia The number one way of getting rid of potassium is through the kidneys. What does alcohol make you do? Diuresis. Acute hypophosphatemia is seen in up to 50% of patients over the first 2-3 days after they are hospitalized for alcohol overuse. Hypophosphatemia is manifested as rhabdomyolysis (muscle breakdown) and weakness of the skeletal muscles. Magnesium deficiency occurs due to that increase in diuresis as well. Hypomagnesemia is often accompanied by hypocalcemia, or lowered calcium levels, which may be aggravated by a deficiency of vitamin D. 1. Incorrect: Hypochloremia is usually caused by excess use of loop diuretics, nasogastric suction, vomiting or diarrhea due to small bowel abnormalities, and loss of fluids through the skin occurring because of trauma such as burns.

The charge nurse is observing a new nurse administer a Mantoux test. The new nurse demonstrates accurate knowledge of the procedure by completing what steps? 1. Administers 0.1 ml of PPD to upper outer arm. 2. Inserts needle under dermis with the bevel up. 3. Uses tuberculin syringe with 27-gauge needle. 4. Wraps site with gauze to prevent leaking. 5. Assesses the injection site after 48 hours.

2. Inserts needle under dermis with the bevel up. 3. Uses tuberculin syringe with 27-gauge needle. 5. Assesses the injection site after 48 hours. The Mantoux test is standardly used to test individuals for immunity to tuberculosis by giving an intradermal injection of tuberculin. This intradermal test uses 0.1 millimeter of solution given with a tuberculin syringe and 27 gauge needle, injected with bevel pointed upward into the inner surface of the forearm. The test must be read between 48 and 72 hours for accuracy.

The nurse receives report about a client who is termed "a drug seeker". The nurse giving report states that the client does not need the pain medication and is just asking for medication because the client is "hooked on it." After receiving report, what actions should the nurse take? 1. Consult with the primary healthcare provider. 2. Monitor the client. 3. Increase gradually the time between pain medication. 4. Encourage the client to wait longer before requesting the medication. 5. Utilize a pain scale to determine level of pain.

2. Monitor the client. 5. Utilize a pain scale to determine level of pain. The nurse should carefully monitor the client. The nurse must serve as an advocate for the client. A pain scale is used to determine level of pain. 1. Incorrect: The nurse must monitor the client before consulting with the primary healthcare provider about the medication. 3. Incorrect: This action assumes that the client does not have pain, which does not take into consideration what is wrong with the client. 4. Incorrect: This action assumes that the client is a "drug seeker". The nurse must carefully monitor the client.

Which client assessments should be made routinely by the nurse to minimize risk of infection from an indwelling urinary catheter? 1. Check to see if drainage receptacle is at the level of the bladder 2. Observe the catheter for flow of urine, odor, color, and any abnormal sediment. 3. Check tubing to assure that there is no tension on the catheter tubing. 4. Make sure that gravity drainage is maintained. 5. Cleanse around urinary meatus three times per day with antiseptic solution.

2. Observe the catheter for flow of urine, odor, color, and any abnormal sediment. 3. Check tubing to assure that there is no tension on the catheter tubing. 4. Make sure that gravity drainage is maintained. Observing urine flow is important as is notation of color, odor and any sediment or blood in the urine. Tubing should be free of kinks and without tension on the tubing. Gravity drainage should be maintained at all times with no loops in the tubing below the level of the drainage receptacle. 1. Incorrect: The drainage receptacle should be below the level of the bladder. 5. Incorrect: There is no need to perform any special care of the meatus. Routine soap and water is all that is necessary when soiled or at the time of routine bathing.

A client diagnosed with Alzheimer's disease becomes agitated and combative when the nurse approaches to perform a shift assessment. What would be the most appropriate first action for the nurse to take? 1. Obtain assistance to restrain the client. 2. Talk quietly to the client. 3. Administer haloperidol. 4. Leave until the family can calm the client down.

2. Talk quietly to the client. The nurse needs to present a calm manner and speak quietly to the client. This will convey trust and decrease tension and stress in the client. 3. Incorrect: The use of positive nursing actions can reduce the use of chemical (drug therapy) restraints.

A client who has Parkinson's disease has a new prescription for benztropine. What does the nurse reinforce to the client about this medication? 1. This medication blocks dopamine in the brain to decrease tremors and muscle stiffness. 2. The client should notify their primary healthcare provider if urinary retention develops. 3. Benztropine can reduce the ability to sweat, so do not become overheated. 4. No lab tests are needed while taking this medication. 5. Sit up or stand up slowly to prevent lightheadedness.

2. The client should notify their primary healthcare provider if urinary retention develops. 3. Benztropine can reduce the ability to sweat, so do not become overheated. 5. Sit up or stand up slowly to prevent lightheadedness. Urinary retention is a side effect of benztropine. Benztropine can reduce the ability to sweat and cause the body to overheat. Do not become overheated in hot weather or while you are being active because heatstroke may occur. Benztropine may cause dizziness, lightheadedness, or fainting. Alcohol, hot weather, exercise, or fever may increase these effects. To prevent these negative effects, sit up or stand slowly, especially in the morning. Sit or lie down at the first sign of any of these effects. 1. Incorrect: Benztropine is an anticholinergic. It works by decreasing the effects of acetylcholine, a chemical in the brain. This results in decreased tremors or muscle stiffness, and helps improve walking ability for clients with Parkinson's disease. 4. Incorrect: Lab tests, including liver function, kidney function, lung function, blood pressure, fasting blood glucose, and blood cholesterol, may be performed while using benztropine. These tests may be used to monitor the client's condition or check for side effects.

Following nasal surgery, the nurse suspects a client has developed diabetes insipidus. The nurse knows what laboratory results provide evidence of diabetes insipidus? 1. White blood cells of 9,500 mm3 (9.5 x 10^9/L) 2. Urine specific gravity of 1.004 3. Serum sodium level of 149 mEq/L (149 mmol/L) 4. Hemoglobin of 20 g/dL (200 g/L) 5. Glucose of 100 mg/dL (5.6 mmol/L)

2. Urine specific gravity of 1.004 3. Serum sodium level of 149 mEq/L (149 mmol/L) 4. Hemoglobin of 20 g/dL (200 g/L) Diabetes insipidus results when the body is deficient in anti-diuretic hormone (ADH), resulting in a fluid volume deficit and shock. Blood becomes concentrated and urine dilute because of extreme loss of water. Specific gravity is very low, as evidenced by a lab result of 1.004. However, serum levels of sodium (149 mEq/L (149 mmol/L)) and hemoglobin (20 g/dL (200 g/L)) are high due to concentration. 1. INCORRECT: Normal white blood cell count is 5,000 to 10,000 mm3 (5-10 x 10^9/L). This WBC result is normal and does not require action by the nurse. 5. INCORRECT: Diabetes insipidus is not related to the disease diabetes mellitus. The blood glucose level in this question is normal.

Which medication does the nurse expect will help decrease tremors in a client diagnosed with hyperthyroidism? 1. Steroids 2. Anticonvulsants 3. Beta blockers 4. Iodine compounds

3. Beta blockers Beta blockers help anxiety and tremors. Beta blockers reduce the effects of adrenaline in the body and help decrease anxiety. In times of stress and emergency the adrenal gland produces adrenaline that acts on various organs in the body to enable us to deal with the situation. For example, the heart beats faster due to adrenaline. In order for adrenaline to be able to do this, various organs have beta receptors to accept the adrenaline and use it to behave differently in times of stress. Beta blockers block these receptors. They stop various organs in the body from accepting adrenaline. Taking them means the heart does less work generally and doesn't get over-worked in times of stress. One of the main symptoms of anxiety is a speeding heart which is part of the fight-or-flight response. In times of danger our body produces adrenaline to stop the heart from beating faster makes us feel calmer. Taking beta blockers for anxiety also makes us feel less shaky. The energy boost to our muscles (from the increased supply of blood and oxygen) which makes us feel 'jittery' and 'on-edge' doesn't happen without a fast heartbeat. 4. Incorrect: Iodine compounds decrease the production of thyroid hormones in the treatment of hyperthyroidism. It does not have an effect on tremors.

The nurse is passing morning medication on a busy long-term care unit and has been delayed in completing rounds. When deciding how to distribute the remaining scheduled medications, which client would the nurse consider at greatest risk if medications are late? 1. The client with congestive heart failure receiving digoxin. 2. The client with epilepsy scheduled to receive phenytoin. 3. The client with myasthenia gravis on pyridostigmine. 4. The client with hypertension due for daily nifedipine.

3. The client with myasthenia gravis on pyridostigmine. Clients diagnosed with myasthenia gravis (MG) need a precise medication administration schedule since drugs such as pyridostigmine have a very short half-life. These medications are used to help decrease the weakness typical in MG clients, and the meds are only effective for 4 to 6 hours. It would be especially imperative to deliver the morning dose on time so that the client would not experience weakness during breakfast, increasing the risk for aspiration. 1. Incorrect: Digoxin is a cardiac glycoside which increases the contractility of the heart muscle while decreasing pulse rate, thus making the heart work more efficiently. This medication is generally given once daily and as such does not present dire consequences to the client if the dose is slightly later than usual. 2. Incorrect: The anti-seizure medication phenytoin is generally given once daily and has a very long half-life. Even if this medication is scheduled twice daily, the client is not likely to suffer any complications if the morning dose is late.

What action by a new nurse who is drawing up a medication from an ampule would require intervention by the supervising nurse? 1. Taps the top of the ampule to remove medication trapped in the top of the ampule. 2. Snaps the neck of ampule away from the body when breaking the top off. 3. Withdraws medication using a 22 gauge needle. 4. Inverts ampule, places needle tip in liquid, and withdraws all of the medication.

3. Withdraws medication using a 22 gauge needle. This action should be corrected by the supervising nurse. Because tiny pieces of glass could have gotten into the medication, the nurse should attach a filter straw to a syringe. If the syringe has a needle in place, the nurse should remove both the needle and the cap and place it on a sterile surface (e.g., a newly unwrapped alcohol pad still in the open wrapper), and then attach filter straw

The nurse is caring for a client who is wheezing and struggling to breathe. Which inhaled medications might be indicated at this time? 1. Fluticasone 2. Salmeterol 3. Theophylline 4. Albuterol 5. Levalbuterol

4. Albuterol 5. Levalbuterol Albuterol and levalbuterol are both rapid acting bronchodilators, that will quickly relieve shortness of breath, chest tightness and wheezing. This client is in distress now. Either medication would be indicated. 1. Incorrect: Fluticasone is a corticosteroid that is used regularly to receive the most benefit. It does not work immediately but may take 12 hours to several days to get the full benefit. Steroid use is for control of symptoms. This client is having symptoms now. 2. Incorrect: Long acting bronchodilators are not for use in an emergency. Salmeterol is an inhaled corticosteroid. It will not stop an asthma attack or breathing problem once it has begun. 3. Incorrect: Theophylline is inexpensive but it is often not utilized as a first line treatment. Takes a long time for this to work, and its purpose is to prevent frequency of attacks, not for emergency use.

The nurse is working on a unit with several postoperative clients. While encouraging the clients to cough and deep breath, the nurse realizes that coughing poses the greatest risk to which client? 1. A female with an abdominal hysterectomy 2. A male who had a right upper lobectomy 3. An adolescent with an open appendectomy 4. An elderly client who had cataract removal

4. An elderly client who had cataract removal Cataract removal involves replacing the eye's lens with an artificial lens that is permanently sutured into place. Coughing would increase intraocular pressure in this client and risk dislodging the lens and eye sutures. The nurse needs to monitor and prevent additional potentially harmful actions such as sneezing, vomiting, bending over, or straining.

A client returns from post anesthesia care unit (PACU) following a mastectomy with a Jackson-Pratt drain in place. What action by the nurse is important? 1. Empty drain every eight hours. 2. Irrigate drain with NS every shift. 3. Drape tubing above breast incision. 4. Empty and compress bulb when 2/3 full.

4. Empty and compress bulb when 2/3 full. A Jackson-Pratt drain is not connected to wall suction, but instead uses gravity and compression to create suction. For maximum efficiency, the bulb must be emptied at only 2/3 capacity. If the bulb becomes filled, suction fails, and fluid will build up in the tissues, possibly leading to wound dehiscence.

The nurse is caring for a client in the 8th week of pregnancy. The client is spotting, has a rigid abdomen and is on bedrest. What is most important to monitor at this time? 1. Protein in the urine 2. Fetal heart tones 3. Cervical dilation 4. Hemoglobin and hematocrit levels

4. Hemoglobin and hematocrit levels The client may be bleeding, and that is an emergency! Common causes of hemorrhage during the first half of pregnancy include abortion and ectopic pregnancy. Ectopic pregnancy is a significant cause of maternal death from hemorrhage and the classic signs of ectopic pregnancy include positive pregnancy test, abdominal pain and vaginal "spotting". Remember that in the ruptured ectopic pregnancy, bleeding may be concealed and severe pain could be the only symptom.

A client with a terminal illness, asks the nurse about palliative care. What would be the nurse's best response? 1. Palliative care is a holistic way of finding a cure for a serious illness. 2. Palliative care begins when the client has 3 months or less to live. 3. Palliative care will require you to change to a palliative care healthcare provider. 4. Palliative care prevents and treats symptoms and side effects of disease and treatments.

4. Palliative care prevents and treats symptoms and side effects of disease and treatments. This is a correct statement. The goal of palliative care is to help the client living with a chronic, life threatening illness. It focuses on the client's symptoms and the relief of these symptoms. Palliative care helps the client obtain their best quality of life throughout the course of their illness. Palliative care can begin at diagnosis. Hospice care is usually offered when the person has 6-12 months or less to live.

The nurse reinforces teaching with a client taking isoniazid for the treatment of tuberculosis (TB) regarding appropriate food choices. Which food choice indicates to the nurse that reinforcement has been successful? 1. Salad with bleu cheese dressing. 2. Smothered liver with onions. 3. Smoked salmon with crackers. 4. Pear salad with lettuce.

4. Pear salad with lettuce. Pears are acceptable fruit. Foods high in tyramine can cause headaches, fast or irregular heartbeats, nausea and vomiting and sensitivity to light. Foods high in tyramine such as aged cheeses, certain meats, liver, smoked fish, sour cream, raisins, bananas and avocados should not be eaten when taking isoniazid. 1, 2, & 3 Incorrect: Avoid foods high in tyramine. Foods high in tyramine such as salad with bleu cheese dressing can result in severe reactions when client is taking isoniazid. Foods high in tyramine such as smothered liver with onions can result in severe reactions when client is taking isoniazid. Foods high in tyramine such as smoked salmon can result in severe reactions when client is taking isoniazid.

Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is in the acute phase of mania? 1. Sit with the client during meals to encourage the client to eat all foods on the tray. 2. Assess the client's food preferences and provide only those foods for the client at meal time. 3. Allow the client to eat in the dining room with other clients. 4. Provide high-protein, high calorie snacks on the nursing unit between meals.

4. Provide high-protein, high calorie snacks on the nursing unit between meals. Having nutritious foods available between meals may help to increase the client's food intake. Nutritious intake is required on a regular basis to compensate for increased caloric requirements due to the hyperactivity.

Hypermagnesemia generally occurs secondary to which problem? 1. Cardiac contractility 2. Hypokalemia 3. Liver failure 4. Renal insufficiency

4. Renal insufficiency 4. Correct: The incidence of hypermagnesemia is rare in comparison with hypomagnesemia, and it occurs secondary to renal insufficiency or iatrogenic overtreatment. 1. Incorrect: Hypermagnesemia does not occur secondary to cardiac contractility. 2. Incorrect: Hypermagnesemia does not occur secondary to hypokalemia. 3. Incorrect: Hypermagnesemia does not occur secondary to liver failure.

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis

4. Respiratory alkalosis The blood gases confirm respiratory alkalosis. Why? The pH is 7.49 (normal 7.35-7.45). This pH indicates alkalosis since it is high. Which other chemical says alkalosis? The PaCO2 of 29 (normal 35-45) is low which indicates alkalosis. The HCO3 is normal. This means that the client is in respiratory alkalosis.

Client satisfaction is a key factor for quality assurance in the health care setting. Which nursing action is likely to improve satisfaction and demonstrates acts of beneficence? 1. Allowing clients to make their own decision about care. 2. Answering all questions posted by the client in an honest manner. 3. Reporting faulty equipment to the proper departments. 4. Sitting at the bedside and listening to an elderly client.

4. Sitting at the bedside and listening to an elderly client. Sitting and listening demonstrates kindness and compassion that are consistent with the ethical term of beneficence. 1. Incorrect: Autonomy is the ethical principle illustrated here. 2. Incorrect: Fidelity is the ethical principle illustrated here. 3. Incorrect: Reporting faulty equipment is an act to promote nonmaleficence or to do no harm.

A client with cancer refuses treatment and asks about options for hospice home care. The client's daughter asks the case manager to talk the client into agreeing to cancer treatment. The nurse explains to the daughter that this violates which client right? 1. To self-determination 2. To decline participation in research studies and experimental treatments 3. To expect reasonable continuity of care 4. To make decisions about the plan of care

4. To make decisions about the plan of care 4. Correct: The client has the right to participate in the plan of care, to refuse a proposed treatment, and to accept alternative care and treatment. 1. Incorrect: The right to self-determination is incorrect because an advance directive or resuscitation status is not involved in this situation.

The nurse is caring for a client taking digoxin. Which electrolyte imbalance should be of most concern? 1. Hypokalemia 2. Hyponatremia 3. Hypomagnesemia 4. Hypocalcemia

Hypokalemia Correct: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity could occur. Incorrect: Hyponatremia, hypomagnesemia, and hypocalcemia do not interfere with digoxin. Any electrolyte imbalance can predispose the client to digoxin toxicity, but hypokalemia is the imbalance that can potentiate digoxin toxicity the most.

A female client with a history of frequent exacerbations of asthma asks the nurse why she is at greater risk for fractures than other women her age. What is the nurse's best response? 1. "The steroids you are taking decrease calcium in the bone by sending it to the blood." 2. "Taking steroids causes bone calcium to increase, thus causing osteoporosis." 3. "Clients who have asthma are not able to exercise enough to prevent fractures from occurring." 4. "Asthma should not put you at increased risk for fractures but you are at risk for decreased blood glucose levels."

1. "The steroids you are taking decrease calcium in the bone by sending it to the blood." Long term use of steroids decreases serum calcium, so the body takes calcium from the bone and puts it in the blood in order to bring the serum calcium back to a normal level. Every time a steroid is given, calcium is removed from the bone, thus leading to a greater risk for osteoporosis and fractures. 4. Incorrect: Drug therapy for asthma (not asthma itself) may put a client at risk for osteoporosis, but not hypoglycemia.

The family of a client recently placed on antipsychotic medications for the treatment of schizophrenia calls the outpatient psychiatric clinic and reports that the client's temperature is 105.1ºF (40.6ºC), and that the client's muscles are stiff. What should the nurse tell the family? 1. Continue to monitor for signs and symptoms of infection. 2. Transport the client to the emergency room. 3. The signs and symptoms will subside within a day or so. 4. They should call the primary healthcare provider tomorrow.

2. Transport the client to the emergency room. The client may be experiencing neuroleptic malignant syndrome, a potentially life threatening adverse reaction. Symptoms include high fever, unstable blood pressure and myoglobinemia. The client should be taken to the ER.

The LPN/VN could safely accept which client assignments? 1. A client two days post appendectomy needing to ambulate. 2. A client with bronchitis receiving nebulizer treatments. 3. A newly diagnosed diabetic client awaiting discharge home. 4. A client newly admitted with exacerbation of myasthenia gravis. 5. A client admitted yesterday for observation following a fall. 6. A client with a nasogastric tube (NG) hooked to low suction.

1. A client two days post appendectomy needing to ambulate. 2. A client with bronchitis receiving nebulizer treatments. 5. A client admitted yesterday for observation following a fall. 6. A client with a nasogastric tube (NG) hooked to low suction. 4. Incorrect: Myasthenia Gravis is a progressive weakening of the neuromuscular system placing the greatest risk on the respiratory system. Although this client is on a medical-surgical floor, there is a need for close monitoring and frequent assessment of the respiratory system, requiring an RN.

The client diagnosed with active tuberculosis has been prescribed isoniazid 300 mg by mouth every day. The nurse is reinforcing client education on the medication. Which client statements indicate an understanding of isoniazid? 1. "I will notify my primary healthcare provider if my urine turns dark." 2. "My primary healthcare provider has prescribed B6 along with the isoniazid to prevent neuritis." 3. "I should avoid eating aged cheeses and smoked fish." 4. "I will eat foods such as tuna twice a week." 5. "I will rise slowly from lying to sitting, or sitting to standing."

1. "I will notify my primary healthcare provider if my urine turns dark." 2. "My primary healthcare provider has prescribed B6 along with the isoniazid to prevent neuritis." 3. "I should avoid eating aged cheeses and smoked fish." 5. "I will rise slowly from lying to sitting, or sitting to standing." Signs of hepatotoxicity from this medication include dark urine, jaundice, and clay-colored stool. Isoniazid- induced pyridoxine (Vitamin B6) depletion causes neurotoxic effects. Vitamin B6 supplementation of 10-50 mg usually accompanies isoniazid use. Aged cheeses and smoked fish are high in tyramine which may cause palpitations, flushing, and blood pressure elevation while taking isoniazid. Avoid these foods during treatment. Isoniazid should be taken on an empty stomach, one hour before or two hours after food. Some clients experience orthostatic hypotension while taking isoniazid, so caution against rapid positional changes. Histamine containing foods such as tuna and yeast extracts may cause exaggerated drug response (H/A, hypotension, palpitations sweating, itching, flushing, diarrhea).

A client has recently been diagnosed with systemic scleroderma. Which of the following client complaints would be of most concern to the homecare nurse? 1. "I feel like food gets stuck in my throat when I eat." 2. "I have a hard time brushing my teeth properly." 3. "My fingers burn when I go outside in the winter." 4. "I get short of breath whenever I exercise."

1. "I feel like food gets stuck in my throat when I eat." Scleroderma is an autoimmune disorder characterized by the excess production of collagen and hardening of tissues. In systemic scleroderma, body organs lose the ability to function as the disease progresses. When parts of the digestive system build up collagen, clients experience frequent acid reflex, constipation, and difficulty swallowing. The nurse would be most concerned about aspiration during or after meals. 2. Incorrect: Because facial skin tightens, clients have difficulty opening the mouth completely. It becomes challenging to properly brush teeth or perform personal mouth care, increasing the likelihood of tooth decay. However, this would not be the biggest concern to the nurse at this time. 3. Incorrect: It is common for clients with one autoimmune disorder to develop other disorders. These symptoms indicate Raynaud's phenomenon, which is often reported by scleroderma clients. Advance of the disease triggers skin on the hands to become tight, stiff, and slightly shiny. The client begins to experience severe pain when fingers are exposed to the cold. Fingertips start out white in color, progressively turning red until re-warmed. Impaired circulation and pain are certainly an area of concern but not the most immediate worry to the nurse at this time. 4. Incorrect: Clients with scleroderma develop scarring ("fibrosis") of lung tissue, decreasing respiratory capabilities and eventually leading to pulmonary hypertension. This client reports shortness of breath just during exercise, indicating that simple daily activities are still achievable. It is obvious the disease has not yet progressed enough to impact ADL's, and therefore this is not the most concerning complaint at this time.

The family of a bedfast 80 year old is providing care in the home. Which reports by the family indicate adequate understanding of interventions that will reduce the risk for skin breakdown? 1. I make sure that the sheets and the foam pad in the chair stay dry. 2. I will not encourage my parent to turn in the bed at night. 3. The perineal area should be kept dry and clean. 4. My parent eats 2 meals per day and drinks a supplement. 5. I may reposition my parent more than every 2 hours if their perception of pressure is intact.

1. I make sure that the sheets and the foam pad in the chair stay dry. 3. The perineal area should be kept dry and clean. 4. My parent eats 2 meals per day and drinks a supplement. 5. I may reposition my parent more than every 2 hours if their perception of pressure is intact. Keeping moisture from the skin is important for reducing the risk of skin breakdown. Keeping the client dry after using a bedpan is important to maintain healthy skin. As long as the intake of food is adequate, no further action is needed with nutrition. The client who is aware of sensations of pressure on the body has less risk of skin breakdown than those that have lost sensation.

The nurse is reinforcing teaching with a client who is at risk for developing a stroke. What primary prevention strategies should the nurse include? 1. Promote a diet rich in fruits and vegetables. 2. Provide instruction on benefits of carotid endarterectomy. 3. Limit sodium intake to 2 grams/day. 4. Engage in low intensity exercise once a week. 5. Avoid tobacco products. 6. Decrease alcohol consumption to two drinks per day.

1. Promote a diet rich in fruits and vegetables. 3. Limit sodium intake to 2 grams/day. 5. Avoid tobacco products. 6. Decrease alcohol consumption to two drinks per day. These strategies are considered primary prevention strategies that can decrease the risk of developing a stroke.

A school-age child is being discharged following treatment for sickle cell crisis. The LPN is reviewing instructions regarding homecare. What statement by the mother alerts the LPN the instruction was successful? 1. "I will notify the school not to allow my child to run at recess." 2. "My child needs to drink at least eight glasses of water every day." 3. "Pain medication must be provided consistently every six hours." 4. "A yearly flu vaccine is not necessary for my child to receive."

2. "My child needs to drink at least eight glasses of water every day." Symptoms and serious complications in clients with sickle cell disease occur because of clumping, misshapen red blood cells, which decreases the amount of oxygen available for body cells. Hydration helps decrease the viscosity (thickness) of the blood, improving circulation while decreasing pain. 3. Incorrect:. While it is true that the sickling of the red blood cells leads to insufficient oxygen for body tissues and intense pain in the crisis stage, pain medication should be on a prn basis, not a rigid schedule. The client could quickly build up dependency on pain medication, adding another complication to care.

An LPN is providing care for a post-Cesarean section client with a history of cardiac disease. When reviewing home dietary plans, the LPN realizes further instruction is needed when the client makes what statement? 1. "I should eat extra fiber to prevent constipation." 2. "I must drink lots of fluid to increase breast milk." 3. "I will check my weight and record it every day." 4. "I need to rest frequently throughout the day."

2. "I must drink lots of fluid to increase breast milk." Although breastfeeding mothers are encouraged to stay well hydrated, increasing fluids in the presence of cardiac disease would also increase the potential for heart failure. This comment by the client indicates there is a need for further instruction. 1. Incorrect: Constipation would increase the work load of the heart, particularly in clients with pre-existing heart disease. This client clearly understands how important it is to have extra fiber in the diet, indicating the teaching was successful.

A client diagnosed with systemic lupus erythematosus (SLE) has been started on hydroxychloroquine sulfate to decrease joint pain and swelling. What statement by the client indicates to the nurse the medication teaching has been effective? 1. "I will be prone to infections while on this medication." 2. "I need to see my eye doctor at least once every year." 3. "I might develop a red rash on my nose and cheeks." 4. "I can stop this medicine after my symptoms are gone."

2. "I need to see my eye doctor at least once every year." Hydroxychloroquine sulfate(Plaquenil) is in the category of DMARDs (disease modifying anti-rheumatic drug) and was originally developed to treat or prevent malaria. When taken once or twice daily, this medication reduces swelling and joint pain while also decreasing skin problems in Lupus clients. Though there are relatively few side effects, the most serious is retinal toxicity which requires treatment by an ophthalmologist. It is imperative for clients on this medication to have an eye examination every 6 to 12 months. here are several categories of medications used to treat SLE; however, none of them should be stopped suddenly. The disappearance of symptoms generally indicates the medication regime is working well, and the client should never suddenly discontinue any medicine unless instructed to do so. Abruptly stopping this drug increases the risk of an exacerbation of symptoms such as nephritis or vasculitis

A nurse has been educating a client newly diagnosed with diabetes, about proper foot care. The nurse knows teaching will need to be reinforced again when the client makes what statement? 1. "I should cut my toenails with nail clippers." 2. "Drying both feet thoroughly is important." 3. "I should never use nail polish on my toes." 4. "Weekly foot inspection must include the soles of the feet." 5. "I need larger shoes that don't pinch my toes."

3. "I should never use nail polish on my toes." 4. "Weekly foot inspection must include the soles of the feet." 5. "I need larger shoes that don't pinch my toes." The nurse is evaluating the client for an understanding of proper diabetic foot care; therefore, an incorrect statement would require further instruction. There is no reason a client with diabetes could not use nail polish on toenails. Inspection of both feet, including the soles of the feet, must be done daily and not weekly. Most importantly, properly fitted shoes are crucial to prevent complications that might result in a blister or eventually an amputation.

An LPN is taking vitals on an infant diagnosed with Tetralogy of Fallot. The mother asks why the baby seems so fatigued and turns blue when crying or feeding. What is the best explanation by the LPN? 1. "Your child has less blood flowing from the heart to the body." 2. "More protein and vitamins should be added to the daily diet." 3. "The heart is not pumping enough blood to oxygenate body tissues." 4. "Increased daily activity can help increase strength and endurance."

3. "The heart is not pumping enough blood to oxygenate body tissues." This statement offers the mother a simple but accurate explanation without being overwhelmingly technical. It is also presented in the open-ended format, allowing the mother to ask additional questions, or express concerns. 1. Incorrect: The amount of blood flow is not diminished, but rather it's the quality of the blood that is the problem. The blood is unoxygenated and therefore the body does not receive enough oxygen to meet activity needs.

Which statement made by a client prescribed naproxen for rheumatoid arthritis would require further investigation by the nurse? 1. "I signed up for swimming classes at the local recreation center." 2. "I take acetaminophen when I have a headache." 3. "I have lost 2 pounds in the past 2 weeks." 4. "I am taking an antacid to help with indigestion."

4. "I am taking an antacid to help with indigestion." Naproxen is a nonsteroidal anti-inflammatory drug (NSAID). It works by reducing hormones that cause inflammation and pain in the body. So what do we know is a concern about NSAIDs? They may cause GI bleeding and dyspepsia. This client might be experiencing these symptoms if they are taking an antacid for indigestion. Follow-up is required.

Which statement made by the client using an inhaler would indicate the need for a follow up? 1. "I should shake the inhaler well before use." 2. "I should breathe out slowly and completely through my mouth before placing the mouthpiece of the inhaler in my mouth." 3. "I should hold my breath for approximately 8-10 seconds before exhaling slowly." 4. "I should administer the two puffs that are ordered in rapid sequence."

4. "I should administer the two puffs that are ordered in rapid sequence." Rapid sequencing of the puffs is not a correct measure for using an inhaler. The client should wait 1 minute between puffs. This statement indicates the need for a follow up. 2. Incorrect: This is a correct measure that should be followed when using an inhaler. Clients should exhale slowly before bringing the inhaler to the mouth.

A cardiac step down unit has requested float staff because of multiple impending admissions. The supervisor can only send one LPN to the floor. Which assignments would be appropriate for the LPN to accept from the charge nurse? 1. A client with COPD complaining of shortness of breath on exertion. 2. A post-cardiac catherization needing assistance with bedpan. 3. A client receiving heparin injections for deep vein thrombosis. 4. A client with atrial fibrillation currently on a diltiazem drip. 5. A client receiving a blood transfusion that requires monitoring. 6. A client post pacemaker insertion, awaiting discharge instructions.

1. A client with COPD complaining of shortness of breath on exertion. 3. A client receiving heparin injections for deep vein thrombosis. 5. A client receiving a blood transfusion that requires monitoring. The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN scope of practice. Client #5 -It is considered within the scope of practice for an LPN to monitor a transfusion of a blood product. 2. Incorrect: This client is post cardiac catherization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. Because positioning on a bedpan requires rolling of the client, an RN should be assigned to assess the insertion site and monitor for the presence of bleeding.

What problem in the client with chronic renal failure would be prevented by receiving epoetin alfa? 1. Anemia 2. Halitosis 3. Edema 4. Pain

1. Anemia Yes, the diseased kidney does not produce the hormone necessary for bone marrow stimulation to promote RBCs. Epoetin alfa stimulates erythropoiesis (production of RBC). 2. Incorrect: No affect in breath odor. 3. Incorrect: No affect in edema. 4. Incorrect: Does not help with pain.

A child has been diagnosed with varicella in the clinic. What should the nurse tell the parents about home treatment of the child? 1. Apply calamine lotion to affected areas several times a day. 2. Provide cool baths with baking soda. 3. Administer aspirin for fever. 4. Do not allow visitors who have never had varicella. 5. Keep fingernails trimmed short.

1. Apply calamine lotion to affected areas several times a day. 2. Provide cool baths with baking soda. 4. Do not allow visitors who have never had varicella. 5. Keep fingernails trimmed short. 3. Incorrect: Do not use aspirin or aspirin-containing products to relieve fever from chickenpox. The use of aspirin in children with chickenpox has been associated with Reye's syndrome, a severe disease that affects the liver and brain and can cause death. Instead, use non-aspirin medications, such as acetaminophen, to relieve fever from chickenpox. The American Academy of Pediatrics recommends avoiding treatment with ibuprofen if possible because it has been associated with life-threatening bacterial skin infections.

A client has been given information about several complementary therapies for the treatment of anxiety disorder. Which therapy selected by the client would require the nurse to check for allergies? 1. Aromatherapy 2. Biofeedback 3. Guided Imagery 4. Acupuncture

1. Aromatherapy Aromatherapy is the use of essential oils from plants and herbs in the form of baths, inhalation, or compresses applied directly to the skin to promote relaxation, decrease depression and enhance sleep. Because these oils come in contact with the client's skin, or by inhalation, it would be important to verify any allergies the client may have prior to initiating therapy.

The LPN/VN encounters a client who says that he has received exposure to a liquid hazardous chemical at work. He reports that he is only 1 of about 20 people. What should the nurse do? 1. Call the supervisor and inform of the possibility of contamination in the surrounding space. 2. Obtain vital signs immediately. 3. Call personnel trained in containment and decontamination immediately. 4. Direct the individual to a bed space immediately. 5. Instruct the client to remove clothing and put on disposable hospital gown.

1. Call the supervisor and inform of the possibility of contamination in the surrounding space. 3. Call personnel trained in containment and decontamination immediately. The nurse should report this to the supervisor who can determine the next action to take regarding isolation, decontamination, and use of the current space. Those who are trained in hazardous exposures should be informed immediately so that appropriate action is taken. These actions are priority for minimizing the exposure of clients and staff to the hazardous chemical. 2. Incorrect: The nurse should avoid contact with the client until personnel trained for handling hazardous exposures are present. 4. Incorrect: Containment is necessary to prevent further contamination of the space and individuals in the area. Directing the client to a bed space would not be containment. 5. Incorrect. The client may need to be directed to a decontamination area to prevent further contamination of the area, so removing clothing before going to this area would put others at risk for exposure to the hazardous chemical.

A client is admitted with atrial fibrillation and heart failure secondary to chronic hypertension. Current medications include: Digoxin, Captopril, Carvedilol, Furosemide, and Warfarin. Based on this profile, what lab work is essential for the nurse to monitor? 1. Digoxin level 2. Potassium level 3. PT/INR 4. aPTT 5. CPK-MB

1. Digoxin level 2. Potassium level 3. PT/INR Look at the hints: Atrial fib and heart failure, so automatically what do we know about his cardiac output? Decreased. Chronic hypertension, what does that mean for afterload? Increased. Look at the meds: antihypertensive, diuretics, anticoagulants, and dig. And we know that digoxin increases the force of the contraction and decreases the heart rate. So what lab work is essential to monitor? Dig level, potassium level because of the loop diuretic, PT/INR because of the anticoagulant 4. Incorrect: aPTT is used to evaluate what? Heparin. 5. Incorrect: Well, this goes up with myocardial infarction.

A nurse suspects that a client admitted to the emergency department is in diabetic ketoacidosis. What data would lead the nurse to this conclusion? 1. Dry mucous membranes 2. Fruity-smelling breath 3. Biot's respirations 4. Glycosuria 5. Client report of abdominal pain

1. Dry mucous membranes 2. Fruity-smelling breath 4. Glycosuria 5. Client report of abdominal pain 1., 2., 4., & 5. Correct: The client with diabetic ketoacidosis will have signs of dehydration due to polyuria and includes dry mucous membranes. Fruity breath odor is from the acetone that occurs with breakdown of fats and formation of ketones, which are acids.. With DKA, the client would be spilling glucose into the urine. Vomiting and abdominal pain are frequently the presenting symptoms of DKA. 3. Incorrect: The client will have Kussmaul respirations. Biot's respiration is a respiratory pattern characterized by periods of rapid respirations, then apnea periods. These are not the type of respirations that occur with diabetic ketoacidosis (metabolic acidosis).

The nurse has been trained to work in a decontamination station for hazardous exposure victims. What should the nurse tell the victim about the process? 1. First you will remove clothing and dispose of it in hazardous material containment area. 2. You will be placed in a warm shower for decontamination. 3. You will spend a minute or so using soap over the entire body before rinsing. 4. You will spend approximately 15 minutes in the shower. 5. You will apply soap from head to toe and then rinse for a few minutes.

1. First you will remove clothing and dispose of it in hazardous material containment area. 2. You will be placed in a warm shower for decontamination. 3. You will spend a minute or so using soap over the entire body before rinsing. 5. You will apply soap from head to toe and then rinse for a few minutes. If the victim can remove his/her own clothing, then instructions should be given to do so and dispose of in hazardous material container. The person will wash for several minutes, beginning with a minute or so of full body rinsing with water to remove any visible contaminants, followed by soap and finally the rinse. The length of time for washing and rinsing will vary with institution and known contaminants. Using soap with good surfactant qualities is important. Generally, the victim is instructed to rinse with tepid water, apply soap from head to toe, and then rinse again with copious amounts of water. 4. Incorrect: Most procedures require about 5 to 6 minutes for the decontamination process. Times may vary depending on policy, contaminants, and the level of ability of the victim.

The nurse is preparing to reinforce teaching to a client diagnosed with essential hypertension on how to decrease the risk of developing complications. What topics should the nurse include? 1. Following the DASH dietary plan. 2. Use of blood pressure monitoring device. 3. Diaphragmatic breathing exercises. 4. Brisk walking for 30 minutes 3-4 times/week. 5. Reduce sodium intake to less than 2700 mg/day.

1. Following the DASH dietary plan. 2. Use of blood pressure monitoring device. 3. Diaphragmatic breathing exercises. 4. Brisk walking for 30 minutes 3-4 times/week. The DASH Eating Plan is recommended for clients who have hypertension. It is high in vegetables, fruits, low-fat dairy products, whole grains, poultry, fish, beans, and nuts and is low in sweets, sugar-sweetened beverages, and red meats. Home blood pressure monitoring can help the client keep closer tabs on their blood pressure, show if medication is working, and even alert the client and primary healthcare provider to potential complications. However, home blood pressure monitoring isn't a substitute for follow-up visits. Reducing stress as much as possible helps to decrease blood pressure. Healthy coping techniques, such as muscle relaxation, deep breathing or meditation are good options. Getting regular physical activity and plenty of sleep can help, too. Regular physical activity can lower blood pressure, manage stress, reduce the risk of several health problems and keep weight under control. 5. Incorrect: A limit of 1500 mg of sodium per day is preferred on the low sodium DASH diet. On the standard DASH diet 2,300 mg of sodium are allowed each day.

Which prescriptions would necessitate the nurse to seek clarification from the primary healthcare provider? 1. Furosemide 20.0 mg p.o. daily. 2. Chlordiazepoxide 50 mg p.o. q4h p.r.n. for agitation. 3. Diphenhydramine 25 mg p.o. hour of sleep for three nights. 4. Folic acid 1 mg daily. 5. Heparin 1000 IU subcutaneously daily.

1. Furosemide 20.0 mg p.o. daily. 4. Folic acid 1 mg daily. 5. Heparin 1000 IU subcutaneously daily. It is inappropriate to have a trailing zero after a decimal point for doses expressed in whole numbers. It can be mistaken as 200 if the decimal point is not seen and read appropriately. The Folic acid order lacks a route, thus needs clarification. This order should be written as Heparin 1,000 units subcutaneously daily. Use commas for dosing units at or above 1,000 or use words such as one thousand to improve readability. Use units rather than IU (International units) as it can be mistaken as IV or 10.

A newly admitted client gives a nurse a pile of legal documents stating, "Put these in my chart." The nurse carefully reviews each document. Which doctuments should the nurse identify as an advance directive and place in the client's medical record? 1. Living will 2. Last will and testament 3. Patient's Bill of Rights 4. Durable Power of Attorney for health care 5. Health Insurance Portability and Accountability Act

1. Living will 4. Durable Power of Attorney for health care The living will is an advanced directive that should be placed in the client's medical record. A living will is a document prepared by a competent individual that specifies the client's wishes regarding health care treatments, resuscitation and life-support measures, end-of-life care, and other specific wishes of the client should the client become incapacitated in the future. The Durable Power of Attorney for health care is an advance directive and should be placed in the client's medical record. The Durable Power of Attorney for health care identifies a health care proxy or surrogate decision maker for the client should the client become unable to make informed health care decisions. The last will and testament is not an advance directive. It is a document that describes the client's wishes regarding the settlement of his/her financial estate after death. This document should be returned to the client

Which independent nursing actions should the nurse initiate for a client admitted with heart failure? 1. Monitor for distended neck veins 2. Measure abdominal girth 3. Monitor urine output from diuretic therapy 4. Inform client regarding signs and symptoms of heart failure 5. Administer medications as prescribed

1. Monitor for distended neck veins 2. Measure abdominal girth 3. Monitor urine output from diuretic therapy 4. Inform client regarding signs and symptoms of heart failure An independent nursing intervention is one that an a LPN/VN can prescribe, perform, or delegate based on their skills/knowledge. A collaborative intervention is one that is carried out in collaboration with other health team members (physical therapist, healthcare provider). Dependent nursing intervention is one prescribed by a healthcare provider but carried out by the nurse. These actions do not require an order by a healthcare provider nor collaboration with another. They are independent nursing functions. 5. Incorrect: Administering prescribed medications is a dependent nursing intervention and cannot be initiated without an order being in place. This is the only option that is dependent on the primary healthcare provider's actions first before the nurse can initiate it.

A client with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue and fever. A urinalysis reveals proteinuria and hematuria. The primary healthcare provider prescribes corticosteroids. During the acute phase of the client's illness, what is most important for the nurse to do? 1. Monitor intake and output and daily weight. 2. Allow for frequent, uninterrupted rest periods. 3. Institute seizure precautions. 4. Protect client from injury that may cause bleeding.

1. Monitor intake and output and daily weight. Look at the clues in the stem. Proteinuria and hematuria. When you see proteinuria what do you need to worry about? The kidneys! Protein is a great big molecule. The only way for protein to be seen in the urine is if there are holes in the glomerulus. So the kidneys are being damaged. Thus, the nurse knows that the biggest problem to "worry" about here is renal failure. The best methods for monitoring fluid status and renal status for a client are to monitor I and O and daily weights. (Also, remember that one weight doesn't mean anything. The hematuria indicates that there has already been glomerular damage.) 2. Incorrect: Systemic lupus erythematosus (SLE) is an autoimmune disease. In this disease, the body's immune system mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs. Fatigue is a major symptom so allowing for frequent, uninterrupted rest periods is important for this client but monitoring for renal failure is more acute.

A client arrives by ambulance after being thrown from a horse. The client is pale, clammy and tachycardic with bruising over left upper abdominal quadrant. The nurse is aware what prescription by the primary healthcare provider takes priority? 1. Obtain blood for type and cross match. 2. Administer hydromorphone IV for pain. 3. Increase Lactated Ringers to 150 mL/hour. 4. Send client to radiology for stat CAT scan.

1. Obtain blood for type and cross match. The signs and symptoms displayed by the client suggest a ruptured spleen and shock. The greatest concern in this situation is internal bleeding and possible emergency surgery. The client will need blood; therefore, the nurse should immediately obtain blood for type and cross match. 2. INCORRECT: There is no indication in the scenario the client has pain. Pain medication should never be administered while the client is still being assessed or is in shock.

A client has been prescribed sodium polystyrene sulfonate 30 grams rectally every 6h times 2. Which laboratory value would indicate that the prescribed sodium polystyrene sulfonate has been effective? 1. Potassium 4.8 mEq/L (4.8 mmol/L) 2. Sodium 148 mEq/L (148 mmol/L) 3. Calcium 8.9 mg/dL (2.2207 mmol/L) 4. Magnesium 1.2 mEq (0.6 mmol/L)

1. Potassium 4.8 mEq/L (4.8 mmol/L) Sodium polystyrene sulfonate's action is to reduce the serum potassium level. The normal range for potassium is 3.5 - 5.0 mEq/L (3.5 - 5.0 mmol/L). The potassium level is 4.8 mEq/L (4.8 mmol/L) which is within the normal range. The potassium level would indicate that the prescribed sodium polystyrene has been effective. 2. Incorrect: A side effect of sodium polystyrene sulfonate is sodium retention. The normal range for sodium is 135 - 145 mEq/L (135-145 mmol/L). The client's sodium level of 148 mEq/L (148 mmol/L) indicates sodium retention. This is not the desired outcome of sodium polystyrene sulfonate. 3. Incorrect: The normal range of calcium is 9.0-10.5 mg/dL (2.25 - 2.62 mmol/L). The calcium level of 8.9 mg/dL (2.2207 mmol/L) indicates hypocalcemia. This is a side effect of sodium polystyrene sulfonate. 4. Incorrect: The magnesium level of Magnesium 1.2 mEq (0.6 mmol/L) indicates hypomagnesemia. This is a side effect of sodium polystyrene sulfonate. The normal range of magnesium is 1.3-2.1 mEq/L (0.65-1.05 mmol/L)

After determining that a client diagnosed with a stroke has adequate swallowing ability, the nurse implements care to safely provide oral feedings to the client. What interventions should the nurse include in this client's care? 1. Provide mouth care prior to feeding. 2. Flex head forward for eating. 3. Have dietary puree foods. 4. Use crushed ice as a stimulant for swallowing. 5. Offer thickened liquids to drink. 6. Position client in semi fowler's position after feeding.

1. Provide mouth care prior to feeding. 2. Flex head forward for eating. 4. Use crushed ice as a stimulant for swallowing. 5. Offer thickened liquids to drink. 1., 2., 4., & 5. Correct: These actions will stimulate sensory awareness, salivation, swallowing, and decrease the risk of aspiration. 3. Incorrect: Pureed foods are not usually the best choice because they are often bland and too smooth making it difficult to swallow. 6. Incorrect: The client should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for feeding and for 30 minutes afterward.

Which male client condition in the after-hours clinic should the nurse see first? 1. Scrotal pain and edema. 2. Erection lasting for 2 hours. 3. Inability to void with a history of benign prostatic hyperplasia (BPH). 4. Purulent drainage from the penis.

1. Scrotal pain and edema This client is likely to have testicular torsion, which requires immediate intervention. Infarction of the testes can occur if not treated promptly. 2. Incorrect: This is not the most life threatening problem. Priapism, a persistent, often painful erection that lasts for more than 4 hours should be treated. 3. Incorrect: With BPH the prostate gland increases in size, leading to disruption of the outflow of urine. This can cause inability to void and needs to be checked but is not the first priority. 4. Incorrect: This client does not have the most serious condition and would not take priority.

The nurse is assisting the client in changing clothes. The client says, "Stop. I don't want you or anyone touching me." What should the nurse do? 1. Stop assisting the client if he does not want it. 2. Inform the client that she is just helping him to get into hospital gown. 3. Tell the client that it is okay. The nurse just wants to help. 4. Say, "Nurses help clients all the time. There is nothing wrong with it."

1. Stop assisting the client if he does not want it. To continue is an act of battery, an intentional tort. 2. Incorrect: The client has already expressed that no help is wanted. 3. Incorrect: Continuing to touch the client without his permission is an act of assault or battery.

The nurse receives new primary healthcare provider prescriptions on a client diagnosed with Addison's disease. What prescription should the nurse question? 1. Weigh QD 2. IV of Normal Saline at 125 mL/hr 3. MRI of pituitary gland 4. Fludrocortisone acetate 0.1 mg by mouth T.I.W. 5. Dehydroepiandrosterone (DHEA) 5 mg by mouth every other day

1. Weigh QD 4. Fludrocortisone acetate 0.1 mg by mouth T.I.W. Correct: QD is listed on the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) official "do not use" list of abbreviations. This should be prescribed as "daily" instead of "QD". The abbreviation T.I.W. stands for three times a week; however, it is an unapproved abbreviation. Use "three times a week".

A client diagnosed with a duodenal ulcer is prescribed lansoprazole and sucralfate. What should the nurse reinforce to the client about how to take these medications? 1. Take together immediately before meals. 2. Take together immediately after meals. 3. Take the sucralfate first, wait at least 30 minutes, then take the lansoprazole. 4. Take the lansoprazole first, wait at least 30 minutes, then take the sucralfate.

4. Take the lansoprazole first, wait at least 30 minutes, then take the sucralfate. When prescribed any medication along with sucralfate, the client should avoid taking the medication at the same time with sucralfate. Sucralfate can make it harder for the body to absorb lansoprazole because it forms a "coating" or "barrier" on the stomach lining. Therefore, the client should wait at least 30 minutes after taking the lansoprazole before taking sucralfate.

Which nursing actions are correct for a client in a Halo Traction? 1. Observe for signs of serous drainage. 2. Inspect skin under the halo vest. 3. Use sterile technique to clean pin sites. 4. Tape a torque screwdriver to the headboard. 5. Tighten a loose pin with a torque screwdriver.

2. Inspect skin under the halo vest. 3. Use sterile technique to clean pin sites. 4. Tape a torque screwdriver to the headboard. Inspecting the skin under the halo vest is necessary to look for excessive perspiration, redness, skin blistering, especially over bony prominences. When cleaning halo pins, sterile technique should be used in an effort to prevent infection which could enter the bone. A torque screwdriver should be readily available in case the screws on the frame need to be tightened by the neurosurgeon. 1. Incorrect: Serous drainage does not indicate infection: purulent drainage, redness, and pain would indicate the likelihood of infection. 5. Incorrect: This is out of the scope of the nurse's practice. This should be done by the surgeon. The nurse should maintain the head in a neutral position while having someone else notify the neurosurgeon.

What is the priority nursing action to take when reinforcing teaching of a client about warfarin? 1. Advise the client to call the prescribing primary healthcare provider before taking any new medications or supplements. 2. Advise the client to notify a healthcare provider if experiencing dizziness or lightheadedness. 3. Advise the client of the need to have the International Normalized Ratio (INR) checked frequently. 4. Advise the client that warfarin is used to prevent thrombosis.

2. Advise the client to notify a healthcare provider if experiencing dizziness or lightheadedness. Dizziness and lightheadedness could be a symptom of bleeding, which is a very common and very serious side effect of warfarin. 3. Incorrect: This option is too vague. The frequency of INR monitoring will be determined by the client's primary healthcare provider. This is not priority over bleeding.

A client diagnosed with a deep venous thrombosis (DVT) has been prescribed warfarin. Which of the client's current medications would the nurse notify the primary healthcare provider related to the prescribed warfarin? 1. Metformin 2. Aspirin 3. Ginkgo 4. Amlodipine 5. Hydrochlorothiazide

2. Aspirin 3. Ginkgo Aspirin's chemical classification is a salicylate. One of the actions of aspirin is to reduce platelet aggregation. Aspirin's action of reducing platelet aggregation if taken with warfarin will also increase the client's risk of bleeding. Ginkgo, a herb, has properties which will increases the risk of bleeding if prescribed in conjunction with the administration of warfarin. Gingko's properties improve blood circulation. Incorrect: Metformin, Amlodipine, & Hydrochlorothiazide functional class is a calcium channel blocker. The interaction of warfarin and amlodipine does not result in an increase or decrease in the actions of warfarin.

What actions would the nurse expect to see in the care plan of a client admitted with Guillain-Barre syndrome? 1. Monitor for descending paralysis. 2. Keep a sterile tracheostomy at the bedside. 3. Monitor for heart rate above 120/min. 4. Maintain in side-lying, supine position. 5. Active range of motion (ROM) every 2 hours while awake.

2. Keep a sterile tracheostomy at the bedside. 3. Monitor for heart rate above 120/min. This client is at risk for respiratory paralysis as the disease progresses. An emergency tracheostomy may need to be performed so the nurse should watch out for imminent signs of respiratory failure. Signs include heart rate that is more than 120 bpm or lower than 70 bpm and respiratory rate of more than 30 bpm. The nurse should monitor for signs of respiratory distress and prepare for intubation if needed. 1. Incorrect: Ascending paralysis would be montiored for with this disease. Paralysis begins in the lower extremities and moves upward. 4. Incorrect: The client should be assisted to a position with head of bed elevated for full chest excursion. 5. Incorrect: The nurse should perform passive range of motion exercises. Active exercise should be avoided during the acute phase as the client is easily fatigued and muscles are weak. Passive ROM stimulates circulation, improves muscle tone and increases joint mobilization.

A child is being discharged home following a bone marrow transplant. When reinforcing discharge instructions to the parents, what information is most important for the LPN/VN to include? 1. Clean toothbrush weekly with alcohol. 2. Avoid eating raw fruits and vegetables. 3. Drink bottled water throughout the day. 4. Apply heating pad to bruised areas of the skin.

2. Avoid eating raw fruits and vegetables. The greatest risk to clients following a transplant is the chance of infection from any source since the client is severely immune-compromised for an extended period of time. There are numerous precautions necessary to avoid bacteria, but one area of concern is food storage, preparation, and consumption. Raw fruits with no skin to peel, such as strawberries, and raw vegetables like broccoli and cauliflower, present a serious risk for bacterial contamination and should not be consumed by new transplant clients. 1. Incorrect: Precise mouth care is vital following a bone marrow transplant; however, rinsing a toothbrush in alcohol is unsafe. Any residual alcohol would cause irritation and trauma to gum tissue, placing the client at risk for mouth inflammation and infection. Clients are instructed to brush teeth twice daily with a soft bristle brush, using a fluoride toothpaste. Some clients are instructed to soak the toothbrush once weekly in a special bleach solution, then rinse in hot water, while others need to replace the toothbrush weekly, based on lab test results. 3. Incorrect: Standing water of any type quickly builds up bacteria, including flower vases and vaporizers. Although bottled water may seem a safe choice, after that bottle is opened, bacteria begins to quickly build up, even if the bottle is recapped. Any water standing more than 15 minutes is considered old and must be thrown out. 4. Incorrect: With bone marrow transplant clients, it will be months before the body begins to stabilize and produce normal blood cells. Bruising and low platelet counts are to be expected for a period of time. When clients develop bruising, the approved treatment is cold compresses or ice packs applied for 15 minutes a couple times per day, and never a heating pad. Additionally, the healthcare provider should be notified so that a current platelet count can be obtained.

The nurse collects data on a client post thyroidectomy for complications by performing which action? 1. Accucheck 2. Chovostek's 3. Ballottement 4. Ice water colonic

2. Chovostek's A positive Chovostek's and Trousseau's is indicative of tetany and low calcium. This can occur if parathyroids are accidently removed when the thyroid is removed

What preoperative information should the nurse provide to the client who is scheduled for an exercise stress test tomorrow morning? 1. Eat a light breakfast two hours before the test. 2. Dress in loose, comfortable clothing. 3. Take nitroglycerin dose 15 minutes prior to test. 4. Limit drinks with caffeine to 8 ounces (240 mL) within 12 hours.

2. Dress in loose, comfortable clothing. The client should dress in loose, comfortable clothing the day of the test because the stress test consists of intense exercise. 1. Incorrect: Don't eat or drink anything except water for 4 hours before the test. The fullness from a meal makes it difficult to perform the stress test. 3. Incorrect: Clients are asked to hold beta-blockers, calcium channel blockers, and nitroglycerin medicines prior to a stress test. These medications either increase or slow down the heart rate, which can affect the test. 4. Incorrect: The client should avoid products containing caffeine for 24 hours prior to the stress test. Caffeine increases the heart rate and can affect the results of the test.

An unlicensed assistive personnel (UAP) reports to the charge nurse that a postoperative client's 8AM blood pressure is 200/104 and the oxygen saturation reading is 86%. What actions would be appropriate for the charge nurse to delegate? 1. Tell the LPN to assess for shortness of breath and evidence of tissue prefusion. 2. Have the LPN reinforce the use of relaxation techniques. 3. Ask the LPN to draw arterial blood gas levels. 4. Instruct the LPN to administer the prescribed dose of labetalol hydrochloride IM. 5. Instruct the UAP to call the primary healthcare provider and notify of change in client's condition.

2. Have the LPN reinforce the use of relaxation techniques. 4. Instruct the LPN to administer the prescribed dose of labetalol hydrochloride IM. The LPN can reinforce teaching. The client's BP is elevated and using relaxation techniques along with the medication that is being administered may help to decrease the client's BP. Labetalol is beneficial in this situation because of its rapid onset of action (approximately 5 minutes). The charge nurse delegates this to the LPN because it would be outside the scope of practice of the UAP and not in the role of the UAP to administer IM medication. 1. Incorrect: The LPN cannot assess, evaluate or teach. These are the roles of the RN and are outside the scope of practice of the LPN. 3. Incorrect: Drawing ABGs from an artery is out of the scope of practice of the LPN. 5. Incorrect. It is not in the role of the UAP to notify the primary healthcare provider of changes in the client's condition. The UAP could not receive additional prescriptions should the primary healthcare provider desire to add or change prescriptions based on the client's change in condition.

The nurse is caring for a client following a total thyroidectomy. What findings would alert the nurse to potential complications? 1. Neck dressing intact, clean and dry 2. Increased blood pressure and pulse 3. High-pitched, harsh respirations 4. Vocal quality weak and clear 5. Left-sided cheek twitching

2. Increased blood pressure and pulse 3. High-pitched, harsh respirations 5. Left-sided cheek twitching There are several potential complications following a thyroidectomy. One life-threatening problem is the potential for a thyroid storm in which a large bolus of thyroid hormone is dumped into the system, causing increased blood pressure and pulse which could lead to intracranial hemorrhage. High pitched, harsh respirations indicate increasing edema and the potential for obstructed airway. A third potential problem may occur if one or more parathyroid glands are removed, placing the client at risk for hypocalcemia, as evidenced by a positive Chvostek's sign. 1. INCORRECT: The surgical dressing around the neck should definitely be intact and dry post-op. Any drainage that may develop would take a while to seep through the dressing. No concerns here. 4. INCORRECT: The client has just had surgery on the thyroid, causing swelling that could affect vocal cords. A weak initial voice is not unusual as long as the vocal quality is clear.

The nurse is caring for a client on the post surgical unit. What should the nurse know about short term treatment of post op pain? 1. There are no concerns about addiction from pain medications following surgery. 2. Pain control following surgery rarely results in addiction. 3. The opioid medications typically result in addiction. 4. The primary healthcare provider will not prescribe an addictive medication.

2. Pain control following surgery rarely results in addiction. When a person is in acute pain following surgery, the risk of addiction to pain medication is rare. The key is to provide the medication over a short period of time to get the client past the initial pain of surgery. Remember the client will be ambulating early. Ambulation and nonpharmaceutical comfort measures should also be provided by the nurse to decrease the need for narcotics as client recovery continues. 1. Incorrect: There are slight concerns about addiction with administration of opioids; however, it is usually not a concern for the majority of post op clients with short term use in the hospital. The nurse should use alternative methods for providing relief as well. Guided imagery, massage, gradual ambulation, are just a few examples. 3. Incorrect: Use of opioids may result in addiction; however, research shows that only a small percentage of the population is prone to addiction. The goal of postoperative pain management is to relieve pain while keeping side effects to a minimum. This is often best accomplished with a multimodal approach. 4. Incorrect: Opioids are potentially addictive; however, they serve a very useful purpose in the treatment of short-term post-op pain.

Which prescription should the nurse question when a client is receiving spironolactone 25 mg by mouth daily? 1. Digoxin 0.125 mg by PO daily 2. Potassium chloride 40 mEq orally t.i.d. 3. Cimetadine 300 mg PO q6h 4. Metoprolol 100 mg p.o. daily

2. Potassium chloride 40 mEq orally t.i.d. Do not give potassium supplements, salt substitutes, or angiotensin-converting enzyme inhibitors to clients taking potassium sparing diuretics because these drugs can increase the risk of developing high to extremely high blood potassium levels. 1. Incorrect: This medication does not adversely interact with potassium sparing diuretics; however, the nurse should be on the alert for digoxin toxicity with hyper or hypokalemia. 3. Incorrect: Cimetadine is a H2 receptor antagonist indicated for ulcers and GI complaints. It does not adversely interact with potassium sparing diuretics. 4. Incorrect: This medication is a beta blocker, which may be given in addition to a diuretic for hypertension control.

Which nursing action represents secondary prevention level? 1. Reinforcing teaching about the effects of alcohol to elementary school children. 2. Providing care for abused women in a shelter. 3. Leading a group of adolescents in drug rehabilitation. 4. Ensuring medication compliance in a client with schizophrenia.

2. Providing care for abused women in a shelter. Providing care for clients in a shelter for abused women indicates that a problem has been identified and is being monitored to prevent the problem from getting worse. The focus of secondary prevention is early detection, use of referral services, and rapid initiation of treatment to stop the progress of the disease. 1. Incorrect: This is primary prevention which is aimed at reducing the incidence of mental or physical disorders within the population. 3&4. Incorrect: This is tertiary prevention which is designed to restore self-suffering and to limit complications and disabilities associated with a disease state, such as substance abuse or mental illness.

A client has returned to the room following a liver biopsy. The nurse is aware what position is best for the client? 1. Left side with right arm elevated 2. Right side for at least two hours 3. Supine with head of bed elevated 4. Left-lateral with pillow between knees

2. Right side for at least two hours Since the liver is located in the right upper abdominal quadrant, the client would be supine or slightly left-lateral with right arm above the head during the procedure. In order to apply pressure directly to the puncture site following the biopsy, the client should be placed directly on the right side. 1. INCORRECT: This position is proper for the process of the biopsy, but not after the procedure. 3. INCORRECT: Though this position may be comfortable for the client, no pressure is being applied to the biopsy site of the liver. 4. INCORRECT: The pillow serves no purpose, and the left-lateral position does not provide any pressure on the biopsy site.

A hospitalized client has developed diabetes insipidus and is given desmopressin. The nurse is aware which laboratory result indicates an improvement in the client's condition? 1. White blood cells of 7,000 mm3 (7 x 10^9) 2. Urine specific gravity of 1.010 3. Hemoglobin of 22 g/dL (220 g/L) 4. Serum sodium of 148 mEq/L (148 mmol/L

2. Urine specific gravity of 1.010 In diabetes insipidus, the kidneys excrete huge amounts of urine, causing the specific gravity to decrease from normal levels of 1.010 to 1.030, which would have been verified by urinalysis. The client's lab result indicates specific gravity within normal limits, evidence the desmopressin has begun to correct the client's condition.

The nurse is assigned five clients on a medical floor. When planning care, the nurse recognizes which clients to be at greatest risk for ineffective oral hygiene? 1. A client who has just had knee surgery taking opioids for pain. 2. A right handed client who had a stroke affecting the right hemisphere of the brain. 3. A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. 4. An elderly client experiencing loss of appetite. 5. A client who takes phenytoin for partial seizures.

3. A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. 5. A client who takes phenytoin for partial seizures. A client with severe nausea and vomiting after chemotherapy is at an increased risk for ineffective oral hygiene problems due to vomiting, decreased oral intake, and the effects of the chemotherapy on the oral mucosa. Phenytoin causes gingival overgrowth, swelling and bleeding of the gums. This can make oral hygiene more difficult. 1. Incorrect: This client can perform oral hygiene with minimal assistance. Knee surgery and opioid pain medication do not interfere with oral hygiene. 2. Incorrect: Movement for one side of the body is controlled by the opposite side of the brain. If stroke affects the right side of the brain, then you will have trouble with the left side of your body. Since this client is right handed and his left side is affected, the client can perform oral hygiene. 4. Incorrect: This client can perform oral hygiene with minimal assistance. There is no information in this option that would put this client at risk for ineffective oral hygiene.

What nursing intervention takes priority for the client one day postoperative bowel resection reporting pain of a 6 on a 0 to 10 pain scale? 1. Assist the client in changing positions. 2. Use a distraction technique. 3. Administer the prescribed analgesic. 4. Encourage the client to walk.

3. Administer the prescribed analgesic. 3. Correct: Pharmacological intervention is indicated. 1. Incorrect: There is no information to indicate repositioning may be effective. 2. Incorrect: Distraction is not an effective strategy for severe pain. 4. Incorrect: There is no information to indicate walking would be effective.

When planning post procedure care for a client who is having a barium enema, what must the nurse include? 1. Cardiac monitoring for potential arrhythmias 2. Monitoring urinary output 3. Administration of a laxative or enema after the procedure 4. Reordering the client's diet

3. Administration of a laxative or enema after the procedure The client must expel the barium post procedure. If the barium is not eliminated, it can harden in the colon and cause an obstruction.

A client is given an intramuscular injection of morphine following a laparoscopic cholecystectomy four hours ago. What client data would best indicate to the nurse that the medication has been effective? 1. Rates pain as 6 on 1-10 scale. 2. Heart rate is within normal limits. 3. Ambulates with assistance of one. 4. Voided 250 mL in 4 hours.

3. Ambulates with assistance of one. The client's ability to ambulate with one assistant indicates that pain is controlled enough to get out of bed. Even a laparoscopic procedure can cause extreme discomfort in the immediate post-op period. This action is the best indicator the client has experienced some pain relief. 1. INCORRECT: Although a baseline pain measurement is not noted, a level of 6 on the 1-10 scale is still very elevated. This client response indicates the morphine was not effective.

A factory employee is brought to the clinic with a hand laceration occurring at work. The employee is quite upset, indicating previous competency on the machine. When reviewing medications, the nurse notes the client has recently started alprazolam at bedtime. What vital information about this medication should the nurse provide to the client? 1. Consider getting new glasses. 2. Stand up slowly when sitting. 3. Do not operate dangerous machines. 4. Instructions for taking medication appropriately.

3. Do not operate dangerous machines. The vital information provided when a client starts any benzodiazepine includes no driving and no operating heavy machinery. The major side effects of this category of drugs include trouble concentrating, impaired coordination, drowsiness and fatigue, all of which may have contributed to this client's accident. The fact the client uses this drug for sleep and then goes to work indicates a lack of comprehension about side effects.

Which comment made by a client scheduled for a lumbar laminectomy and discectomy indicates to the nurse that the client needs further instructions? 1. After the incision is healed, I can go for daily walks. 2. By the time I am discharged, my back and leg pain will be better. 3. I can turn by myself after surgery, but I will need help to get out of bed. 4. The staff will frequently check my feet and legs for feeling and movement.

3. I can turn by myself after surgery, but I will need help to get out of bed. The client must log roll with assistance. The spine must be kept in proper alignment to allow the area time to rest and heal. The nurse should reinforce this information with the client. 1. Incorrect: After the incision heals, it is acceptable practice to go for daily walks so this is an accurate understanding of what the client can do after the surgery. 2. Incorrect: Successful laminectomies and discectomies will relieve back and leg pain so this is accurate, also. 4. Incorrect: The nurse knows it is very important to perform neurovascular checks after ANY orthopedic surgery. Any changes from their baseline should be reported to the primary healthcare provider immediately. This indicates successful understanding by the client.

A nurse is to administer a time release capsule to a client who has difficulty swallowing. Which intervention would be the best course of action for the nurse to take? 1. Open the capsule and sprinkle it on applesauce. 2. Melt the capsule in juice or water. 3. Notify the charge nurse. 4. Break the capsule in half using a pill splitter.

3. Notify the charge nurse. If the client has difficulty swallowing a capsule or tablet, the charge nurse ask the primary healthcare provider to substitute a liquid medication if possible. 1. Incorrect: Sprinkling the medication over applesauce or pudding may be the only option the nurse has if there is no other form, but since this medication is time-released, the best answer and priority would be to get a liquid form, if available, for the drug.

Donepezil has been prescribed to a client with cognitive impairment. The nurse is reinforcing teaching of the family members. Which statement by the family member indicates understanding of this medication? 1. This medicine will control agitation and aggression. 2. This medication should be given at bedtime since it is for insomnia. 3. Notify the primary healthcare provider if the client is vomiting coffee ground material. 4. This drug is given as needed for confusion.

3. Notify the primary healthcare provider if the client is vomiting coffee ground material. A rare but very serious side effect that can occur: black stools, vomit that looks like coffee grounds, severe stomach/abdominal pain. Notify the primary healthcare provider immediately. 1. Incorrect: An antipsychotic medication such as risperidone is used for agitation, aggression, hallucinations, thought disturbances, and wandering. Donepezil helps to decrease the symptoms of dementia (impairment of memory, judgment, abstract thinking and personality changes) in client's with Alzheimer disease. 2. Incorrect: Donepezil should be given in the evening just before bedtime, however, it is not for insomnia. Sedative/hypnotics such as zolpidem and temazepam are given for insomnia. 4. Incorrect: Donepezil should be given regularly in order to get the most benefit from it. Do not stop taking it or increase the dosage unless the primary healthcare provider changes the dose. It may take a few weeks before the full benefit of this drug takes effect.

A client with altered level of consciousness is admitted to a medical unit, the nurse finds the client with no pulse and initiates CPR. The primary healthcare provider instructs the respiratory therapist to prepare for intubation. The nurse discovers a Do Not Resuscitate (DNR) bracelet on the client's wrist during the initial assessment. Which immediate action should the nurse take to advocate appropriately for this client? 1. Assist the respiratory therapist to prepare the client for immediate intubation. 2. Attempt to contact the client's family. 3. Notify the primary healthcare provider immediately of the client's DNR bracelet. 4. Notify the charge nurse immediately of the client's DNR bracelet.

3. Notify the primary healthcare provider immediately of the client's DNR bracelet. The nurse should immediately notify the primary healthcare provider upon discovering the client's DNR bracelet. The DNR bracelet is an indicator that the client or their healthcare surrogate decision maker wants the client's wishes be known regarding healthcare treatment and resuscitation. 4. Incorrect: Notifying the charge nurse of the client's DNR bracelet is not priority. The primary healthcare provider must be notified first.

After artificial rupture of membranes (AROM), the baseline fetal heart rate tracking begins to show sharp decreases with a rapid recovery with and between contractions. Which action by the nurse is priority? 1. Position the client on her left side 2. Increase the IV fluid rate 3. Place the client in the knee-chest position 4. Administer oxygen per tight face mask

3. Place the client in the knee-chest position The fetal heart pattern is that of repetitive deep variable decelerations. This pattern is likely due to a prolapsed umbilical cord after AROM. The priority action is to relieve the pressure on the cord from being trapped between the presenting part and the pelvis. This can be accomplished by manual pressure on the presenting part, placing the client in Trendelenburg position, or placing her in the knee-chest position. 1. Incorrect: This action will improve placental perfusion, but will not relieve compression of a prolapsed cord. If the cord is compressed, it doesn't matter how well perfused the placenta is because the oxygen cannot reach the baby. Late decels and low BP would be an indicator that we need to increase uterine perfusion by positioning on left side.

A client with recurrent angina and hypertension has been started on new medications. When reviewing the admission forms, the nurse should immediately question which prescription? 1. 2 gm sodium diet 2. Metoprolol 25 mg PO once daily 3. Potassium 10 meq PO once daily 4. Diltiazem 120 mg PO once daily

3. Potassium 10 meq PO once daily This client is being treated for recurrent angina with hypertension. The admission prescription includes spironolactone daily, which is a potassium-sparing diuretic; therefore, the client should NOT be taking a daily dose of potassium.

What should the nurse know when caring for a client diagnosed with Grave's disease who is scheduled to receive radioactive iodine? 1. Stay 6 feet from people for 2 weeks. 2. This medication is given intravenously as a one-time dose. 3. Radioactive iodine will leave the body in urine and saliva within a few days. 4. You cannot receive radioactive iodine if you are pregnant. 5. Radioactive iodine is absorbed by the parathyroid glands.

3. Radioactive iodine will leave the body in urine and saliva within a few days. 4. You cannot receive radioactive iodine if you are pregnant. Within a few days after treatment, the radioactive iodine will leave the body in urine and saliva. If the client is pregnant, she should not receive radioactive iodine treatment. This kind of treatment can damage the fetus's thyroid gland or expose the fetus to radioactivity. Women should wait a year before conceiving if they have been treated with radioactive iodine. 1. Incorrect: Stay away from babies for 1 week and do not kiss anyone for 1 week. 2. Incorrect: Radioactive iodine is given in a capsule or liquid form. One dose is usually all that is needed. 5. Incorrect: Radioactive iodine is absorbed by the thyroid gland. It destroys the thyroid. So now the client becomes hypothyroid.

The nurse is caring for a client who is taking an antipsychotic medication for the treatment of schizophrenia. The nurse is told in report that the client has akathisia, as a side effect of their antipsychotic medication. What symptom should the nurse expect this client to have? 1. Upward gaze of the eyes. 2. Involuntary movement of the tongue. 3. Reports of restlessness. 4. Lack of movement or slowed movement.

3. Reports of restlessness. Reports of restlessness, inability to sit still, and nervous energy indicate akathisia. These symptoms respond poorly to treatment. If possible, the dose of the medication may be reduced. 1. Incorrect: Upward gaze of the eyes indicates dystonia, a possible adverse reaction to the antipsychotic medications. 2. Incorrect: Tardive dyskinesia has the symptoms of involuntary movement of the tongue, chewing movements of the mouth, and lip smacking. These symptoms may be irreversible. 4. Incorrect: Slowed movement refers to the side effect of bradykinesia. Lack of movement is referred to as akinesia.

The nurse enters the client's room to administer the morning dose of digoxin. Before administration, the nurse checks the client's apical pulse to find the rate to be 70. What should the nurse do? 1. Hold the medication as the pulse rate is too low. 2. Wait 30 minutes and attempt to give the medication again. 3. Contact the primary healthcare provider. 4. Give the medication as prescribed.

4. Give the medication as prescribed. The pulse rate is high enough to give the medication. A pulse rate of less than 60 would warrant holding the medication.

A hospitalized client diagnosed with rheumatoid arthritis is receiving IV methylprednisolone every six hours. What is the best method for the nurse to provide client safety? 1. Place "fall precautions" sign above client's bed. 2. Change the intravenous site for steroids daily. 3. Restrict any visitors with visible illnesses. 4. Put client on full contact precautions

3. Restrict any visitors with visible illnesses. Rheumatoid arthritis is an autoimmune disease that affects not only body joints but also organs of the body. Receiving methylprednisolone as treatment further suppresses the immune system, making the client even more at risk of infection. Restricting visitors with colds, respiratory problems and other infectious processes is the best method to protect the client. 1. INCORRECT: The question states the diagnosis is rheumatoid arthritis, but there is no indication the client is unsteady or needs to be on "Fall Precautions". Although the client is fatigued and has brittle bones, there is no evidence the client needs assistance ambulating. A sign is not necessary.

The nurse on a large surgical unit needs to collect data on several clients returning from procedures. Which client should the nurse monitor first? 1. Lumbar puncture reporting a headache. 2. Cystogram reporting burning on urination. 3. Thoracentesis reporting shortness of breath. 4. Cardiac catherization with a decreased pedal pulse below insertion site.

3. Thoracentesis reporting shortness of breath. A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. This client should report an improved respiratory, not shortness of breath. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should monitor this client first.

Which statement by a client would indicate to the nurse that the client understands important points about alendronate? 1. "It is recommended that I recline for 15 minutes after taking my medication." 2. "Food should be eaten immediately after taking alendronate." 3. "My medication tablet should be chewed for rapid absorption." 4. "I should drink a full 8 ounce glass of water with my medication."

4. "I should drink a full 8 ounce glass of water with my medication." Alendronate is a biophosphonate drug used in the treatment of osteoporosis and other bone diseases. The client should take each tablet in the morning with a full glass of water (6-8 ounces or 180-240 ml) at least 30 to 60 minutes before the first food, beverage or medication of the day, to increase absorption.

What instruction should a client know about a newly prescribed salmeterol inhaler? 1. "Use the inhaler immediately if wheezing and shortness of breath occur during exercise." 2. "Use the inhaler when you experience a stuffy nose due to seasonal allergies." 3. "Carry the inhaler with you at all times and take 2 puffs anytime you experience an exacerbation." 4. "This inhaler should be used routinely as prescribed even when free of symptoms."

4. "This inhaler should be used routinely as prescribed even when free of symptoms." Salmeterol is a maintenance medication. It can prevent asthma attacks and exercise induced bronchospasm. Salmeterol acts as a bronchodilator. It works by relaxing muscles in the airways to improve breathing. 3. Incorrect: Salmeterol is a maintenance medication. Albuterol is used as a "rescue inhaler" for bronchospasms.

A client who has chronic renal failure has been prescribed synthetic erythropoietin for the prevention of anemia. Which data should be reported to the primary healthcare provider? 1. Hemoglobin level of 10 g/dL (1.6 mmol/L) 2. Blood pressure of 120/84 3. Constipation 4. Swelling of feet and ankles

4. Swelling of feet and ankles Erythropoietin is generally well tolerated. Swelling of feet and ankles may indicate the beginning of a cardiovascular problem. Clients taking this drug are at risk for myocardial infarctions and risk of blood clots. 1. Incorrect: The purpose of this drug is to increase hemoglobin levels. A level of 10g/dL (1.6 mmol/L) would be considered favorable even though still low. The client would still need the medication since anemia still exists. If hgb is above 12 g/dL (1.9 mmol/l), the level should be reported as the client does not need the med any longer.

The parents of a child hospitalized with cystic fibrosis have been given discharge instructions. The nurse knows that teaching has been successful when the parents make what statement? 1. "Our child will need to have a gluten free diet." 2. "The enzymes should be given at bedtime daily." 3. "Salt needs to be decreased in our child's diet." 4. "We need to prepare high calorie, high fat meals."

4. "We need to prepare high calorie, high fat meals." Cystic fibrosis is an inherited disorder in which abnormally viscous secretions affect the respiratory and digestive systems. Because the client is unable to absorb nutrients, several dietary adaptations are crucial, including frequent small meals along with digestive enzymes to help the client process food. The meals should be high calorie, high fat with increased amounts of sodium to help stabilize fluids. 2. Incorrect: Pancreatic digestive enzymes, such as Creon or Pancreaze, must be given with every meal or snack in order to help the digestive system absorb nutrients properly. Because clients with cystic fibrosis need frequent small meals throughout the day, digestive enzymes must also be provided throughout the day with any food. 3. Incorrect: Clients with cystic fibrosis lose abnormally large amounts of salt in sweat, and the glands are unable to reabsorb needed sodium into the body system. Rapid dehydration is common due to decreased sodium levels, which are exacerbated during exercise or hot weather. These clients are encouraged to increase salt intake.

The nurse on a surgical unit is collecting data on several post-operative clients. Which observation should the nurse report immediately to the primary healthcare provider? 1. A post transurethral resection client with cherry colored urine 2. A post mastectomy client drains 40 mL of bloody drainage within 3 hours of the surgery 3. A post ileostomy client with a beefy red stoma and mucus drainage 4. A post thyroidectomy client reporting tingling in toes and fingers

4. A post thyroidectomy client reporting tingling in toes and fingers One potential risk during a thyroidectomy is the accidental removal of some or all of the parathyroid glands. The client would develop signs and symptoms of hypocalcemia from decreased blood levels of calcium. As muscles become rigid and twitch, the resulting tetany would cause the client to experience a tingling sensation in toes and fingers. The nurse needs to notify the primary healthcare provider so that a calcium level can be drawn and the client given supplemental calcium. 2. Incorrect: Mastectomy clients return from surgery with one or more drains placed under skin flaps in the breast tissue. These drains are part of a collection system that allows serous drainage to be removed from the surgical site, thus enhancing the healing process. 40 mL over 3 hours is not an excessive amount. This is an expected finding that does not need to be reported. 3. Incorrect: The sign of a healthy stoma post-op is a beefy red appearance and slightly elevated above the level of the abdomen. It is expected that the stoma will have a mucoid discharge for a day or so until normal stool begins to form again. This client displays normal post-operative findings with nothing unexpected.

A nurse is caring for a client who has been prescribed sucralfate. Which client education intervention would the nurse include for the client prescribed sucralfate? 1. Take medication 1 hour after meals. 2. Crush tablets prior to taking medication. 3. Consume 1000 mL of fluid every 24 hours. 4. Avoid antacids 1 hour before and after this medication.

4. Avoid antacids 1 hour before and after this medication. Sucralfate is absorbed more effectively in an acidic state. Since an antacid medication will increase the alkaline state, the client should avoid taking antacids within 1 hour before or after taking sucralfate to increase the absorption rate of sucralfate. 1. Incorrect: Sucralfate should not be taken 1 hour after a meal. To increase the absorption of sucralfate the medication should be taken on an empty stomach when the stomach is more acidic. 2. Incorrect: Clients should not crush, or chew sucralfate tablets. The outer layer of the tablet has specific formulated pharmacokinetic properties that should not be crushed or chewed. 3. Incorrect: A potential side effect of sucralfate is constipation. An increase of fluids during the medication therapy is recommended to decrease the side effect of constipation. An intake of 1000 mL of fluid per 24 hours intervention is not enough fluid to reduce the possibility of constipation.

Which medication should the nurse administer first after receiving the morning shift report? 1. Levothyroxine to the client with hypothyroidism and a thyroid stimulating hormone (TSH) level of 2.8 mU/L 2. Amlodipine to the client with hypertension and a blood pressure of 150/86 3. Regular insulin sliding scale dose to the client with diabetes and a 210 blood glucose level. 4. Cefotaxime intravenous piggyback to the newly admitted client with a diagnosis of pneumonia and a white blood cell count (WBC) of 12,000mm3

4. Cefotaxime intravenous piggyback to the newly admitted client with a diagnosis of pneumonia and a white blood cell count (WBC) of 12,000mm3 4. Correct: The first dose of intravenous antibiotic medication is the priority since the WBCs are elevated and the antibiotic should be administered first. 1. Incorrect: The TSH is normal so the thyroid medication is not the priority. 2. Incorrect: Amlodipine is for high blood pressure and is important but the antibiotic is the priority. 3. Incorrect: It is important to administer the regular insulin but it is not priority over initiating the intravenous antibiotic medication.

What should the nurse recognize as the major barrier of chemotherapy success in treating cancer clients? 1. Inadequate knowledge of the side effects of chemotherapy 2. Difficulty obtaining an IV access 3. The development of alopecia 4. Toxicity to normal tissues

4. Toxicity to normal tissues Chemotherapy is toxic to both cancerous and non-cancerous cells. Widespread destruction of non-concancerous "normal" cells can limit the use of chemotherapeutic agents. 2. Incorrect: Implantable ports are most often used for chemotherapy administration and eliminate the difficulty of obtaining a repeated peripheral IV site.

The nurse is preparing to administer nadolol to a hospitalized client. Which client data would indicate to the nurse that the medication should be held and the primary healthcare provider notified? 1. Blood pressure 102/68 2. Glucose 118 3. Urinary output (UOP) 440 mL over previous 8 hour shift. 4. Heart rate 56/min

4. Heart rate 56/min This is a beta blocker. It slows the heart rate. If a client's heart rate is less than 60 beats per minute, notify the primary healthcare provider and ask if the client should receive this medication. Administering a beta blocker to a client who has a heart rate less than 60 could possibly cause the client to develop symptomatic bradycardia and hypotension. 1. Incorrect: If the client's BP drops below 90/60, this beta blocker should be held and the primary healthcare provider notified. The BP in this option is high enough to administer the medication, but the BP in clients on beta blockers should be monitored and the client should be taught about signs and symptoms of hypotension. 2. Incorrect: This is a normal glucose level. If the client is a diabetic, beta blockers can mask the signs of hypoglycemia. Diabetics on beta blockers should monitor their blood sugar carefully. 3. Incorrect: Urinary output is adequate. Beta blockers do not alter renal function. However, if pulse and BP are reduced too much, renal perfusion could ultimately be affected.

Two days after a client has a chest tube inserted, the nurse notes constant bubbling in the water seal chamber. What action should the nurse take? 1. Do nothing since this is normal. 2. Decrease the amount of suction. 3. Replace CDU unit with another one. 4. Notify primary healthcare provider.

4. Notify primary healthcare provider. The water seal chamber is the middle of the three chambers and helps to create the one-way flow of drainage and air from the client to the CDU. The water seal chamber should bubble only intermittently when the client coughs, sneezes or breathes, creating a fluctuation of the water known as "tidaling". Constant bubbling in that chamber indicates an air leak somewhere in the system. Because the nurse cannot fix this independently, the primary healthcare provider must make that determination. 1. INCORRECT: The water seal chamber helps create the one-way flow of drainage and air from the pleural space to the CDU. Constant bubbling in that chamber is not normal. 2. INCORRECT: Constant bubbling in the water seal chamber is not controlled by the amount of suction. Decreasing suction would not alter the type of bubbling in the middle chamber. 3. INCORRECT: Though the nurse may discover damage to the CDU unit itself, simply replacing the unit with a new one may not correct the problem in the water seal chamber.

A client with chronic arterial occlusive disease has a bypass graft of the left femoral artery. Postoperatively, the client develops left leg pain and coolness in the left foot. What is the priority action by the nurse? 1. Elevate the leg. 2. Check distal pulses. 3. Increase the IV rate. 4. Notify the primary healthcare provider.

4. Notify the primary healthcare provider. In this case, there is nothing on the list the nurse can do to fix the problem. The primary healthcare provider must be notified immediately. Anticipate that the client will be returning to surgery because these are symptoms of an arterial problem that needs to be addressed immediately. 2. Incorrect: Checking the pulses is delaying treatment and does not fix the problem. In this question you have only 1 option, so you must go with what is best for the client.

The nurse is reinforcing instructions to a client with chronic obstructive pulmonary disease (COPD) about nutrition and maintaining body weight. Which information is most important for this client? 1. Do postural drainage just before meals. 2. Consume fluids only at meal times. 3. Prepare meals high in carbohydrates. 4. Plan rest periods before and after meals.

4. Plan rest periods before and after meals. Both ingestion and digestion require a great deal of energy expenditure for clients. Resting prior to eating helps decrease dyspnea, allowing the client to complete an entire meal. Relaxing afterwards compensates for the increased blood flow sent to the gastrointestinal system during digestion, again minimizing respiratory effort. Frequent rest periods throughout the daily are vital for COPD clients. 1. Incorrect: Postural drainage techniques help COPD clients loosen and expel excessive mucus that builds up from inflammation within the lung tissue. Because of specific therapy positions, including those in which the client faces head down, there is the chance of wheezing or vomiting. This can lead to aspiration or infection. The best time to complete chest therapies is at least an hour before or two hours after a meal. 2. Incorrect: Fluids help to thin excessive mucous secretions typical in chronic obstructive pulmonary disease. Also, if the client is using oxygen, the mucous membranes will quickly dry out. COPD clients are encouraged to drink at least 64 ounces of caffeine free liquids throughout the day, rather than just at mealtime. 3. Incorrect: Because dyspnea interferes with eating, weight loss and malnutrition are areas of concern for clients with COPD. Small frequent meals high in protein are important to maintain nutrition and improve the immune system.

A client with a history of congestive heart failure (CHF) has been admitted with digoxin toxicity. After reviewing the initial laboratory results, the nurse knows what abnormal findings most likely contributed to the digoxin toxicity? 1. Sodium 2. Calcium 3. Albumin 4. Potassium 5. Magnesium

4. Potassium 5. Magnesium Hypokalemia and hypomagnesemia both can increase the client's potential to develop digoxin toxicity. Digoxin and potassium both bind at the same location on the ATPase pump. When potassium levels are low, more digoxin will attach to the sites, leading to toxicity. Low magnesium levels sensitize the cardiovascular system to the toxic effects of digoxin. 1. Incorrect: The presence of digoxin in the body does slightly inhibit the activity of the NA/K+ pump. However, even though the sodium level is slightly elevated, there is no direct correlation between that increased sodium level and digoxin toxicity.

To reduce the risk of developing a hematoma post-balloon angioplasty, the nurse should implement which measure? 1. Elevate the head of the bed 45 degrees. 2. Check the puncture site every 8 hours. 3. Assist the client to the bathroom to void. 4. Prevent flexion of the affected leg.

4. Prevent flexion of the affected leg. Let the clot remain stable for a while. The insertion site should stay immobile for several hours to reduce bleeding. 1. Incorrect: No, that's flexing the hip and disrupting the clot. It may take several hours before a client is allowed to sit up in bed.2. Incorrect: Checks are needed more frequently than every 8 hours.3. Incorrect: No! Don't get up and walk yet, although in general, clients who have angioplasty can walk around within 6 hours after the procedure.