Uworld PN,Hurst part 2,NCSBN PN
Metformin side effects
1. Dizziness 2. Nausea 3. Vomiting 4.Diarrhea 5. Abdominal discomfort 6. Lactic acidosis
Immediately after a liver biopsy, a client is placed on the right side for 60-90 minutes. What is the rationale for placing the client in this position? 1. Helps stop bleeding if any occurs. 2. Restores circulating blood volume. 3. This is the position of greatest comfort. 4. Helps reduce fluid trapped in the biliary ducts.
1. Correct: Anyone who has a liver biopsy is at risk for bleeding. The clotting factors are produced in the liver, as is prothrombin. Any time a needle is inserted into the body and removed, bleeding can occur. Whenever there is a risk for bleeding, the preventive measure is to apply pressure. Lying on the right side applies pressure to the liver. A towel may be rolled up and placed under the right side for added pressure. Again, pick the most life threatening answer. This is what could kill the client. 2. Incorrect: Lying on the right side does not lead to restoration of circulating blood volume. 3. Incorrect: Lying on the right side is not a position of comfort. Applying pressure is the goal, as the client is at risk for bleeding. 4. Incorrect: Lying on the right side does not reduce fluid trapped in the biliary ducts.
The nurse, caring for a client who has terminal cancer, finds that the client is extremely restless. In response to this data, what would be the appropriate nursing action? 1. Play soothing music. 2. Use chamomile aromatherapy. 3. Place soft restraints on arms. 4. Dim room lights. 5. Keep conversations quiet. 6. Massage forehead.
1., 2., 4., 5., & 6. Correct: Music therapy may produce relaxation by quieting the mind and promoting a restful state. Aromatherapy with chamomile may also help overcome anxiety, anger, tension, stress, and insomnia in dying clients. When the lights go down and the room darkens, this signals to the brain that it's time for rest. Keeping conversations quiet will help to decrease stimuli. Simple techniques such as repositioning pillows or bed clothes and gentle massage (if tolerated) can also provide relief from pain. 3. Incorrect: Restraints will only agitate the client more. Remember, use restraints as a last resort. When an individual is nearing their final days, terminal restlessness is a common symptom. Terminal restlessness (sometimes called terminal agitation) includes anxiety, agitation and confusion. Other symptoms include hallucinations, paranoia, and disorientation. These signs are more intense than simple mood changes and can be very troubling for family members. A calm, quiet and stress-reduced environment, with reassurance from those who are close to the person, can often help to relieve this symptom. Option 1 is true. It's believed that music has been used since practically the beginning of time to help people deal with difficult feelings and better connect to one another. Music has a strong and immediate influence over our emotions, and naturally increases our neurochemicals or "feel good" endorphins. Option 2 is true. Chamomile has been found to be very effective in eliminating feelings of sadness, depression, disappointment, and sluggishness while inducing a sort of happy or charged feeling. Chamomile is effective in calming down annoyance, anger, and irritation. It has analgesic properties, which effectively reduces pain in the muscles and joints. Chamomile essential oil has also been used as a mild sedative to calm nerves and reduce anxiety by promoting relaxation. Inhaling it is one of the best ways to utilize essential oils for anxiety. The fragrance is carried directly to the brain and serves as an emotional trigger. Option 3 is false. Don't do this. Restraints will only agitate the client more. Remember, use restraints as a last resort. Option 4 is true. One of the hormones produced by dimming the lights is melatonin. Also known as the "hormone of darkness", melatonin promotes relaxation and sleep. Option 5 is true. The goal is to decrease stimuli. So, we want to create a quiet environment. Turn off the TV. Talk softly, calmly, and quietly. Option 6 is true. People use massage for a variety of health-related purposes, including to relieve pain, rehabilitate sports injuries, reduce stress, increase relaxation, address anxiety and depression, and aid general wellness.
A postoperative surgical client has a prescription for monitoring of intake and output (I&O). The I&O sheet has been picked up by the unlicensed assistive personnel (UAP) for the 7AM-3PM shift. Intake Output IV fluid-1025 mL Urine - 1350 mL PRBC-250 mL NG tube - 75 mL Jackson Pratt - 22 mL
1350 + 75 + 22 = 1447 mL
Cefazolin (Ancef)
1st generation cephalosporin ask if the patient has allergic reactions like anaphalaxis and angioedema
record your assigned clients vital signs before taking your break
The nurse needs to monitor vital signs before administer medications
Miconazole (Monistat)
Topical cream Vaginal suppository or cream antifungal that helps treat candidiasis, is inserted into the vagina with an applicator best to apply at bed time avoid intercourse until inflammation is ressolved typical duration of treatement 3-7 days
Autism Spectrum Disorder
a disorder that appears in childhood and is marked by significant deficiencies in communication and social interaction, and by rigidly fixated interests and repetitive behaviors not responding to their name. avoiding eye contact. not smiling when you smile at them. getting very upset if they do not like a certain taste, smell or sound. repetitive movements, such as flapping their hands, flicking their fingers or rocking their body.
Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer's) have the same osmolality as plasma and are administered
are admisnter to expand intravascular fluid volume and replace the fluid osses commonly associated with vomiting abd diarrhea,burns, and traumatic injury.
beta blockers (metropolol,atenolol, bisopolol)
are given for heart faliure and hypertension
dextrose is given to
hypoglycemia
Which health problem does the nurse recognize as putting the client at risk for hypomagnesemia? 1. History of heart disease 2. Ingesting magnesium based antacids 3. Parathyroid disorder 4. Alcohol abuse
. Alcohol abuse 4. Correct: We get magnesium from food. Because an alcoholic drinks, and thereby eats very little, magnesium intake is often not adequate. Also, alcohol suppresses the release of ADH. Decreased ADH leads to diuresis and magnesium loss.
A homeless person has been admitted to the medical unit and placed on airborne precautions for suspected Pulmonary Tuberculosis (TB). The nurse will monitor for which signs and symptoms? 1. Weight gain 2. Fatigue 3. Bloody sputum 4. Diaphoresis during sleep 5. Anorexia
. Fatigue 3. Bloody sputum 4. Diaphoresis during sleep 5. Anorexia 2., 3., 4. & 5. Correct: Feeling tired all the time or fatigue, weight loss rather than weight gain, loss of appetite, fever, coughing up blood and night sweats are the most common signs and symptoms of active TB.1. Incorrect: Weight gain is not a symptom of TB. Weight loss is a common symptom of TB due to decreased desire to eat.
A child was diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) in the clinic one week ago. Today the child's mother calls the clinic to tell the nurse, "Ever since my child has been on methyphenidate he has not been able to sleep." What is the best response for the nurse to make?
3. "To prevent insomnia, give him the last daily dose at least 6 hours before bedtime." 3. Correct: This is a correct statement. If the medication is sustained-released, administer the dose in the morning. 1. Incorrect: This is premature. Try changing the time to help with sleep. 2. Incorrect: This does not help the problem. The child needs to sleep. 4. Incorrect: The client has not overdosed based on this information.
After injecting enoxaparin subcutaneously into the abdomen, which action should the nurse take? 1. Gently rub the injection site when the needle is withdrawn 2. Have the client maintain a side lying position for at least five minutes 3. Remove the needle and engage the needle safety device 4. Apply heat to the site
3. Remove the needle and engage the needle safety device 3. Correct: After a Subcutaneous injection, the needle is removed and the needle's safety device is engaged. 1. Incorrect: Do not massage the injection site of enoxaparin. Rubbing is the same as massaging the site. 2. Incorrect: The client does not have to maintain a certain position following the administration of enoxaparin. 4. Incorrect: Heat is not applied to the injection site after enoxaparin is injected.
The nurse cares for a client who is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which precaution is important for the nurse to implement? 1. Perform hand hygiene after shift report. 2. Implement droplet precaution for the client. 3. Stock the client's room with dedicated equipment. 4. Elimination of dairy products from the client's diet.
3. Stock the client's room with dedicated equipment. 3. Correct: The client's room should be stocked with dedicated equipment just for that client to prevent the nurse from spreading MRSA to other clients through cross-contamination. The nurse should perform hand hygiene before and after client contact. Clients that are infected with MRSA should be placed on contact precautions. Eliminating dairy products from the client's diet is not necessary. 1. Incorrect: The nurse should perform hand hygiene before and after client contact. 2. Incorrect: Contact precautions should be implemented. 4. Incorrect: Eliminating dairy products from the client's diet is not necessary.
The nurse is reinforcing teaching for a client diagnosed with cirrhosis about the functions of the liver. What functions should the nurse include? Select All That Apply 1. Removes old RBCs from the body. 2. Produces clotting factors. 3. Detoxifies the body .4. Releases digestive enzymes. . 5. Breaks down medications.
Rationale 2., 3., & 5. Correct: Three of the four functions are listed: the liver produces clotting factors, detoxifies the body, and breaks down medications. It also synthesizes albumin.
Glasgow coma score of 13
Scores of 13 to 15 correspond to mild closed head injury; 9 to 12, to moderate head injury; and 8 or less to severe brain injury. The Glasgow Coma Scale does not correlate with survival outcome in cases of severe head trauma with coma.
Antimuscarinic, anticholinergic agents
Tolterodine/Detrol LA Oxybutynin/Ditropan Solifenacin/Vesicare used for overactive bladder, and urge urinary incotinence
terazosin
alpha adregernic blocker/it relaxes smooth muscles including peripheral vasculature can relieve urinary retention bening prostatic hyperplesia in BPH place at risk for falls take at bed time change positios slow can cause ejaculatory dysfunction
Methoxetrate(reumathrex)
antineoplastic antidepressant DMARD used to treat RA, and Psoriasis can cause bone marrow suppression patients taking this medication are at risk for infection and should avoid crowded places should receive inactivated vaccines(influenza, pneumococcal)not herpes zoster Methoxetrate is teratogenic, also hepatoxic
Transmission-based precautions
are additional infection control practices implemented for clients who are known or suspected to be infected or colonizedThe presence of bacteria on a body surface (e.g., the skin, mouth, intestines or airway) that doesn't cause active disease. with infectious agents. In addition to standard precautions, clients may require additional, transmission-based infection control precautions. Transmission-based precautions will supplement standard precautions for clients with documented or suspected infection (or colonization) with highly transmissible or epidemiologically important microorganisms. The three types of transmission-based precautions include: Contact precautions Droplet precautions Airborne precautions
Adolescent pregnancy risks
hypertension, iron-deficiency anemia, premature birth, stillbirth, LBW infants, and prolonged labor Factors such as lack of family support,sexual abuse, and poor nutrititional statues can negatively impact pregnancy
a patient had a parathyroid adenoma removed 2 days ago. she is now complaining of muscle cramps in her hands and feet. you should suspect
hypocalcemia
Chlorthalidone Hydrochlorothiazide side effects:
hypokalemia-muscle cramps-dysrrthmias hyponatremia-altered mental status and seizure hyperuricemia-may worsen or precipitate gout hyperglycemia-adjust of diabetic meds
Major side effects of ACE inhibitors
hypotension, hyperkalemia, cough, angioedema, and birth defects,temporary increase in serum creatine
bradycardia
hypothyroidism
After a liuver biopsy position the client
on the right side a minimum of 2 hours
Transdermal Scopolamine
prevention of motion sickness mydriasis and cycloplegia can result
UAP tasks for NG tubes
• Provide oral care to patient with NG, gastrostomy, or jejunostomy tube.• Weigh patient who is receiving enteral feeding.• Position and maintain patient receiving enteral feeding with the head of bed elevated.• Notify RN or LPN about patient symptoms (e.g., nausea, diarrhea) that may indicate problems with enteral feedings.• Alert RN or LPN about enteral feeding infusion pump alarms.• Empty drainage devices and measure output.
Removing PPE
1. gloves 2. goggles 3. gown 4. mask
Theophylline levels
10-20
Calcium levels
8.5-10.5 mg/dL
The nurse is reinforcing education for a client taking a monoamine oxidase inhibitor (MAOI). Which foods should the nurse make sure the client avoids? Select all that apply. A. Smoked fish B. A ripe avocado C. Wine D. Cottage cheese E. Grilled Chicken
A,B,C,E
Rosuvastatin side effects
Abdominal discomfort Insomnia Morning headache
Acetaminophen side effects
Anemia (long term use) Liver and kidney failure Dyspnea (prolonged high doses) angioedema hives, itching
Plavix (clopidogrel)
Antiplatelet Can cause thrombocytopenia ,platelet count <150,000mm3 and increase the risk for bleeding
Ethambutol (Myambutol)
Antitubercular SE - Optic neuritis, decrease in visual acuity Notes - Routine vision test (monthly), Serum Creatine
Education for hemophilia:
Avoid aspirin and ibuprofen Avoind intramascular injections/ instead use subQ Avoid contact sports and safety hazards, instead perform noncontact activities Dental hygiene, use soft bristtle toothbrush Should weara medical alert
patient teaching for Warfarin
Avoid inconsistent or excess of : broccoli' grapefruit spinach sparagus kale brussel sprout green tea cranberry juice
When taking tetracyclines, what should be avoided?
Dairly products antacids iron tablets take on an empty stomach take with a full glass of water do not take it at night -because they cause chelation of tetras. which reduces the GI absorbtion
The nurse is caring for a client with jaundice, elevated liver enzymes and an elevated serum bilirubin. What color urine does the nurse expect to find? 1. Pink tinged 2. Straw colored 3. Clear 4. Dark amber
Dark amber 4. Correct: Yes! The bilirubin will be excreted in the urine and discolor it dark.
Metoclopramide (Reglan) side effects
Excessive blinking eyes Lip-smacking Puffing of cheeks protruding of the tongue chewing movements frowning and blinking of the eyes twisting fingers twisted or rotated neck(torticollis)
brachytherapy.
Internal radiation is called brachytherapy. Brachytherapy allows for delivery of radiation to the target tissue through radioactive seeds or ribbons, while minimizing exposure to surrounding healthy tissue.
Restaing technique
Repeating the major theme You say your co-workers never invite you
Kava Kava Uses
anxiety and insomnia
client with the highest risk for peritonitis: appendectomy
appendectomy,Liver disease with cirrhosis . Such disease often causes a buildup of abdominal fluid (ascites) that can become infected. Kidney failure getting peritoneal dialysis.
Lactulose MOA
by converting ammonia produced by intestinal bacteria to ammonium which is polar and therefore cannot readily diffuse into the blood. Lactulose also enhanced diffusion of ammonia into the colon for excretion
isotonic IV fluids (eg; 0.9 % sodium chloride,lactated ringer's)
have the same osmolaity as plasma and are administered to expand intravascular fluid volume. This solutions replace fluid losses commonly associated with vomiting and diarrhea,anaphalaxis burns and traumatic injury,extreme hyperglycemia.
Aldosterone
increases sodium and decreases potassium
Anticholinergis side effects
pupillary dialtion dry mouth urinary retention constipation atony contraindicated in closed /narrowangle glaucoma,bowel ileus,and urinary retention.
Cephalexin:
similar to penicillin ask if patient is allergic to penicillin
in the immediate postoperative period after
thyroidectomy, the first priority is to maintain a patent airway
relaxation techniques to relieve headache during preeclampsia
to help releave headache
nitroglycerin
vasodiltes
Calcium channel blockers: nifedipine amlodipine felodipine nicardipine
vaslidators used to treat hypertensio and chronic stable angina Promote relaxation of vascular smooth muscle leading to dicrease systemic vascular resistance and arterial blood pressure
What interventions is most appropriate when caring for a client with impairment of cranial nerve II
verbally explain nursing interventions in detail
Decreased bicarbonate reabsorption
will produce metabolic acidosis compensatory response to respiratory alkalosis
Amikacin, Gentamicin, Tobramycin
aminoglycoside antibiotic
Serotonin antagonists
are antiemetic agents that are indicated for the treatment of nausea and vomiting. Serotonin antagonists block the serotonin receptor sites located throughout the body responsible for the mediation of nausea and vomiting.
Mitotic inhibitors
are chemotherapeutic agents that are indicated for the treatment of malignancies and cancerous cells. They are most often used in combination chemotherapy regimens to enhance the overall cytotoxic effect.
Closed Head Injury (CHI)
brain matter is not exposed or penetrated -often accompanied by secondary brain injuries -75% affected have problems with discourse (fragmented, difficult to follow, word retrieval difficulty)
A 9 year old awating surgery .Which intervention is developmentally appropriate for this client's plan of care?
Discuss the plan or process Use simple diagrams with correct anatomical terminology
Naproxen use
NSAID antipyretic anti-inflammatory pain and inflammation
Legal documents that support clients' rights include
advance directives, a living will, do not resuscitate (DNR) order and an informed consent
hemoglobin levels
males: 14-18 females: 12-16
postprandial short acting insulin
regular:peak 2-5 hrs,use in IV for ketoacidosis, sliding scale Lispro,aspart,gluisine, peak 0.5-3 hours best option for postmeal hyperglycemia
Dietary potassium should be avoided when
taking : spironolactone triamterene amiloride ACE ARBS
steady muscle contraction caused by hypocalcemia
tetany
"A client is about to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching session, the nurse should provide which instruction to the client?
"Apply a sunscreen before exposure to the sun.
"Hormonal effects of the antipsychotic medications include:
"retrograde ejaculation and gynecomastia.
Ketorolac (Toradol)
*class*: nonsteroidal anti-inflammatory agents, nonopioid analgesics *Indication* pain *Action*: Pain relief due to prostaglandin inhibition *Nursing Considerations*: -may cause GI bleeding, Stevens-Johnson Syndrome, anaphylaxis, drowsiness - should not exceed 5 days of therapy - bleeding risk increased with garlic, ginger, and ginkgo - may decrease effectiveness of hypertensive medications and diuretics
normal troponin levels
0-0.4 ng/mL
Prothrombin time/international normalized ratio
1.5-2.5
Birth weight doubles by
6 month and triple by 1 year of age.
Severe Asthma Exacerbation:
Accesory muscle use Chest tightness High pitch expiratory wheeze Tachypnea cough diminish breath sounds
Pregabalin (Lyrica)
Anticonvulsant/Antineuralgic
what patients can be assigned a private room
C.diff,Tuberculosis,Ebola
The nurse is discussing information about sexually transmitted infections (STIs) with adolescents. Which infection should the nurse emphasize as the most commonly occurring STI? Chlamydia Human immunodeficiency virus Herpes simplex 2 Gonorrhea
Chlamydia Correct Response Chlamydia has the highest incidence of any sexually transmitted infection in this country. Prevention is similar to safe sex practices taught to prevent any STI, such as using a condom for protection during intercourse.
rales
Crackles; wet crackling noise in lungs
Hawthorn extract for
Heart faliure
cephalexin
Keflex Antibiotic
suggesting
Offering alternatives, e.g., "Have you ever considered...?"
ethical principle of beneficence
Obligation to respect the integrity and promote the welfare of the client Including family needs It can involve not saying all known information immediately but delaying notification until appropriate support is in place
Osteoarthritis
Osteoarthritis is the most common form of arthritis, affecting millions of people worldwide. It occurs when the protective cartilage that cushions the ends of the bones wears down over time. Although osteoarthritis can damage any joint, the disorder most commonly affects joints in the hands, knees, hips and spine. Osteoarthritis symptoms can usually be managed, although the damage to joints can't be reversed. Staying active, maintaining a healthy weight and some treatments might slow progression of the disease and help improve pain and joint function. Osteoarthritis symptoms often develop slowly and worsen over time. Signs and symptoms of osteoarthritis include pain. Affected joints might hurt during or after movement. Joint stiffness might be most noticeable upon awakening or after being inactive. The joint might feel tender when applying light pressure to or near it. The client might not be able to move the joint through its full range of motion and might feel a grating sensation when using the joint. The client might also hear popping or crackling on joint movement. Bone spurs may occur. These extra bits of bone, which feel like hard lumps, can form around the affected joint. Swelling occurs due to soft tissue inflammation around the joint. Joint protection can reduce stress on arthritic joints and decrease pain. There are several joint protection principles, which if followed, will help to conserve energy and preserve joint function. Encourage the client to recognize body signals. If the client is experiencing pain after an activity, the client should consider that they have been too active or done too much. Don't disregard the pain but respect the pain felt. For arthritis clients, there is a 2-Hour Rule which states that if you have more arthritis pain two hours after exercise than you did before, consider cutting back the next time. Basically, adjust your activity level to your pain level. Avoid any activity that causes pain and find a better way of accomplishing the task. Make compromises which will protect the joints. If standing causes pain, attempt to do the activity while sitting. Avoid excessive pressure on the small joints of the hand. For example, if opening a water bottle is painful, don't force the hand. Get a bottle opener that works or have someone else open it. Also, avoid heavy lifting. There are many assistive devices which will help the client accomplish tasks that are otherwise difficult and painful. Jar openers, reachers, dressing sticks, long handled cleaning tools, raised toilet seats, and shower benches are just a few examples of assistive devices which are easy to find. The client should use the largest and strongest joints and muscles. Use both arms when lifting or carrying an object. By using the largest and strongest joints, less stress occurs on single joints or weaker areas of the body. Use good posture and body mechanics. There are proper ways to stand, sit, bend, reach, and lift that will allow the client to put less stress on joints. By moving properly, the client can preserve joints. Avoid staying in one position for too long. Staying in the same position for a long time can cause joints to stiffen and become painful. Change positions as often as possible to protect joints. Balance activity and rest. When the body signals that it has had enough, schedule a period of rest. By balancing activity and rest, the client will be able to do more, though it might take longer, and will be protecting joints. Avoid prolonged periods of immobility. Prolonged inactivity and immobility will cause stiffness and increased pain. Gentle range of motion exercises should be performed daily. Each joint should be put through its full range of motion by bending, stretching, and extending the joint. Reduce excess body weight. Extra weight adds stress to weight-bearing joints. By losing weight and then staying at their ideal body weight, the client will be protecting joints.
The primary healthcare provider prescribed tolbutamide 250 mg orally twice a day. The pharmacy dispensed tolbutamide 0.5 g scored tablets. How many tablets will the nurse administer? Round your answer using one decimal point.
Step 1: 1000 mg : 1 g = x mg: 0.5 g x = 500 mg Step 2: 500 mg: 1 tab = 250 mg : x tab 500 x = 250 X = 0.5
Nifedipine (Procardia)
calcium channel blocker
diltiazem
calcium channel blocker
intial fluid administer in ketoacidosis
normal saline 0.9%
increase fetal activity withgestational hypertension
decrease
medications and supplements that increase bleeding risk before surgery
garlic gingko vitamin E warfarin
anorexia
hypothyroidism
gum hyperthrophy
occurs in phenytoin toxicity
betadine.
povidone-iodine
Adverse effects of calcium channel blockers
■ HEADACHE (vasodilation) ■ Peripheral EDEMA (not due to fluid overload) ■ BRADYcardia ■ Heart failure and heart block ■ HYPOtension, QT prolongation * CONSTIPATION is the MOST COMMON side effect Flushing orthostatic hypotension
Atenolol Mode of Action:
Selectively blocks Beta 1 adrenergic receptor sites; decreases sympathetic outflow to the periphery, suppresses renin-angiotensin-aldosterone system.
dysthymic disorder
a mood disorder involving a pattern of comparatively mild depression that lasts for at least two years
warfarin for atrial fibrilation
antibiotics can affect INR value take warfarin at the same time everyday
Lithium is used for
bipolar affective disorder stay hydrated
medications marked XL or SR
should not becut or crushed
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. Correct: 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. 4. Incorrect: The client is trying to coerce the client, and this could be considered assault.
The nurse in charge of a rehabilitation center is planning the client assignments for the day. Which client should the nurse assign to the unlicensed assistive personnel?
A client on strict bed rest and a 24-hour urine collection
The nurse is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?
A client requiring frequent ambulation with a walker
A nurse is participating in a community health fair. As part of the health promotion process, when should the nurse conduct a mental status examination?
Anytime health screening is done A mental status check is a critical part of baseline information and should be a part of every examination, whether general or specific. You will notice that three of the options indicate a problem with mental status; however, this is a "health promotion" question. Associate the word "health" in the correct option with the question. Additionally, this is a general question and the only general option is the correct option.
"A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to:
"explore the content of the hallucinations.
An adolescent is depressed. The client's prescribed medication is fluoxetine. What is the best response by the nurse when the client says, "How will this medicine make me feel better?"
1. It will regulate a neurotransmitter called serotonin
Discaharge of serosanguineous after appendectomy
is normal
when a patient with gastroenteritis vomits green
it could mean bowel obstruction
Metronidazole (Flagyl)
1. Used to treat anaerobic infections 2. DO NOT USED ALCOHOL (antabuse effect will be nauseous)
he nurse is planning care for a client who has a fractured hip. Which nursing interventions are appropriate for this client? 1. Turn every two hours 2. Place a pillow between legs when turning 3. Sit in a chair three times per day 4. Encourage fluid intake 5. Encourage ankle and foot exercises
1., 2., 4. & 5. Correct: The client must be turned every two hours. You may not be able to turn the client totally on the side of the fracture, but you must relieve pressure points. Place pillow between legs to keep affected leg in abducted position. Encourage fluid intake and ankle and foot exercises to prevent deep vein thrombosis (DVT). 3. Incorrect: The client has a fractured hip that has not been surgically fixed. Sitting up in a chair could do more injury and cause more pain.
OTC Acetaminophen contraindicated in
liver problems
INR for heart valve disease
2-3.5 never between 4-5
SIADH can occur due to
lung cancer
total parenteral nutrition
should never be stoped absuptly
The nurse is collecting data on a client who is having a breast augmentation. Which client information would be most important for the nurse to report to the surgeon before surgery?
3. Client's last menstrual period was 8 weeks ago.
Which statement would demonstrate to the nurse the highest risk for suicide or self-directed injury? 1. "I can't do anything right anymore." 2. "I am not sure what to do anymore." 3. "I just cannot take this loneliness anymore." 4. "No one cares about me."
3. Correct: This statement indicates that the person cannot tolerate the current situation. The client is at risk for harm self.
do not administer warfarin if INR is greater than
4
BUN normal reange
6-20
The nurse is caring for a client with jaundice, elevated liver enzymes and an elevated serum bilirubin. What color urine does the nurse expect to find? 1. Pink tinged 2. Straw colored 3. Clear 4. Dark amber
4. Correct: Yes! The bilirubin will be excreted in the urine and discolor it dark. 1. Incorrect: No, a sign of bleeding. 2. Incorrect: No, a sign of no bilirubin. 3. Incorrect: Definitely not any bilirubin in this one so not for the jaundiced client.
What is essential to assess in a client before undergoing repair of a depressed skull fracture
A depressed skull fracture is an inward indentation of the skull that may cause pressure on the brain. Asses for ICP
parkland formula
4ml x weight in kg x BSA Burned= total infusion volume 1/2 (divide total by 2)of amt over the first 8 hours
Acute illness in type 1 diabetes
May trigger the frelease of stress hormones,which leads to higher blood hlucose and ketone levles(sometimes leading to ketoacidosis) Do not skip administration os insulin dose even if not eating. Isulin theraphy should continue as prescribes during acute illness. Sick day management: Increase frequency of blood glucose level checks(1-4 hrs) Icreaseing or decreasing the dose of insulin as needed based on blood glucose levels Mantain adequate hydratin Test for ketones
carciad catheterization
Cardiac catheterization (kath-uh-tur-ih-ZAY-shun) is a procedure used to diagnose and treat certain cardiovascular conditions. During cardiac catheterization, a long thin tube called a catheter is inserted in an artery or vein in your groin, neck or arm and threaded through your blood vessels to your heart.
Kava Kava side effects
Early symptoms liver damage include yellowed eyes and skin (jaundice), fatigue, dark urine
place a patient if suspected air embolism
Head should be lowered(trendlenburg),left side
Thiazides side effects
Hypokalcemia, hypomagnesium, hypercalcemia, hyperglycemia
The nurse on a medical unit is reviewing the data on a client admitted to a medical unit. Which data supports the diagnosis of glomerulonephritis?
Malaise Blood pressure - 16O/92
Cyclobenzaprine
Muscle Relaxant
A client with schizophrenia says "He just returned from Mars", what will be a good rresponse
Why do you think you made that trip
Advance directives or living will
describes the client's health care decision(eg. do not resuscitate). As a part of an advance directive, the client may designate a representative to make health care decisions for the client- a durable POA for health care. The client's statement requires further clarification regarding what type pf POA is in place. An advance directive makes clear a client's care wishes(eg, do not resuscitate) A POA power of attorney designates a representative to act on a person's behalf. It is important to clarify that the client has the type of POA who can make health care decisions
There's a new medication order that reads: "administer 1 gtt ciprofloxacin solution OD Q 4 h" What action should the nurse take?
Call the prescriber to clarify and rewrite the order Correct Response Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a potentially dangerous "workaround." The nurse should call the health care provider who prescribed the medication and clarify the order.
A client who takes warfarin after coronary artery stent placement calls the health clinic to ask, "Can I take Alka-Seltzer for an upset stomach?" How should the nurse respond? "Use one-half the recommended dose of Alka-Seltzer." "Avoid Alka-Seltzer because it contains aspirin." "Take Alka-Seltzer at a different time of day than the warfarin." "Select another antacid that does not interfere with warfarin."
"Avoid Alka-Seltzer because it contains aspirin." Correct! Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin, an antiplatelet medication, will potentiate the anticoagulant effect of warfarin and may result in increased bleeding tendencies.
A client with a history of paranoid personality disorder is admitted to the hospital with extreme weight loss. Family states client has been refusing medications and food due to fears of being poisoned. What initial response by the nurse is most important?
"You certainly are having scary thoughts." The client is so fearful of being poisoned that physical harm has occurred secondary to personal starvation. The responsibility of the nurse is to address the client's fears and establish a trusting nurse/client relationship in order to meet the goal of helping the client feel safe enough to begin to eat.
The nurse is collecting data about a 16 year-old's use of coping mechanisms. The teen had multiple serious injuries after a motor vehicle accident. Which characteristics are most likely to be displayed by this teen?
Denial, projection, regression Correct Response Helplessness and hopelessness may contribute to regressive, dependent behavior. Denying or minimizing the seriousness of the injuries is used to avoid facing the worst situation or consequence of the accident.
The nurse is teaching a group of clients in cardiac rehabilitation how blood flows through the heart. In what order should the nurse present this information? List the order in which blood flows through the heart, starting from deoxygenated blood in the body.
Deoxygenated blood comes from the body to the heart via the superior and inferior vena cava. From there blood enters the right atrium, then travels to the right ventricle. The right ventricle pumps the blood to the lungs via the pulmonary artery where the blood becomes oxygenated. From the lungs, oxygenated blood goes to the left atrium via the pulmonary vein, then to the left ventricle. The left ventricle pumps the blood out through the aorta to the body.
In caring for a client exposed to radiation, the nurse knows that the type of damage due to radiation exposure depends on which factors? Select all that apply 1. Dose rate 2. Organs exposed 3. Technician 4. Time of day 5. Type of radiation
1., 2. & 5. Correct: The extent of damage due to radiation exposure depends on the quantity of radiation delivered to the body, the dose rate, the organs exposed, the type of radiation, the duration of exposure, and the energy transfer from the radioactive wave or particle to the exposed tissue. 3. Incorrect: The technician has no bearing on the type of damage due to radiation exposure. 4. Incorrect: The time of day has no bearing on the type of damage due to radiation exposure.
Phenytoin (Dilantin)
10-20 mcg/mL Anticonvulsant
The nurse is providing care to a client who post laparoscopic cholecystectomy. Which finding would be of concern? 1. Right upper quadrant abdominal discomfort 2. Clay colored stool 3. Light yellow urine 4. Pruritus 5. Icteric sclera
2., 4., & 5. Correct: Injury to nearby structures, such as the bile duct, liver and small intestine can occur after this surgery. Clay colored stools and jaundice of the sclera are caused by recurring stricture or stone of the common bile duct. Pruritus occurs when bile reaches the skin. 1. Incorrect: The gallbladder is in the right upper abdominal quadrant, so discomfort would not be uncommon in this area postoperatively. 3. Incorrect: Light yellow colored urine is normal. Bile duct obstruction (biliary obstruction) occurs when there is a blockage in the bile ducts. Bile ducts transport bile from the liver and gallbladder through the pancreas and into a part of the small intestine called the duodenum. Bile is dark green or brownish yellow in color. It is produced by the liver to help digest fats, and the gallbladder creates it to help with the digestive process and absorption of fats. Bile also helps to clear out the liver. A biliary obstruction can occur in any of the bile ducts in the body. If a bile duct obstruction remains untreated, it can result in fatal liver diseases. Bile ducts found in the liver are separated into two kinds. Intrahepatic ducts are found inside of the liver. They are a collection of smaller tubes that collect and transport bile to the extrahepatic ducts. There are two extrahepatic ducts outside of the liver, one on the right and one on the left. These two ducts combine to form the common hepatic duct, which runs into the small intestine after passing through the pancreas. The biliary duct is the bile duct that emerges from the gallbladder and opens into the common hepatic duct, after which it is called the choledochal or common bile duct. When bile ducts become obstructed, bile builds up in the liver causing jaundice in the client. Known causes of bile duct obstruction include gallstone disease and a history of gallstones. Some common symptoms of biliary obstruction include light-colored stools, dark urine, jaundice, itching, pain in the upper right side of the abdomen, nausea, vomiting, weight loss, and fever. Now look at the options. Option 1 is false. Hope you didn't pick this one. This client is post laparoscopic cholecystectomy. You would expect some discomfort or pain. Pain unrelieved by pain medication would be of concern. Nothing to worry about here. Option 2 is true. Clay colored stool would be of concern. Bile salts are released into stool by the liver and give them their brown color. When the liver is not producing enough bile, or when the flow of the bile is blocked, stools become clay-colored. Gallbladder removal surgery can lead to narrowing of the bile ducts. Option 3 is false. A light yellow urine color is normal. We would worry if the urine was a dark yellow or brown color. Urine gets its color, which is typically yellow, from a pigment called urochrome, or urobilin. Lighter colored urine is more diluted, whereas darker urine contains less fluid. Very dark urine could be a sign that the client is dehydrated. Option 4 is true. If the common bile duct is still blocked by stones or stricture, bile will not be able to get into the small intestine. It can get into the skin causing jaundice and itching. Option 5 is true. Icteric sclera means yellowing or jaundice of the sclera. This is due to high bilirubin levels and is commonly associated with itchiness, pale feces and dark urine. Biliary Colic may cause scleral icterus as a gallstone can block the bile duct.
The nurse is performing CPR on an adult client with facial and neck trauma. Which location should be the nurse chose to check for a pulse in this client? 1. Apical area 2. Carotid artery 3. Femoral artery 4. Radial artery
3. Correct: Pulses that are best palpated are large and close to the trunk of the body. The femoral artery is large and at the trunk (proximal) of the body. 1. Incorrect: It would take too long to use a stethoscope and listen for an apical pulse on the client. A quicker area of checking the pulse would need to be used. 2. Incorrect: The client has bilateral neck trauma. The carotid artery would not be the best site to assess for a pulse. 4. Incorrect: The radial artery is not as large as the femoral artery and is distal to the femoral artery.
A nurse walks into the medication area of a long-term care facility and sees a colleague taking a pill from a resident's supply of narcotics. The nurse says, "Please don't say anything. I need my job and I have a migraine." What action should the nurse take? 1. Reassure the colleague that you won't tell this time. 2. Insist that the colleague get some help. 3. Report what was seen to the supervisor. 4. Send the colleague home.
3. Correct: The nurse should follow the procedure to return the narcotic, and then the nurse should report the observation to the supervisor. The nurse must serve as client advocate by reporting a nurse who may be impaired. 1. Incorrect: This may be the first observation; however, it is unlikely that it is the first incidence. The impaired nurse must be reported. You are responsible to the clients on the unit, not to the staff member. 2. Incorrect: The supervisor is the one to provide information on obtaining help. The hospital or long term care facility will have a policy for the supervisor to follow. Usually this policy also includes rehabilitation. 4. Incorrect: The nurse should leave if she is taking narcotics. The supervisor will be the one to send the nurse home. The supervisor needs to determine if the degree of impairment would interfere with the ability to drive home safely. Impaired nurses can become dysfunctional in their ability to provide safe, appropriate client care. Addiction is considered a disease, but the addicted nurse remains responsible for actions when working. Nurses should be aware of the signs and symptoms of substance abuse and know when to report a coworker suspected of substance abuse to management. While it may be very difficult to suspect a co-worker of substance abuse, and the fear of reprisal may keep some nurses from action, it's important to take the steps necessary to confront or notify the nurse manager of your suspicions. Educate yourself on the organization's policy and procedures for employee substance abuse and employee assistance programs. Careful documentation of any changes in the suspected impaired nurses' behaviors is important. Legal aspects to report a substance-abusing nurse vary among individual states, but nurses have an ethical and moral duty to clients, colleagues, the profession of nursing, and the community to take action. Documents such as the American Nurses Association Code of Ethics for Nurses provide a framework for client safety. Consider the following: Do not ignore poor performance. Do not lighten or change the nurses' patient assignment. Do not accept excuses. Do not allow yourself to be manipulated or fear confronting a nurse if patient safety is in jeopardy. So in this question we have a nurse who is taking a client's narcotic medication. What actions should the nurse take? Let's look at the options. Option 1. So are you going to cover for the nurse and not tell anyone? No, this will not only hurt the nurse in the long run, but could lead to client harm. It's a safety issue, isn't it? Yes. Option 2. What about insisting the nurse get some help? Well, the nurse may say ok, but then never seek help. The person caught will generally do or say anything to keep the authorities from finding out. As a colleague, you can offer support, but don't go there alone. Follow the policy of the institution and state. Option 3. Report what is seen to the supervisor? Yes. Get it out of your hands and into the hands of the person responsible for instituting the policy for substance abuse by staff. Option 4. Send the nurse home? Not your call. Notify the supervisor to deal with the situation. The nurse should leave if she/he is taking narcotics. The supervisor will be the one to send the nurse home. The supervisor needs to determine if the degree of impairment would interfere with the ability to drive home safely.
A client is prescribed trimethoprim/sulfamethoxazole for recurrent urinary tract infections. Which statement by the nurse about this medication is correct? "Be sure to take the medication with food." "It is safe to take with oral contraceptives." "You can stop the medication after five days." "Drink at least eight glasses of water a day."
Drink at least eight glasses of water a day." Correct! Submit Trimethoprim/sulfamethoxazole is a highly insoluble medication and should be taken with a large volume of fluid. This medication can be taken with or without food. The full prescribed amount should be taken at evenly-spaced intervals until the medication is finished. Unlike many other antibiotics, trimethoprim/sulfamethoxazole does not seem to affect hormonal birth control such as the pill, the patch or ring.
potassium levels
3.5-5.0 mEq/L
normal potassium levels
3.5-5.0 meq/L
The nurse is caring for a client who sustained closed head injury,which of the following will require immediate attention: 1. ecchymotic area over the left temple 2. glasgow coma of 13 3. BP of 136./76 4. Headache that worsen with cough
4
A homecare LPN is visiting a 6 month old with a new colostomy for Hirschsprung's disease. The mother expresses concerns about caring for the colostomy throughout the child's lifetime. What is the best response by the LPN? 1. "Your child is too young to worry about appearance." 2. "I will have the ostomy team stop by with information." 3. "You seem very concerned about your child's future." 4. "This ostomy may be temporary and might be reversed."
4. "This ostomy may be temporary and might be reversed." 4. Correct: The mother is expressing concern about the infant's ostomy and being able to provide ostomy care at home. The LPN has provided clear and simple information to initiate further conversation focusing directly on ostomy care. 1. Incorrect:. This response does not focus on the mother's concerns about performing independent ostomy care. The mother has not mentioned any concerns regarding the child's appearance. 2. Incorrect: While having the homecare ostomy team provide further support or teaching is a good idea, this reply would transfer care of the client to other health team staff. The LPN is ignoring the proper therapeutic techniques to address the mother's expressed concerns at this moment. 3. Incorrect: Although this is an open-ended statement by the LPN, it does not focus on the mother's anxiety about performing independent ostomy care at home. The LPN is making an assumption with this comment. Nurses need to use interviewing techniques to effectively communicate in a nonthreatening way with clients. Identify client-centered options. The focus of the nurse should be the client. Items that test your ability to be client-centered tend to explore client feelings, identify client preferences, empower the client, provide the client choices, or in some way put emphasis on the client. The client is the priority. What can you recall about Hirschsprung's disease, also referred to as congenital megacolon? Recall this is a birth defect in which ganglion cells (nerve cells) are missing from areas of the gastrointestinal system. The defect can include the rectum and sigmoid colon, making it extremely difficult for the individual to empty the bowel. However, the lack of nerve cells can extend up through the colon, preventing stool from moving through and creating dangerous bowel blockages. There are no tests which can be performed during pregnancy to detect this disorder. Hirschsprung's disease can be identified shortly after birth when the newborn fails to pass meconium stool, although it may take longer for this issue to be identified. Symptoms, which are based on the amount of nerve cells missing, can include swollen abdomen with vomiting, growth failure and even bloody stools. A clue in an older child may be constipation that does not respond to the usual medications. When this disorder is suspected, tests for confirmation include an abdominal Xray, lower GI series and even a rectal biopsy. Because this disease can be life-threatening, surgery to alter bowel function may be necessary, including creating an ostomy which may be temporary or permanent. But the issue in the question is the mother's concern about doing independent ostomy care on the infant! You know skin excoriation and leaking can occur if ostomy care is not precisely followed step by step. In fact, the baby could develop an infection. No wonder the mother is concerned. How could this LPN best encourage her? Option 1: Certainly not. Although the child is important, the client is actually the mother verbalizing concerns about caring for the new ostomy. This response focuses on the child's appearance, which is not the main issue in this question. The LPN's response is also denying the client's right to express particular feelings. Try again. Option 2: Again, not good. The mother would have been instructed on ostomy care prior to leaving the hospital, but is entitled to feel anxious about providing care independently. More importantly, while it is a great idea to have the ostomy team visit the mother at home, the LPN is transferring care of this client to another member of the healthcare team instead of addressing current verbalized concerns. Option 3: Definitely off-base! While this is an excellent open-ended statement, it does not address the correct issue. The mother is concerned about doing ostomy care independently at home. While there may be some deep seated, inner fear about prognosis and outcome for the child, it is presumptuous for the LPN to assume the mother means anything other than what is stated. Option 4: EXCELLENT. First, this comment by the LPN provides accurate information which directly addresses the client's stated concerns. In Hirschsprung's disease, colostomies allow the bowel to rest and are often able to be reversed. Secondly, the manner in which the LPN has provided simple, clear information allows the mother the opportunity to ask other questions.
Kayexelate does what?
Gets rid of K+ slow and late K-exits-late
nephrotic syndrome
characterized by massive proteinuria caused by glomerular damage. corticosteroids are the mainstay and hypoalbuimiemia, result in sevefre edema most evident in the abdomen,face, perineum
Which needs immediate attention: 1. A patient reports difficulty breathing after bronchoscopy 2. Abdominal cramping aftera colonoscopy 3. Sore throatr after a bronchoscopy
A patient reports difficulty breathing after bronchoscopy
Hydroquinone(plaqueril) antimalaria DMARD
check your eyes every 6 months
target blood pressure for a patient with diabetes
<140/90
cholesterol levels :
<200 mg/dL
The goal HbA1C for a patient with diabetes
<7%
pancrelipase
for pancreative enzyme deficiency used every time they eat it contains amylase,lipase, protease
Atenolol (used for)
hypertension
heat intolerance
hyperthyroidism
suction control chamber
Gentle, continuous bubbling
history of alcoholism admitted for detoxification; 6 mg of ativan what additional prescription administer immediately -
Vitamin B1 (thiamine)
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?
Wear clean gloves. CORRECTThe nurse should wear clean gloves to prevent the transmission of MRSA
Ascites is treated with...
diuretics parasenthesis
once PE is resolved
oral anticoagulants factor xa inhibitor
phases of grief
denial, anger, bargaining, depression, acceptance
Metoclopramide is prescribed for:
treatement for delayed gastric emptying,GERD and antiemetic
Amitriptyline (Elavil)
tricyclic antidepressant
Basal, intermediate acting insulin /NPH
twice daily duration 12-18 hrs
For apatient with ADHF/acute decompensated heart faliure,marginal blood pressure,crackles in the lungs,low oxugen saturation,JVD and peripheral edema due to receive Betablocker /Metropolol
Hold the medication as Ace inhibitor can cause the patient to deteriorate
Sims position
Sims' is a semi-prone position where the client assumes a posture halfway between lateral and prone. This is used for clients who need their airway protected.
During a well-baby visit, the nurse is evaluating developmental milestones for the 7-month-old child. Which of these developmental activities should the child be able to perform?
Sits without support Correct Response The age at which a child typically develops the ability to sit steadily without support is around 7 to 8 months. Saying several words, drinking from a cup and using a neat pincer grasp are developmental milestones that most children do not reach until age 11 to 12 months.
A client who has been on bed rest for several days is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last.
In order to keep a client safe, the nurse should first check the client's orientation to determine the client's ability to follow instructions. Second, to avoid orthostatic hypotension, the nurse should assist the client to sit on the side of the bed. Third, apply the gait belt to ensure safety while ambulating. Fourth, assist the client to stand for a few seconds. The fifth action is to ambulate in the room.
Pioglitazone (Actos)
Antidiabetic
Diphenoxylate Hydrochloride with Atropine Sulfate
Antidiarrheal
3 point gait when ascending stairs
1.Assume the tripoid position and place body weight on the crutches while preparing to move the unaffected leg. 2. Place the unaffected leg onto the step 3. Transfer body weight from the crutches to the unaffected leg and then use the unaffected leg to raise the body up onto the step. 4. Advance the affected leg and the crutches together up the step.
nasal spray administration
Assume a High Fowler' position with the head slightly forward Insert the nasal spray nozzle into an open nostril, occluding the other nostril with a finger Point the nasal spray tip toward the side and away from the center of the nose Spray the medication into the nose while inhaling deeply Remove the nozzle from the nose and breath through the mouth Repeat the above steps for the other nostrils Blot a runny nose with facial tissue, but avoid blowing nose for several minutes after installation
Autism - signs
Lack of mother-child eye contact, language delay/repetitive language, peroccupation w/ "parts of toys" before age 3.
Statins are contraindicated in
pregnancy Severe liver or muscle injury
A nurse manager informs the nursing staff at a morning report that a clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of which process during research?
Autonomy Correct Response Individuals must be free to make independent decisions about participation in research without coercion from others. The key to this question is to notice that each staff member can choose whether to participate in the research study. "Individual choice" only relates to the correct response.
The automated external defibrillator (AED) has been applied to a client receiving cardiopulmonary resuscitation (CPR). Indicate how the nurse will proceed by placing the following actions in the correct order. (Instructions: Drag and drop the steps into the correct order.)
press analyze button wait for AED to analyze call out stand clear press schock button allow AED to administer shcok immediately resume shock
A client develops pernicious anemia after a Billroth II procedure and is to receive vitamin B12 intramuscularly. What should the nurse include when reinforcing discharge instructions? 1. B12 can be stored in a lighted area. 2. The B12 injections will be stopped when symptoms disappear. 3. The B12 injections will be continued for the client's life. 4. Vitamin B12 will be taken by mouth once the maintenance dose is determined.
3. The B12 injections will be continued for the client's life. 3. Correct: With pernicious anemia, the client lacks the intrinsic factor. Without the intrinsic factor, B12 cannot be absorbed. The client will require B12 shots throughout the lifespan. 1. Incorrect: B12 should be protected from the light. 2. Incorrect: B12 cannot be stopped once symptoms disappear due to lack of intrinsic factor. Must be continued throughout the lifespan. 4. Incorrect: B12 cannot be administered orally. The client lacks the intrinsic factor. Therefore, B12 cannot be absorbed in the GI tract. B12 must be given by injection.
A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse include when creating a sign to post outside of the client's room? a. Protective Mask b. A closed door sign c. Gown d. Puncture-proof sharps container e. Hand Hygiene
A protective mask is correct. Clients who have active pulmonary tuberculosis require airborne precautions. Everyone entering the room requires respiratory protection, in the form of an appropriate filtration mask. A closed door is correct. Clients who have active pulmonary tuberculosis require airborne precautions. Everyone entering or leaving the room should close the door behind them. A puncture-proof sharps container is correct. Nurses must always dispose of needles and sharp instruments in puncture-proof sharps containers. Hand hygiene is correct. Hand hygiene is essential before and after all contact with clients.
water seal chamber :
A slight rise and fall (fluctuation) of the water in the water seal chamber as the client breathes is called tidaling and is normal. levels of water for the water seal chamber and the suction control chamber are prescribed by the healthcare provider and should be maintained at the prescribed levels. Clamping of the tube should never be done without a prescription. Clamping a chest tube can lead to a tension pneumothorax, which can be a life-threatening situation. Later, when it is time for the chest tube to be removed, you should instruct the client to take in a deep breath and do valsalva maneuver
Aantiseptic
A substance that can be applied to reduce the number of microorganisms, including isopropyl alcohol (greater than 50% concentration), povodine iodine solutions such as Betadine and 2% chlorhexadine solution such as ChloraPrep.
Which type of comment should the nurse expect from a client exhibiting clang associations? 1. Concrete explanations for abstract ideas 2. Reporting very small details when explaining something 3. Comments that are illogically associated 4. Use of rhyming words when talking
4. Correct: The client may use rhyming words, such as dog, bog, cog, jog. It is the meaningless rhyming of words, often in a forceful manner. 1. Incorrect: This type of comment indicates concrete thought. Concrete thinking is characterized by immediate experience rather than abstraction. 2. Incorrect: This type of comment indicates circumstantiality. This is characterized by indirectness and delay before the person gets to the point or answers a question. The person gets caught up in countless details and explanations. 3. Incorrect: These indicate loose associations or derailment. It is a sequence of unrelated or only remotely related ideas.
Scabies precautions
private room and contact precautions Use contact precautions with protective garments (e.g. gowns, disposable gloves, shoe covers, etc.) when providing care to any patient with crusted scabies until successfully treated; wash hands thoroughly after providing care to any patient
nonselective beta blockers
propranolol, timolol, nadolol, pindolol bronchial smooth muscle constriction, are contraindicated in clients with asthma
Non-selective beta blockers
propranolol, timolol, nadolol; can ause bronchoconstriction, or bronchial smooth muscle constriction,peripheral vasospasm and predispose diabetic pts to hypoglycemia contraindicated in patients with asthma
Concusion signs:
A brief disruption in level of conciousness Amnesia regarding the event (retrograde amnesia) Headache
Pyuria means:
pus in the urine
A client has a prescription for nitroglycerin gr 1/400 SL prn for angina pain. How many tablets should the nurse give the client? Use numbers and decimals only. Exhibit
Answer: 0.5 Rationale: Prescribed: nitroglycerin gr 1/400 Step 1 is to convert grains to mg (gr 1 = 60 mg) 1/400 = 1/400 x 60/1 = 60/400 = 3/20 = 0.15 mg Step 2: Think - 0.15 is ½ of 0.30. You want to give the equivalent of ½ tablet as needed. Step 3: D/H x Q = X 0.15/0.3 x 1 tablet = 0.5 tablet nitroglycerin SL
Dythymic disorder Symptoms "CHASES"
Also called: Dysthymia: Dysthymia is defined as a low mood occurring for at least two years, along with at least two other symptoms of depression. Examples of symptoms include lost interest in normal activities, hopelessness, low self-esteem, low appetite, low energy, sleep changes, and poor concentration. Treatments include medications and talk therapy. Concentration Hopelessness Appetite Sleep Energy Self-Esteem
A nursing instructor is presenting a discussion on nephrotoxic medications? Which class of medications would the instructor discuss?
Aminoglycoside Aminoglycoside antibiotics are nephrotoxic. Nephrotoxic medications can cause damage to the kidneys. Examples of aminoglycoside antibiotics are tobramycin, gentamicin, streptomycin, and paromomycin. Clients with kidney damage should not be prescribed aminoglycoside antibiotics.
After receiving TPN the client reports nausea, abdominal pain, and excessive thirst. What is the BEST action to take?
Check the client's blood glucose [58%] Hyperglycemia results in excessive thirst increased urination abdominal pain headache fatigue and blurred vision
A client with a musculoskeletal disorder has been newly fitted with a lower limb orthotic. Which activity can the nurse delegate to the certified nursing assistant (CNA)?
Assist with transferring the client from the bed to the chair. Correct! The CNA (i.e., UAP) can assist with routine activities of daily living, including transferring clients from a bed to a chair or wheelchair. When performed correctly, these routine tasks usually have a predictable outcome. Checking the client's skin involves assessment and monitoring the client's response requires evaluation, both of which are nurse-only activities. A physical therapist would teach the client how to ambulate with an orthotic.
The nurse is planning the client assignments. Which is the least appropriate assignment for the unlicensed assistive personnel (UAP)?
Assisting a child who is profoundly developmentally disabled to eat lunch
Naproxen side effects
GI bleeding Blood dyscrasias Tinnitus Headache Insomnia Vision changes Rash Angioedema Jaundice Tachycardia Back pain Nausea Melena Take with food
Implied consent
Type of consent in which a patient who is unable to give consent is given treatment under the legal assumption that he or she would want treatment. the consent it is presumed a patient or patient's parent or guardian would give if they could, such as for an unconscious patient or a parent who cannot be contacted when care is needed
active TB and expectorating blood tinge sputum
active
hemoglobin
males: 14-18 female: 12-16
The primary healthcare provider prescribes an intravenous infusion of D5 W at 125 mL per hour. The tubing has a drop factor of 20 gtt/mL. How many drops per minute should the nurse administer? Round answer to the nearest whole number.
The formula is: mL per hour x drop factor time 125 x 20 = 2500 = 41.666 = 42 60 60 Since partial drops cannot be counted, always round to the nearest whole number which, is 42.
medication that reduce effects of levothyroxine /synthroid
antiacids calcium iron preparations take medicaion on empty stomach,preferably in the morning ,separately from other medications
Metronidazole education
antibiotic to treat parasitic,bacterial and protozoan infections may cause metalic taste, dark urine
"A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which response is appropriate?
"""I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this.""
The nurse caring for a client diagnosed with type 1 diabetes mellitus is discussing the client's medication. What statement made by the client is incorrect and indicates a need for further reinforcement of information?
"I always make sure to shake the NPH bottle hard to mix it well." Correct! The bottle should by rolled gently, not shaken. Shaking the bottle results in small air bubbles, which may result in errors when drawing up the insulin in the syringe.
Digoxin toxicity
-Cholinergic—nausea, vomiting, diarrhea, blurry yellow vision (think van Gogh), arrhythmias, AV block. -Can lead to hyperkalemia, which indicates poor prognosis.
BNP normal value
100
INR for most conditions
2-3
The nurse should monitor the results of which laboratory test for a client taking atorvastatin? 1. Complete blood count (CBC) 2. Cholesterol level 3. Troponin level 4. Cardiac enzymes
2. Cholesterol level 2. Correct:Atorvastatin is a lipid-lowering agent. The expected outcome of treatment with atorvastatin is lowering of the serum cholesterol and triglycerides.1. Incorrect: The CBC results would not be used to evaluate the effectiveness of treatment with atorvastatin.3. Incorrect: The troponnin level evaluates the presence of cardiac muscle damage. 4. Incorrect: Cardiac enzymes would monitor for cardiac muscle damage.
serum calcium levels
8.6-10.2
captopril
ACE inhibitor
Isotretinoin
Accutane black box
pioglitazone
Actos Antidiabetic most important to report , bilatera; pitting edema on ankles
A client will be undergoing a colonoscopy in the morning. Which task is appropriate to delegate to the unlicensed assistive personnel?
Answering the call light promptly after the enema has been given
Bupropion (Wellbutrin)
Antidepressant For major depressive disorders,seasonal effective disorder,dysthimia/persistent depressive disorder. Do not cut or crush, this can lead to seizures. S/E: weight loss do not drink alcohol when taking the drug
Sharing perceptions
Asking the patient to verify the nurse's understanding of what the patient is thinking or feeling Stating observation or summation that the client can validate or reject: You say that you don't care but I can sense that you are upset.
Example of delusion of reference
Believe secret messages are broadcast on a weekly basis, can record and watch them repeatedly "Someone is trying to get a message to me through the articles in this magazine, I must break the code so that I can receive the message"
Benign prostatic hyperplasia
Benign prostatic hyperplasia, also called benign prostatic hypertrophy (BPH), actually begins in puberty when the walls of the prostate begin to very slowly thicken. It is simply part of a male's growth pattern and there is no way to stop this process, although it generally takes decades before symptoms are noticed. Remember that the prostate is located just below the bladder. As the walls thicken, the prostate enlarges, pushing against the bladder and altering normal urination patterns. The client may begin to experience symptoms similar to a UTI. These symptoms can start with bladder pain or burning with noticeable hematuria. Over time, the client develops urinary frequency and urgency, straining to start or maintain a stream, and difficulty actually emptying the bladder. You are aware that retained urine can quickly lead to urinary tract infections. Eventually the client may experience "terminal dribbling", meaning the urine stream slows after voiding but continues to 'leak', leading to wet clothing and embarrassing moments. The problem cannot resolve on its own, so clients will need to see a primary healthcare provider for assistance. Tests such as a simple ultrasound to look for retained urine, or blood work for the PSA level, can help diagnose the problem. More invasive diagnostic tests include a rectal exam or a cystoscopy. Treatment options will depend on the client's age, prostate size, health and severity of symptoms, but non-invasive methods are tried first. Most primary healthcare providers will start with medications, such as finasteride to shrink the size of the prostate. ("Least invasive first"). The primary healthcare provider may also order alpha-blockers such as doxazosin or tamsulosin to minimize symptoms. But it generally takes 6 months before the client notes a significant decrease in those symptoms. If medications are not successful, the client may need one of several possible surgical procedures to remove part of the prostate and allow the bladder to function normally. (You learned about a TURP procedure in nursing school). As you review the options, keep in mind you are looking for evidence, as reported by the client, that the medications are not working. What might you expect in a client with this diagnosis? Option 1: Good one. Discomfort and bladder pain indicates a situation which should be checked by a primary healthcare provider, particularly in the presence of additional symptoms. Pain is a way the body tells us that something is wrong and should be addressed! A return, or continuance, of bladder pain warns the client something is amiss. Very often it's the pain that causes a client to seek professional advice! Option 2: Not quite. Problems with urination, especially when there is retained urine, can easily lead to recurring urinary tract infections. In fact, if ignored or left untreated, a UTI could even lead to sepsis. Fever and chills are indications of a very severe infection that should be addressed immediately. However, these symptoms independently do not indicate prostate problems. Option 3: Great! One of many initial problems experienced by clients is urinary frequency along with urgency. Difficulty initiating and maintaining a urine stream is what generally leads a client to seek medical help. If the medication is not working properly, the client will either see no improvement, or symptoms that were resolved will return again. Option 4: Absolutely. Recall that the process of urination is not working correctly because of the pressure against bladder walls. While it is difficult for the client to start and maintain a stream of urine, it is also equally challenging to stop the flow of urine because the bladder does not empty entirely. Urine will continue to leak at the end of urination, referred to as "terminal dribbling". Despite efforts to stop the flow, a client often experiences leaking of urine onto clothing which can prove embarrassing and frustrating. If this issue is not resolved or improved, the client needs to report this so the medication can be adjusted. Option 5: Nope. Nighttime sweats can be attributed to several situations, but not BPH. Women experiencing menopause often complain of night sweats before, during, and sometimes even after menopause. More importantly, nighttime sweats are an important indicator of tuberculosis and should be evaluated. However, they are not associated with benign prostatic hyperplasia.
The nurse is cqaring for a client with C.difficile colitis
Contact isolation precautions Hand hygiene(soap and water) non sterile gloves gown private room/single client room use dedicated equipment
The primary healthcare provider prescribed fentanyl 75 mg IM. The pharmacy dispensed fentanyl 50 mg per mL. How many mL will the nurse administer? Round to one decimal point.
Enter the answer for the question below. Rationale 50 mg: 1 mL = 75 mg: x mL50 x = 75x = 1.5
The nurse is stuck in the hand by an exposed needle that was accidentally left in the client's bed. What action should the nurse take first?
Immediately wash hands vigorously with soap and warm water. Correct! The immediate action of vigorously washing the hands will help reduce the risk of potential exposure to bloodborne pathogens. The nurse should then follow the facility's policy and procedure for employee needlestick injury.
At 7:30 am, a client diagnosed with type 1 diabetes has a blood glucose reading of 306 mg/dL (17 mmol/L). The client reports being very hungry and thirsty. After the nurse reports the lab result and the client's comments, what type of insulin should the nurse anticipate to administer? Insulin detemir (Levemir) Insulin lispro (Humalog) NPH insulin Insulin glargine (Lantus)
Insulin lispro (Humalog) Correct! Insulin lispro (Humalog) is a rapid-acting insulin that will help to quickly reduce the client's serum glucose level. Be sure the client's breakfast tray is delivered within 5 to 10 minutes after using any rapid-acting insulin. NPH insulin is an intermediate-acting insulin. Insulin glargine (Lantus) and insulin detemir (Levemir) are long-acting or "basal" insulins; they are usually administered once a day, at bedtime.
When caring for clients with sicle cell anemia SCD
Is critical to observe for indications of SCC.Severe acute pain is a common symptom of SCC caused by impairedcapillary blood flow(ie;vasoocclusion)and tissue eschemia.Without prompt recognition and intervention , vasoocclusion can lead to irreversible damage(eg;myocardial infarction, limb necrosis,stroke)and death
Salmeterol
Long-acting beta agonist bronchodilator is administer with an inhaled corticosteroid for long term control of moderate to severe asthma is not used a s an emergency recue drug in asthma
A nurse is caring for a client with a panic disorder. What findings do you suspect to find: 1. dry skin 2. chest pain 3. decrease pulse 4. delusional thinking
Panic disorder is a type of anxiety disorder. It causes panic attacks, which are sudden feelings of terror when there is no real danger. You may feel as if you are losing control. You may also have physical symptoms, such as Fast heartbeat Chest or stomach pain Breathing difficulty Weakness or dizziness Sweating Feeling hot or a cold chill Tingly or numb hands
UAP CANNOT
Perform initial assessment, check medication response,administer medications
pneumocyctitis pneumonia
Pneumocystis pneumonia is a type of infection of the lungs (pneumonia) in people with a weak immune system. It is caused by a yeast-like fungus called Pneumocystis jirovecii (PJP). People with a healthy immune system don't usually get infected with PCP.
A client, who receives hemodialysis three times a week, has been placed on a fluid restriction of 1000 mL/day. What is the nurse's best action when the client is seen drinking a 12 ounce (360 mL) soft drink?
Reinforce the importance of the fluid restriction with the client.
What blood test should be reviewed before administer Vancomycin
Serum creatine, should be monitor daily during IV vancomycin treatment to look for an increase serum levels
Acute closure glaucoma symptoms
Sudden onset of severe pain Reduced central vision Blurred vision Occular redness seeing halos around lights this is consider an emergency
when taking calcium
Take divided doses of 500 mg within an hour of meals constipation is a side effect Caltrate (calcium carbonate )is the prefered calcium supplement Does not need to taken at a particular time of the day
A particulate respirator is essential for protection from exposure to which of the following diseases?
Tuberculosis
fractured femur
Use of tranquilizers can be a risk factor for compound femur fracture. Proton pump inhibitors. Osteoporosis is a factor of risk for compound femur fracture. Lack of body movement/regular physical activity can be a risk factor for compound femur fracture. Weak bones, cancer and earlier cases of fracture are all factors of risk for compound femur fracture.
methhylergonovine
Uterotonic and analgesic It can treat severe bleeding from the uterus after childbirth. Brands: Methergine Related medications Cabergoline Dihydroergotamine (Migranal) Caffeine / Ergotamine (Caffeine/ergotamine) tell your doctor if you have or have ever had high blood pressure or blood vessel, heart, kidney, or liver disease.
Bupropion
Wellbutrin for smoking cessation - Serious neuropsychiatric events including depression, etc.
methhylergonovine side effects
What are the possible side effects of methylergonovine (Methergine)? increased blood pressure (severe headache, blurred vision, buzzing in your ears, anxiety, shortness of breath); chest pain, sweating, pounding heartbeats or fluttering in your chest; seizure (convulsions);
UAP reports to the nurse that a pt has become pale
When ther is an acute change of status is the nurses resposabilty to immediately asses and check on the client
does a nurse needs to witness a consent
While the nurse is not technically, or even legally, responsible for providing the information necessary for informed consent there is an ethical responsibility to look out for the patient's best interest. The nurse's role is both as a witness and as the patient's advocate
Can a UAP take vital signs in a patient with delireium
Yes
For the Acute Asthma attack
albuterol Ipratropium
digoxin visual disturbances
alteration in color perception and visual changes
Gingo Biloba
antiplatelet agregation can increase bleeding time
Verapamil
calcium channel blocker lowers HR
Cullen's sign
ecchymosis in umbilical area, seen with pancreatitis
Long acting insulin
glargine, detemir, degludec once daily
A nurse is removing PPE after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?
gloves
NSAIDS cardiovascular side effects
heart attack stroke high blood pressure heart faliure from fluid retention
Acetaminophen/Codeine overdose
hepatoxicity
when a patient refuses to take prescribed pancrelipase
hold until thye pt eats
Levofloaxcin (Levaquin)
is an appropriate antibiotic to use for treating pneumonia.
SIADH
is an endocrine condition in to whuch antidiuretic hormone production leads to water retention, increased total body water, increased total body water, and dilutional hyponatremia (low serum sodium) Hyponatremia can cause seizures,
Hunthintongh disease
is an uncurable atusomal disease herediatry disease,that causes progressive nerve degenaration ,result in impaired movement swallowing and cognitive abilities. Chorea (tic) is a carachteristic,onset between 30-50,death occurs within 20 years Autososmal dominant traits require only one copy of theaffected gene, from carrier parent to manifest.
damage to the spine level T5
perform ROM seceral time a day
Omeprazole (Prilosec)
proton pump inhibitor for GERD
Pacreatic enzymes
should not be crushed or chewed should be swallowed whole or sprinkled on an acidic food Should not be taken with milk
patients with polyps
should not be taking NSAIDs, including aspirin can make asthma symptoms worst
The nurse is caring for a client following thoracentesis 1 hour ago , which of thefollowing finding require immediate attention? respirations of 24 tendernes at the puncture site Temperature of 99.6 small amount of bleeding at the puncture site
small amount of bleeding at the puncture site
alpha blockers treat
urinary retention can cause orthosstatic hypotension take the medication at bed time' avoid abrupt position changes avoid medications fopr erectyle dysfuntion
adult female hemoglobin
11-15
PT
11.0-12.5
The nurse is caring for a client on the surgical unit. The primary healthcare provider prescribed morphine sulfate 20 mg IM one time dose. The nurse has available: morphine sulfate in a 20 mL vial, labeled 15 mg per mL. How many mL should the nurse administer? Record answer using one decimal place.
15 mg: 1 mL = 20 mg: x mL15x = 20x= 1.33 = 1.3
An unresponsive client begins to vomit. What intervention by the nurse would have the highest priority? 1. Suction the client's mouth. 2. Turn the client onto their side. 3. Apply oxygen per face mask. 4. Insert an oropharyngeal airway.
2. Turn the client onto their side 2. Correct: To prevent aspiration, the first thing to do is turn the client onto their side. Leaving the client in the supine position will allow vomitus to get into the lungs when the client breathes.
The nurse is talking with a client who is exhibiting defense mechanisms. Which of the following statements by the client would exemplify projection? 1."I purchased a gift for the nurse because I was rude yesterday." 2."I became angry at my spouse and threw a glass against the wall." 3."I backed my car into a pole because my spouse was distracting me." 4."I have been informed of my poor prognosis, but I know I will live a long time."
3
Which statement by the spouse of a client diagnosed with Alzheimer's indicates to the nurse that the spouse is dealing appropriately with stressors? 1. "I am in charge of every aspect of the care provided." 2. "I do not expect our children who live out of town to help." 3. "I keep a list of small tasks ready for people who ask me if they can help." 4. "I only go to my primary healthcare provider when I am sick."
3. "I keep a list of small tasks ready for people who ask me if they can help." 3. Correct: Encourage caregivers to say "yes" when someone offers assistance. It's smart to have a list ready of small tasks that others could easily take care of, such as picking up groceries or driving the person to an appointment. 1. Incorrect: The caregiver should be willing to surrender some control. Delegating is one thing. Trying to control every aspect of care is another. People will be less likely to help if the caregiver micromanages, or insists on doing things their way. 2. Incorrect: The caregiver should spread the responsibility. Get family members involved as much as possible. Even someone who lives far away can help. Encourage the caregiver to divide up caregiving tasks. One person can take care of medical responsibilities, another with finances and bills, and another with groceries and errands. 4. Incorrect: Encourage the caregiver to stay healthy by keeping on top of primary healthcare provider visits. They should not skip annual routine, checkups, or medical appointments. Identify the central person in the question. Usually the nurse is required to respond to the needs of the client. Some questions focus on the needs of others, such as a child, parent, spouse, or roommate. To select the correct answer, you must identify the central person in the stem. Identify specific determiners in options. These convey a thought or concept that has no exceptions. Words such as just, always, never, all, every, none, and only are absolute and place limits on the statement that generally is considered correct. Statements including these words generally make the statement false as the statement is general and broad and does not allow for exceptions. Prolonged periods of caregiving coupled with a client's life limiting illness can contribute to stress and burnout. Caregiving is an experience for which most people are not prepared. It is common for them to become physically, emotionally, and economically overwhelmed by the responsibilities and demands of caring for a family member. The stress may result in emotional problems such as depression, anger, and resentment. Decreased social interactions occur putting the caregiver at risk for social isolation. Stress can progress to burnout and result in negligence and abuse of the client. Feeling powerless is the number one contributor to burnout and depression. Encourage the caregiver to focus on the things that can be controlled. Caregivers should ask for help. Taking on all of the responsibilities of caregiving without regular breaks is a reliable recipe for burnout. Encourage them to look into respite care. Or recruit friends and family to run errands, bring a hot meal, or "baby-sit" the care receiver so the caregiver can take a welldeserved break. The caregiver should speak up. They should not expect friends and family members to automatically know what the caregiver needs or how they are feeling. Encourage the caregiver to spread the responsibility. Have then get as many family members involved as possible. Set up a regular check-in. Ask a family member, friend, or volunteer to call the caregiver on a set basis. The caregiver should say "yes" when someone offers assistance. It's smart to have a list ready of small tasks that others could easily take care of, such as picking up groceries. Be willing to surrender some control. Delegating is one thing. Trying to control every aspect of care is another. The caregiver needs to maintain health. They should go to their primary healthcare provider for routine checkups and appointments. Encourage exercise. Exercise is a powerful stress reliever and mood enhancer. Aim for a minimum of 30 minutes on most days. A daily relaxation or meditation practice can relieve stress and boost feelings of joy and wellbeing.
The nurse is admitting an adolescent reporting severe depression and amenorrhea. What additional observations by the nurse would suggest the client may develop anorexia nervosa? 1. Tight fitting clothes 2. Oily, elastic skin 3. Brittle, dry nails 4. Gingival infections 5. Low blood pressure
3. & 5. Correct: This client is reporting symptoms consistent with anorexia nervosa, a serious and potentially life-threatening eating disorder that develops secondary to the type of family or social stress experienced in adolescence. In addition to severe depression and amenorrhea, the nurse has identified brittle, dry nails and a low blood pressure secondary to weight loss as additional indications of anorexia nervosa. 1. Incorrect: Despite the fact that anorexic clients experience severe weight loss, they continue to view themselves as heavy and generally wear loose fitting clothing to hide what they perceive as an overweight body. 2. Incorrect: Because of skeletal muscle atrophy and poor nutritional intake, anorexic clients display sallow, dry skin with brittle nails and hair. Oily, nonelastic skin would not be noted in a client with anorexia nervosa. 4. Incorrect: Gingival infections and dental caries are typical of clients with bulimia, another eating disorder in which stomach acid from frequent vomiting causes gum infections or dental caries. This is not common in anorexics. Option 1: Definitely not. These clients have low self-esteem and believe that they are fat. So rather than showing off a thin figure, they tend to wear loose or ill-fitting clothing in order to hide their body. Over-sized clothing is usually a clue, since they obviously appear thin. Option 2: Nope! Because nutrition is poor, an anorexic individual experiences skeletal muscle atrophy secondary to loss of body fat. Oily skin would not occur in these dehydrated clients. Elastic skin is just another way to describe skin turgor. Hydrated, healthy skin has good elasticity and bounces back when pinched. Nonelastic skin would refer to poor skin turgor, which often accompanies malnourishment along with sallow, but not oily, skin. Option 3: Yes, this is a positive indication of anorexia! Poor nutrition will lead to dry skin, brittle nails, and even a loss of hair. Because these clients are so pre-occupied with buying and preparing "healthy" foods, they often do not notice other symptoms. They are obsessively focused on what they believe is an overweight body rather than the appearance of their hair and nails. Option 4: This is not a symptom of anorexia, but rather indicates another eating disorder - bulimia. In that eating disorder, the clients tend to binge on food and then induce vomiting out of guilt to get rid of the calories ingested. Because of this frequent vomiting, stomach acid washes over the teeth and gums, causing infections and cavities. Since there is not a dramatic weight issue, this eating disorder may not be diagnosed for years. Option 5: Good choice. The anorexic client has many physical manifestations typical of poor nutrition, including weight loss and electrolyte imbalance. They also have a very low blood pressure secondary to lack of food and fluids, constant dieting, and rigorous exercise. These clients generally die from cardiac arrhythmias.
The licensed practical nurse (LPN) is assisting with care for a client who has an absolute neutrophil count of 500. Which action by the LPN would be inappropriate? 1. Using an alcohol-based hand rub for hygiene before and after glove removal. 2. Advising visitor with known respiratory infection to not enter the client's room. 3. Taking fresh flowers into the client's room that were delivered by the local florist. 4. Leaving the thermometer and sphygmomanometer in the client's room.
3. Correct: First of all, did you recognize that the absolute neutrophil count (ANC) was very low? So what does this mean for this client? The neutrophils are an important component of the blood that is responsible for fighting infections. A client with a low neutrophil count is considered to be neutropenic and precautions for preventing infections are needed to protect the client. Carrying the fresh flowers into the room that were delivered by a florist may seem like a harmless gesture. But, it is not! Plants and flowers can harbor fungal spores that can be harmful to clients who are immunosuppressed. Therefore, the LPN should not take fresh flowers into this client's room. 1. Incorrect: Using an alcohol-based hand rub for hygiene is the preferred method for decontaminating the hands, unless the hands are visibly soiled. This should be used before and after glove removal. Therefore, the LPN would be using an acceptable practice . 2. Incorrect: Since the client has a low neutrophil count and is at risk for infections, the nurse should institute measures to protect the client. This would include advising any visitor with a known respiratory infection to not enter the client's room. The LPN would be protecting the client. 4. Incorrect: The room for a client with neutropenia should have its own equipment that is not taken out and shared with other clients. This includes such things as thermometers and sphygmomanometers. This equipment should be properly disinfected prior to being brought into the client's room and is not shared with other clients to reduce the risk of contamination to the immunosuppressed client. The LPN would be performing safe nursing care. Neutrophils are a predominant type of WBCs that are responsible for fighting infections by attacking and destroying bacteria, viruses, and fungi that invade the body. We can get a better look at the client's ability to fight infection by looking at the ANC because it is a more accurate measurement of immune function than the WBC count or the neutrophil count alone. When the ANC drops below 1,000, the client is considered to be neutropenic. Also, neutropenia can be defined simply as being a lower than normal neutrophil count which is 2.2 to 8 X 10^9/L. So, you can see that the ANC of 500 is very low, and the client's risk for infection is much higher. This client is not only at risk of getting infections from other people, but also from bacteria that is normally present in their own body. The most common cause of neutropenia is treatment of cancer by chemotherapeutic agents. In this question, you needed to identify an action by the LPN that could put the client at increased risk of infection. The action that could be potentially harmful to the client would be taking the fresh flowers into the client's room that were sent from the florist. The fungal spores in the flowers could be harmful to the immunosuppressed client. The other measures listed are appropriate actions for clients who are immunocompromised. We know that hand washing is the single most important infection control measure for preventing nosocomial infections. When caring for this client that is neutropenic, the nurses should always wash their hands. When the nurse enters this client's room, an alcohol-based hand rub for hygiene is considered the preferred method for decontaminating the hands, unless the hands are visibly soiled, and the alcohol hand rub should be used before and after glove removal. Institution of measures to protect the client from infections would include advising any visitor with a known respiratory infection to not enter the client's room. Other visitors should follow the same precautions that are being carried out by the nurses, such as hand washing, gowning, and use of masks. This client with neutropenia should have equipment that is dedicated to this client only and is not taken out and shared with other clients. This is done to reduce the risk of infection transmission. Dedicated equipment includes such things as thermometers and sphygmomanometers. This equipment should be new or properly disinfected prior to being brought into the client's room. Disposable equipment is used when possible. With exception of the delivery of flowers to the client, the LPN would be performing safe nursing care in the other actions.
The nurse is looking at the plan of care for a child with a fractured femur in Bryant's traction. The nurse is aware that planned interventions should focus on preventing what major complication?
3. Neurovascular impairment. 3. Correct: Bryant's traction is a type of skin traction with the potential for several complications. Though the traction is important, this child is being treated for a fractured femur. The major complication with any fracture is neurovascular integrity. The nursing priority is monitoring neurovascular status, including areas such as pulses, sensation, motor function, edema, skin temperature and capillary refill in bilateral toes. 1. Incorrect: Bryant's traction is a type of skin traction, not skeletal traction. Skin traction is non-invasive so there are no pin sites or invasive wires. 2. Incorrect: Any type of traction has the potential for slippage of knots since the pulley weights are attached by ropes or held by tape to skin. While the nurse needs to frequently verify those attachments are secure, loss of counter traction is not the worst complication. 4. Incorrect: Because the client is kept supine in this traction, there is a high potential for skin breakdown to the buttocks or sacral area. Special interventions are required to prevent development of decubiti for clients in Bryant's traction. When you think of types of traction, the two main categories are skin traction and skeletal traction. Bryant's traction is a type of skin traction generally used to treat severe fractures, such as fractured femurs, or congenital hip dysplasia in children. This mechanism is used to maintain alignment of broken bones or to help realign the hips in dysplasia. Compression wraps are wound around bilateral legs and the client is positioned supine with legs held vertically. Longitudinal traction is applied by attaching a rope around a pulley at the traction foot plate. This applies traction to the femoral head with a weight that is usually 30 pounds or less, based on weight or age. The client in this scenario is a child with a fractured femur placed into Bryant's traction. There are many potential complications with this type of traction which the nurse needs to re-assess frequently. Proper alignment is crucial and the child must remain in the supine position. The nurse will need to assess skin, check connections from the traction to the client's leg wraps, the level of pain and the position of the weights. But what would you consider the priority? Option 1: Definitely not. You would be accurate to associate infection with traction, but only skeletal traction, which is invasive. Bryant's traction is a type of skin traction, which is non-invasive. There are no pins, no wires, and no invasive equipment of any kind. Concern about infected pin sites is not applicable here. Option 2: Not this one. When using any type of skin traction, loss of traction is always a concern. If the weight rests on the floor, or the knots become untied, that would result in loss of alignment and counter-traction, seriously impacting healing. While checking the security of the traction equipment and knots is definitely important, this is not the main complication. Option 3: Wonderful. Anytime you are caring for a client with fractures, neurovascular integrity is the primary focus. The client could ultimately experience permanent damage affecting motor function, sensation, or even loss of the extremity. The nurse must frequently assess the "five P's" of vascularity, including pain, pallor, paresthesia, paralysis and pulselessness. Identification and immediate intervention with complications may be the difference between the client's return to normal function and permanent disability. Option 4: Close but not quite. Because Bryant's is a type of skin traction, potential for skin breakdown is certainly a big concern. The client will be kept supine, and even with careful positioning, this could lead to sacral decubiti. There are compression wraps applied to the legs which could cause dryness and skin irritation. Assessing skin status frequently is crucial but not associated with the major complication.
aPTT
30-40 seconds
respiratory rate in infants
30-60
The charge nurse is making client assignments. Which assignments are appropriate for a licensed practical nurse to perform? Select all that apply 1. Assessment of newly admitted diabetic. 2. Prepare discharge planning for a client diagnosed with Parkinson's disease. 3. Provide care to client requiring multiple blood transfusions. 4. Care for a one day post op mastectomy client. 5. Insert an indwelling urinary catheter for the client scheduled for surgery.
4,5
The nurse is caring for a client diagnosed with schizophrenia. What action would the nurse consider a priority for this client? 1. Schedule alone time for client to relax. 2. Frequently reorient the client to surroundings. 3. Encourage participation in all social activities. 4. Assign same staff to provide client care daily.
4. CORRECT. Schizophrenia is a group of psychotic disorders characterized by thought disturbances, bizarre behaviors and social withdrawal. Because of the numerous emotional and psychologic dysfunctions, there are many possible goals. However, the priority objective is to help the client develop a trusting relationship in order to achieve other goals. Assigning the same staff to provide care daily is the first step toward that objective. 1. INCORRECT. Clients with schizophrenia tend to self-isolate due to paranoid thoughts or hallucinations. Social withdrawal is a problem with these individuals and should not be encouraged by the nurse. Relaxation is not a priority goal for this client. 2. INCORRECT. This client was just admitted with schizophrenia. Getting this disorder under control will take some time, requiring both medications and therapy. Reorienting the client to the surroundings frequently is important but not the priority at this time. 3. INCORRECT. During the initial treatment period, the client may display hostility or angry, defensive behaviors which make group activities inappropriate. Eventually the client can be encouraged to participate in reality-based events but not in this early phase. Schizophrenia is actually a group of psychotic disorders characterized by thought disturbances, bizarre behaviors, abnormal speech patterns, social withdrawal and difficulty communicating. The exact mechanism of this disorder is unknown, though research indicates a link to genetics which causes an imbalance in neurotransmitters like dopamine, glutamate and serotonin. This long-term disorder causes a total disconnect between the individual and reality, which may be controlled but is not curable. The individual may experience hallucinations or delusions along with bizarre positioning and inappropriate emotional responses. These clients are often paranoid, leading to social isolation. Caring for such individuals is challenging and requires extreme patience. As you know, there are many goals for the nurse to consider. These clients have difficulty establishing reality because of hallucinations or delusions. You can see how easily these thought disturbances can cause paranoia, making it very difficult for the client to express needs. Recalling Maslow, care of a client should always begin with physical needs. So ask yourself, how could the nurse get this client to cooperate and interact? Option 1: Nope. You may reason that a client preferring to be alone may find comfort and relaxation that way. However, schizophrenic clients tend to hallucinate more when alone, further complicating efforts to orient the client to reality. Relaxation is rare in these individuals without medications and psychotherapy. Option 2: Not quite. The nurse will need to frequently reorient the client to more than just surroundings. While it is important to gently and calmly remind client of day, time and place consistently, the client may not believe the nurse initially. Option 3: Definitely not. In the initial phase of treatment, the client will avoid interactive contact due to distrust and the inability to communicate effectively. Group or social activities are definitely not appropriate at this time. Eventually the nurse may encourage reality-based activities as long as the events are not competitive in nature. However, early in treatment, disturbed thoughts and lack of ability to cope would quickly overwhelm the client. Option 4: Awesome choice! Remember that clients with schizophrenia have paranoid thoughts and are suspicious of everyone. A trusting relationship is necessary before a client will accept any interventions such as medications or therapy. In fact, without a trusting relationship, the client may not even accept food from anyone. Therefore, establishing trust is crucial at this time.
Normal level of RBC
4.2-6.1
The primary healthcare provider prescribed fentanyl 75 mg IM. The pharmacy dispensed fentanyl 50 mg per mL. How many mL will the nurse administer? Round to one decimal point.
50 mg: 1 mL = 75 mg: x mL50 x = 75x = 1.5
hypovolemic shock
A condition in which low blood volume, due to massive internal or external bleeding or extensive loss of body water, results in inadequate perfusion.
positive caricella zoster titer
A positive VZV IgG result indicates the presence of antibodies to varicella zoster virus. ... If active infection is not suspected based on the patient's history, clinical presentation, and other laboratory results, then a positive IgG result is likely due to past infection.
omeprazole (prilozec)PPI side effects
Abdominal pain Flatulence Diarrhea/Constipation N/V Risk for pneumonia,C. difficile diarrhea,osteoporosi
An adolescent is admitted to the psychiatric unit following a repeat suicide attempt. What is the nurse's priority action?
Assign a staff member to stay with the client CORRECT. The client is newly admitted following a repeat suicide attempt and therefore safety is the priority issue. The client should not be left alone, even when using the bathroom, until the primary healthcare provider determines the risk of suicide has abated.
Hookworm prevention
Avoiding skin contact with sand or soil, and regular veterinary care for your pets -- including deworming -- will help ensure healthy pets and healthy people. Wearing shoes and taking other protective measures to avoid skin contact with sand or soil will prevent infection with zoonotic hookworms
control delusions
Believing that another person, group of people, or external force controls thoughts, feelings, impulses, or behavior
Alprazolam (Xanax):
Benzodiazepine Anxiety,panic attcks
Flumazenil
Benzodiazepine antagonist, antidote eg;a;prazolam
Alprazolam (Xanax)
Benzodiazepine for anxiety
side effects od chemotherapy
Common side effects of chemotherapy drugs include: Nausea. Vomiting. Diarrhea. Hair loss. Loss of appetite. Fatigue. Fever. Mouth sores.
A client is forgetful and experiencing short-term memory loss. While collecting data about short-term memory loss, which action should the nurse take first? Ask the client to state his date of birth. Confirm that the client's hearing is intact. Observe the client while performing an activity. Ask the client to name the current U.S. president.
Confirm that the client's hearing is intact. Correct Response A baseline evaluation of a client's neuro-sensory status should include checking for hearing loss. The client's inability to hear may cause them to answer questions incorrectly, which can be misinterpreted by the nurse as short-term memory loss or confusion. The other actions should then also be implemented to further evaluate the client's cognitive and mobility status.
Delusions
False beliefs that have no basis of reality and are unrelated to a client's culture or intelligence Delusions are on the positive side of schizophrenia When presented with proof that the delusion is irrational or untrue, the client continues to believe its real
Theophyline Toxicity
Hypotension, Albuminuria, Tachycardia and Anorexia 10-20 flu-like symptoms with arrhythmias, seizures Often exacerbated with use of cipro or erythromycin. report: anorexia, vomiting, nausea, restlessness, and insomnia. avoid caffeine and drugs like ciprofloxacin, cimetidine
medications contraindicated for the elderly
Lorazepam Amitriptilyne Chlormephinaline
A nurse is caring for a client who requires droplet precautions Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?
Mask
A nurse is providing education to a client being discharged on lithium. What should the nurse be sure to have the client report?
Persistant GI distress
Opiod side effects
Resperatory distress, sedation, dizziness, nausea, constipation,hypotension,vomiting
Methylphenidate
Ritalin/Concerta used for ADHD improves attention to reduce distraction, focus and listening skills also, treat narcolepsy on assessment check weight, height, and BP, loss of appetite
chronic open angle glaucoma
Silent disease, most common form of glaucoma, most treatable cause of blindness, if goes untreated the pt gradually loses peripheral side vision, can occur secondary to traum, even years later, overuse of topical steroids
nasal fluticasone/flonase
Sit position and the head slight forward NAsal tip is inserted into the nostril as the other nostril is occluded Inhale deeply through the nurse
The nurse visits a family to provide information regarding hospice in-home care. Which of the following would the nurse discuss as covered by the hospice benefit? (Select all that apply.) Staff on call 24 hours Temporary respite care Curative care treatments Prescription medications Spiritual services
Staff on call 24 hours Correct! Temporary respite care Correct! Prescription medications Correct! Spiritual services Correct! Per hospice coverage guidelines, temporary respite care, medications, spiritual services and accesses to on call staff 24-hours a day are covered. Curative treatments are covered by palliative care, not hospice care.
Rosuvastatin (Crestor)
Strong stain drug, that could drastically cut LDL and reduce total cholesterolamd tryglicerides,it can also ibcrease HDL A serious complication is rhabdomyolysis (muscle toxicity)
Precations to take when performing wound care in a burn victim
The burn patient is given opioid analgesics such as morphine as ordered. An opioid agonist such as fentanyl (Sublimaze) may be given intravenously or orally before performing painful wound care. If given orally, administer the medication 45 minutes before the procedure. If given intravenously, administer the drug 5 to 10 minutes ahead of time. The intramuscular route is not routinely used until fluid shifts have stabilized because absorption is less reliable. Nonsteroidal antiinflammatory drugs (NSAIDs) also may be prescribed. Pain is aggravated by anxiety, so use measures to reduce fear and anxiety in the management of pain. Document the patient's response to interventions. The burn patient, without protective skin, is at great risk for infection. Routinely monitor for signs of local infection (i.e., pus, foul odor, increased redness) and systemic infection (i.e., fever, increased white blood cell [WBC] count). Infection can come from the staff, visitors, the environment, and the patient's own body. Specific infection control measures vary with the agency. Strict hand washing should be practiced by the patient and all who enter the room. Body hair around wounds is usually shaved or cut to prevent wound contamination. However, do not shave the eyebrows—if shaved, they tend to grow back in a disorganized pattern. Carry out wound care as ordered or according to routines of the specialty care unit. Monitor the patient's tympanic or rectal temperature to detect declining body temperature. Keep the room warm and use external heat sources as needed. The room temperature should be above 76°F. In a burn intensive care unit, the temperature may be above 85°F. Attempt to limit body surface area exposure during wound care. Body heat loss may be increased if the patient is on an air-fluidized bed, so carefully monitor the temperature of the bed. Calorie needs may be as much as twice the patient's baseline needs. Regular meals may need to be supplemented with between-meal feedings. Stress to the patient the need for increased intake during the recovery period. Try to create an environment conducive to eating and encourage the patient to eat all food served. Provide assistance with meals, if needed. Some patients require tube feedings or total parenteral nutrition (TPN) to meet their calorie needs. Encourage the patient to drink protein drinks rather than water Patients with burns may have mobility restrictions imposed by the injury or the treatment. The hazards of immobility, including pressure sores, joint contractures, pneumonia and atelectasis, constipation, and urinary infections Monitor range of motion in affected joints and perform passive or active exercises unless contraindicated. Keep injured limbs in functional positions as much as possible n addition, exercise unaffected joints to maintain flexibility and strength. Impaired mobility may interfere with the patient's ability to participate in his or her own care. Evaluate the ability to provide self-care and provide assistance as needed. As the patient moves toward recovery, the rehabilitation team helps the patient to adapt self-care activities for permanent injuries.
guaiac test
The stool guaiac test or guaiac fecal occult blood test is one of several methods that detects the presence of fecal occult blood. The test involves placing a faecal sample on guaiac paper and applying hydrogen peroxide which, in the presence of blood, yields a blue reaction product within seconds
Intimate violence is associated with
The term "intimate partner violence" describes physical violence, sexual violence, stalking, or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy. Physical, emotional,verbal,sexual or economimcal abuse Abuse begins or intensifies during pregnancy
Use the mnemonic F.R.A.I.L. M.O.M. & D.A.D. for assessing older clients in the primary care setting.
Use the mnemonic F.R.A.I.L. M.O.M. & D.A.D. for assessing older clients in the primary care setting. FRAIL MOM & DAD F = Falls R = Relative or caregiver strain A = Activities of daily living I = Incontinence L= Living situation M = Memory Impairment O = Oculo-otic impairment (visual and auditory problems) M = Malnutrition D = Drugs A = Advance directives D = Depression
delirium tremens
a psychotic condition typical of withdrawal in chronic alcoholics, involving tremors, hallucinations, anxiety, and disorientation. a disorder involving sudden and severe mental changes or seizures caused by abruptly stopping the use of alcohol
paresthesia
abnormal sensation of numbness and tingling without objective cause
What should be instructed to take along with tetracyclines,
additional contraceptives use sunblock
latex allergy
allergy to avocado ,tomato,and banana lip swelling when blowing up ballons
sentinel event
an accident or incident that results in grave physical or psychological injury or death:
In congestive heart faliure,hypotension and endocarditis what labs should be reported
bacteria or fungi in your bloodstream,anemia
Streptococcal Pharyngitis (Strep Throat)
bacterial infection of the tonsils and pharynx causing a sore throat and frequently swollen lymph nodes
betablockers can cause(-lol)
bronchoconstriction decrease HR
Ibuprofen and aspirin can cause
bronchospasm in clients who suffer of asthma
symptomps of bleeding
bruising blood in urine Melena
Amlodipine
calcium channel blocker used for hypertension
acetylsalicylic acid (ASA)Aspirin is for
can be used for angina pain Keeping the blood flowing preventing platelets from staying together
Candida albicans(yeast)
can colonize and infect vulovoaginal region
EPO
can help reduce anaemia a manmade copy of a hormone called erythropoietin made by your kidneys. It stimulates the body to make more red blood cells and can reduce fatigue.
headaches that worsen with cough
can incraese intraccranial pressure
glucocoericoids (eg;prednisone)combined with other NSAIDs like naproxen
can increase the risk for GI bleeding report black tarry stools
clinical manifestations for pulmonary embolism
chest pain dyspnea hypoxemia tachypnea
belt restraint is used for
confused or disoriented patient who is on bed rest
Hypospadias
congenital abnormality in which the male urethral opening is on the undersurface of the penis, instead of at its tip
permanent mental and physical retardation caused by congenital deficiency of thyroid hormones
cretinism
what to assess when givin magnesium sulfate
deep tendon reflex
Antimuscarinic, anticholinergic agents common side effects
dry mouth cognitive dysfunction constipation
clarification
examiner's response used when the patient's word choice is ambiguous or confusing "I'm not sure I understand that, could you repeate it please"
signs of hyperglycemia (high blood sugar)
excessive thirst, excessive hunger, excessive urination
lumpectomy
excision of a small primary breast tumor and some of the normal tissue that surrounds it
H1 Receptor Agonists (Antihistamines)
fexofenadine,cetirizine,levocitirizine,loratadine Antihistamine, released from mast cells for alleegic rhinitis,allergic conjutivitis, and hives.
When on coumadin therapy, which foods should closely be monitored?
food rich in vitamin K PT and INR are reduced
enlargement of the thyroid gland, causing the neck to appear swollen
goiter
HDL cholesterol
good cholesterol
Donning PPE
hand hygiene 1. gown 2. mask 3. goggles 4. gloves
the nurse is reinforcing with a client with irondeficency anemia
have your iron supplement with a source of vitamin C
Lactulose use
hepatic encephalopathy (metabolism by microbiota yields lactic & acetic acids → ↑ excretion of ammonium) improves mental status
management of severe asthma
high dose inhaled SABA(albuterol) every 20 min Ipratropium nebulizer systemic corticosteroids(solumedrol) oxygen
For abdominal paracenthesis position the client
high fowler's
walking with a cane
hold cane on stronger side close to body advance cane 4-12 inches while supporting weight with stronger leg and cane advance weaker leg Hold cane on UNAFFECTED side move injured leg after moving cane
clients with cirrhosis have hypolalemia due to:
hyperaldosteronism from use of duiretics and ascites
shortage of aldostrtone cause
hyperkalemia
triglyceride levels should be
less than 150
In acute decompensated heart faliure
low blood pressure crackles in the lungs low oxygen saturation JVD peripheral edema Betablokers can worsen and further clinical deterioration
portals of entry
mouth,nose GI tract break in the skin
Patients in Kitoacidosis or hypermolar hyperglycemic state intial treatement:
normal saline bolus, next insulin
Lactulose
osmotic laxative For excretion of amonia in cirrhosis with hepatic encephalopathy and not soleyly to treat constipation, the dose is adjusted to achieve 2-3 stools each day
Antiplatelet drugs should not be taken by
patients with intracranial hemorrhage bleeding peptic ulcer Active bleeding
Transdermal Scopolamine placement
place on hairless area behind the ear wash hands before and after remove old path before applying new one keep ot of reach from children and pets
to collect urine sample from a child who is not toilette trained
place several cotton balls in a dry diaper and later squeeze urine onto a dipstick
Babinski's reflex
reflex test that reveals nervous system lesions; performed by stroking sole of foot
what instructions should be given to a client with adfvanced COPD
report sputom production obtain pneumoccocal vaccine
log rolling aclient in bed
requires multiple staff members
Common side effedt of Metoclopramide
sedation fatigue restlessness headache sleepness dry mouth constipation diarrhea
For a patient with COPD meal times
set up small ,frequent meals, and rest periods before and after meals
Insulin
sshifts glucose and potassium from intravscular space into intracellular space
UAP can assist
stable clients with,ADLs.hygiene,ambulation, turning and repositioning obtaining full V/S assist with treatement and prevention of aspiration
when giving phenytoin (Dilantin)via NG
stop feeding for 1-2 hours calcium and enteral feeding can reduce absorption
After thyroidectomy patients are at risk for:
swelling leading to respiratory distress report immediately if, difficulty breathing and activate rapid response
NSAID overdose
tachycardia hypotension
what reduce the effectivness of contraceptives
tetracycline rimfampin
Certain herbs garlic, gingko and vitamin E can increase
the risk for bleeding
Leukoplakia
thickened, white, leathery-looking spots on the inside of the mouth that can develop into oral cancer
dabigratam /pradaxa
thrombin inhibitor reduce the risk of stroke and clots store in the original container
osteogenesis imperfecta
transmitted by autosomal dominant inheritance Check blood pressure manually to avoid cuff over-tightening Lift the baby by slipping a hand under the back , buttoks Reposition frequently using supporting devices and gel padding to avoid molding soft bones of the skull.
Amikacin, Gentamicin, Tobramycin side effects
use during pregnancy can result in bilateral congenital deafness ototoxicity cranial nerve VIII nephrotoxicity Allergic reaction, fever, difficulty breathing, rash vertigo, tinnitus are early effects report changes is urinary out put , hearing and balance
if a client express no improvement after taking antidepressant escitalopram/lexapro SSRI
usually takes 1-4 weeks from first dose to see improvement if no improvement is not seing after 2 months reevaluation is necessary
Dangers of Oxytocin
uterine tachysystole Water intoxication Hypotension
Enoxeparin,aspirin,heparin
validate prescription before administer
when preventing lyme diasease
wear pants outdoors, use insect repellent
Whentaking corticosteroids
wear shades
Can an UAP remove a condom catheter
yes
UAP tasks for Mechanical Ventilation
• Obtain vital signs and report these to RN .• Perform bedside glucose testing, if needed. .Provide personal hygiene and skin care and oral care (after being taught and evaluated in this procedure) .• Assist with frequent position changes, including ambulation, as directed by the RN .• Perform passive or assisted range-of-motion exercises .• Measure urine output and report information to RN.
UAP can
- ADLs- Bathing- Grooming- Dressing- Toileting- Ambulating- Feeding (without swallow precautions)- Positioning- Bed making- Specimen collection- I&Os- Vital signs
ACE inhibitor side effects
- Impaired bradykinin metabolism by ACE → ↑ bradykinin levels → dry cough AND angioedema (!!!) The angioedema often involves the tongue/lips/eyelids!!!! Can cause problems breathing!! - ↓ Angiotensin II → ↓ aldosterone release → hyperkalemia !!! - ↓ Angiotensin II → less constriction of efferent arterioles → ↓ GFR → up to 30% ↑ in serum Creatinine is expected in most patients within 2-5 days of initiating ACE inhibitor therapy. - Taste disturbance (metallic taste) - Rash - Headache, fatigue, nausea - Hypotension allergic reactions, rash or a dry cough, and should not be taken by a pregnant woman or individual at risk for kidney failure.
Dextromethorphan
-Antitussive (antagonizes NMDA glutamate receptors). -Synthetic codeine analog. Has mild opioid effect when used in excess. -Naloxone can be given for overdose. Mild abuse potential. -May cause serotonin syndrome if combined with other serotonergic agents
ACE inhibitors
-pril are teratogenic specially during the 13th week gestation can cause oligohydramnios,fetal growth restriction
Metformin is contraindicated in:
-renal dx, hepatic dx acidosis, alcoholics, hypoxia, -increased risk for latic acidosis (pH <7.25) - during hypoxia, hypo perfusion, renal insufficiency Cardiac catherization 3 days before procedure
A client has been admitted with folic acid deficiency anemia. Which referral would most likely be appropriate for the nurse to make? 1. Alcoholic Anonymous 2. American Sickle Cell Anemia Association 3. Pernicious Anemia Society 4. Aplastic Anemia Support Group
1. Alcoholic Anonymous 1. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. This referral would be appropriate. 2. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. It is an inherited form of anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout the body. Normally, red blood cells are flexible and round, moving easily through blood vessels. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. These irregularly shaped cells can get stuck in small blood vessels, which can slow or block blood flow and oxygen to parts of the body. 3. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. The body needs vitamin B12 to make red blood cells. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. This protein is released by cells in the stomach. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. 4. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. Aplastic anemia is a rare but serious condition. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. Folate-deficiency anemia is a decrease in red blood cells due to a lack of folate. Folate is a type of B vitamin. Folate (folic acid) is needed for red blood cells to form and grow. Folate can be obtained by eating green leafy vegetables and liver. However, the body does not store folate in large amounts. So, a person needs to eat plenty of folate-rich foods to maintain normal levels of this vitamin. In folate-deficiency anemia, the red blood cells are abnormally large. Such cells are called macrocytes. They are also called megaloblasts, when they are seen in the bone marrow. That is why this anemia is also called megaloblastic anemia. Causes of this type of anemia include too little folic acid in the diet, hemolytic anemia, long-term alcoholism, and the use of certain medicines (such as phenytoin, methotrexate, sulfasalazine, triamterene, pyrimethamine, trimethoprim-sulfamethoxazole, and barbiturates). The following raise the risk for this type of anemia: • Alcoholism • Eating overcooked food • Poor diet (often seen in the poor, the older people, and people who do not eat fresh fruits or vegetables) • Pregnancy • Weight loss diets
Which tasks would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Prepare a client's room for return from surgery. 2. Observe for pain relief in a client after receiving acetaminophen with codeine. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogasttric (NG) tube. 5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy (PEG).
1. Prepare a client's room for return from surgery. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogasttric (NG) tube. 1., 3, & 4. Correct. These are appropriate tasks for an UAP to complete. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. Also, making a surgical bed for the client returning from surgery is a basic procedure. 2. Incorrect. The UAP cannot assess or evaluate or even monitor the effectiveness of pain medication. That is what you are asking the UAP to do here. The client has received a narcotic and you have asked the UAP to evaluate the effectiveness of the medication. 5. Incorrect. Administering tube feeding into a PEG tube is beyond the scope of practice for the UAP. This is a procedure which requires a licensed personnel. Catheter placement must be confirmed, client identity checked, tube site flushed with water or sterile water and flow rate determined. 1. Follow the 5 rights of assignment: Right task, right person, right circumstance, right direction, right supervision. 2. With Select All That Apply questions, look at each option as a true/false statement. Match what is being asked in the stem with the options. If the stem is asking for a true response, then the true options should be selected. With Select All That Apply questions there will be two or more correct options Follow the 5 rights of delegation: Right task, right person, right circumstance, right direction, right supervision. What can the UAP do? The UAP can assist the stable client with activities of daily living and can collect routine data, such as vital signs, and I&O. So let's look at the options now. Option 1. Is a special skill needed to prepare a client's room for return from surgery? No. Making a surgical bed is a basic procedure that the UAP has the skill to complete. The UAP can also place and set up any necessary equipment needed for the client, such as a vital sign machine, suction equipment, etc. Option 2. The UAP cannot assess, evaluate or even monitor the effectiveness of pain medication. That is what you are asking the UAP to do here. The client has received a narcotic and you have asked the UAP to evaluate the effectiveness of the medication. The UAP does not have the knowledge or training to complete this task. Option 3. The UAP can provide hygiene needs to a client like perineal care. Remember the UAP can help with activities of daily living. Option 4. The UAP can provide hygiene needs to a client like cleaning of the nares. This is part of daily hygiene. Option 5. Administering tube feeding into a PEG tube is beyond the scope of practice for the UAP. This is a procedure which requires a licensed personnel. Catheter placement must be confirmed, client identity checked, tube site flushed with water or sterile water and flow rate determined. The UAP is not allowed to perform these observations and implement this procedure. They made it sound like you were just pouring a can of tube feeding in. Simple, right? Don't let simple words talk you into selecting the wrong answer.
Which prescriptions would the nurse recognize as being appropriate for the client who is immunocompromized with shingles? 1. Private room 2. Negative pressure airflow 3. Respirator mask 4. Face Shield 5. Positive pressure room
1., 2. & 3. Correct: According to the current standards of Standard Precautions per the CDC, the client who is immunocompromised with shingles should be placed on airborne and contact precautions initially, which require the use of a private room with negative pressure airflow and a N-95 respirator mask. 4. Incorrect: A face shield is used when there is risk of splashing or spraying of blood or body fluids. This is not required for airborne precautions. 5. Incorrect: Negative pressure is required in order to prevent the airborne infection from spreading outside of the room. Positive pressure is used only in protective environments such as when immunocompromised clients require protection from potential infectious agents outside of the room.
A client is hospitalized with Dissociative Amnesia. Which nursing interventions are appropriate for this client? 1. Obtain client likes and dislikes from family members. 2. Flood the client with data regarding the forgotten past. 3. Expose client to stimuli that was a happy memory of the past. 4. Do memory games to help the client restore memory. 5. Ensure client safety.
1., 3. & 5. Correct: A comprehensive baseline assessment is important for the development of an effective plan of care. Considering likes and dislikes may help the client remember. Using information to expose the client to stimuli that was a happy memory may help the client remember. Client disorder may lead to inattention to safety. 2. Incorrect: Do not flood the client with data regarding the forgotten past. Clients who are exposed to painful information from which the amnesia is providing protection may decompensate even further into a psychotic state. 4. Incorrect: Do not test the client with amnesia.
UAP tasks for IV therapy
• Measure and record oral intake and output.• Report swelling or redness at IV site or patient complaints of discomfort at IV site to RN.
UAP tasks for Wound Care
• Perform dressing changes for chronic wounds using clean technique (need to consider state nurse practice act and agency policy).• Empty wound drainage containers and document drainage on intake and output record.• Report changes in wound appearance or drainage to RN.
Black Cohosh
menopausal symptoms/hot flashes
what care can be assigned to UAP
UAP's can perform tasks on stable clients in uncomplicated situations. task like routine, simple, repetitive, common activities that do not require nursing judgment such as hygiene, feeding, ambulation. everyday things.
A nurse is caring for a client who is receiving methyldopa. Which assessment finding would indicate to the nurse that the client may be having an adverse reaction to the medication?
Sedation Correct Response Methyldopa (Aldomet) is used to treat hypertension. The nurse should assess the client for alterations in mental status, such as sedation. Other common side effects are dizziness, dry mouth, headache and weakness. These changes should be reported to the health care provider.
A PN can delegate
Ambulate an oxigen dependent person to the bathroom Check pulse oximeter and report result if less than 12 resp/min or more than 22 resp/min Turn and reposition a client with pneumonia Provide oral hygiene for a person with COPD Feeding tube feeding
Sjorgen's dyndrome
An immune system disorder characterized by dry eyes and dry mouth. With this disorder, the body's immune system attacks its own healthy cells that produce saliva and tears. Sjögren's often occurs with other such disorders, such as rheumatoid arthritis and lupus. The main symptoms are dry mouth and dry eyes. Treatments include eye drops, medications, and eye surgery.
near miss
An unplanned event that did not result in injury, illness or damage - but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage; in other words, a miss that was nonetheless very near.
A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test.
CORRECTA client who has or might have tuberculosis requires airborne precautions. That means a private room with negative-pressure airflow. Room 208 is the only one of these options that fits these requirements.
A nurse is assisting in the care of a client with a history of hoarseness and difficulty swallowing for several weeks. The client is diagnosed with laryngeal carcinoma. Which nursing intervention should have priority attention?
Compare daily weights with the admission weight Correct Response Clients with these findings may not get adequate nourishment. An evaluation of the nutritional state can be accomplished by assessing the weight regularly. The client will certainly need to have alternatives to family support for any help through the therapy that may be necessary. Remember Maslow's hierarchy of needs: physiologic needs supersede psychosocial needs.
A client's attorney prepares a living will and comes to the hospital to obtain the client's signature. A nurse is asked to witness the client's signature on the document. Which action by the nurse is most appropriate?
Decline to witness
A client refuses to take the medication prescribed because the client prefers to take an herbal preparation instead. What is the first action the nurse should take? Contact the client's health care provider about the refusal Report the behavior to the charge nurse Explain the importance of the medication to the client Discuss with the client to find out about the preferred herbal preparation
Discuss with the client to find out about the preferred herbal preparation Remember, the collection of additional data is typically the initial approach when problems arise. Although the client has the right to refuse the medication, it's possible that the herbal preparation does not have the intended purpose of the prescribed medication or may even have unintended side effects.
to prevent codeine adverse effects
drink 8 glassess of water sit on the side of the bed for a few minutes take medicine with food change positions slow take stool softeners or laxatives
Signs of Right Sided Heart Failure
edema, jugular vein distension, peripheral edema, ascites, hepatomegaly Awakening at night with shortness of breath. Shortness of breath during exercise or when lying flat. Coughing. Wheezing. Difficulty concentrating. Dizziness. Fatigue. Fluid retention causing swelling in the ankles, legs, feet and/or abdomen.
NSAIDs can cause what?
eg: ibuprofen can cause cardiovascular issues, including heart attack, stroke high blood pressure, and heart failure from fluid retention, reduce the effects of diuretics and other BP meds associated with peptic ulcers and kidney disease
Folic Acid Analog
methotrexate (Folex) used in the treatment of cancer
Selective beta blockers
metoprolol, atenolol, bisoprolol given for heart failure and hypertension contraindicated in patients with asthma
selective beta blockers
metoprolol, atenolol,bisoprolol are given for heart faluire and hypertensioncontrol
Phenazopyridine (Pyridium)
might discolor urine orange-red Genitourinary Medication
can nurses in a hospital unit review the medical records of all clients in that unit?
no, only assigned to you
signs of excess levothyroxine
report palpitations/tachycardia weight loss and insomnia
Warfarin coumadin use
to prolonged clotting
ketogenic diet therapy for children
Several studies have shown that the ketogenic diet does reduce or prevent seizures in many children whose seizures could not be controlled by medications. Over half of children who go on the diet have at least a 50% reduction in the number of their seizures. Some children, usually 10-15%, even become seizure-free. Is a diet high in fat and protein
SAD PERSONS scale
Sex(men are more succesful,women make more attempts) Age( teen/young adult age 45>) Depression and hopelessness Previous Attempts Ethanol or Other Drugs Rational Thinking Loss (hearing voices) Social Supports Lacking (living alone) Organized Plan No Spouse Sickness(terminall illness
St. John's Wort
Treatement for depression may cause hypertension and serotonin syndrome when used with other antidepressants
Saw Palmetto uses
benign prostatic hyperplasia
Heparin Associated Thrombocytopenia (HAT)
benign, transient, and mild form of thrombocytopenia that generally occurs within the 1st few days of treatment with UFH in heparin naive patients normal platelet coutn 150,000-400,000
Which manifestations, if noted in a pregnant client, would the nurse need to report to the primary healthcare provider? 1. Calf muscle irritability 2. Facial edema 3. Pressure on the bladder 4. Blurry vision 5. Epigastric pain
1., 2., 4., & 5. Correct: These are danger signs/symptoms of pregnancy and need further investigation by the primary HCP. These signs could indicate preeclampsia, fluid and electrolyte disturbances, and other high risk complications during pregnancy. 3. Incorrect: As the baby gets bigger, it pushes on the bladder, causing pressure, so this is an expected symptom in pregnancy.
Chlorpheniramine
Chlor-Trimeton Antihistamine sedating histamine not for elder
A client has been receiving heparin for five days and now has an order to begin taking warfarin in the evening. Which intervention should the nurse take next?
Administer the warfarin in the evening as prescribed Correct! Warfarin takes two to three days before its anticoagulant effect begins to peak at a therapeutic level. Therefore, the heparin is continued until that point. The prothrombin time (PT) or international normalized ratio (INR) is used to monitor the effectiveness of warfarin therapy and heparin will be monitored daily using the activated partial thromboplastin time (aPTT) lab test.
Promethazine (Phenergan)
Antiemetic. Side effects: drowsiness, anticholinergic effects, EPSs, potentiates effects when given with narcotics. Nursing interventions: monitor VS, safety precautions, IM (large muscle)
Drugs associated with orrgostatic hypotension
Antihypertensive medications -beta and alpha-blockers Antipsychotics and antidepressants Diuretics Nitroglycerine, hydralazine Narcotics(morphine) Antidepressants Recommend to: Rise slowly from the bed take meds a bedtime Avoid straining,walking in hot weather, coughing stay hydrated
A nurse has just inserted an indwelling urinary catheter in a client scheduled for surgery. What should the nurse document? 1. Size of catheter. 2. Color of urine. 3. Date and time of insertion. 4. Type catheter inserted. 5. Infusing rate of IV fluid.
Correct: 1. Size of catheter. 2. Color of urine. 3. Date and time of insertion. 4. Type catheter inserted.
nasal fluticasone
Flonase Assume high Fowler's position with head slightly tilted forward. Insert the nasal spray nozzle into an open nostril, occluding the other nostril with a finger. Point the nasal spray tip toward the side and away from the center of the nose. Spray the medication while inhaling Breath through the mouth Repeat Avoid blowing nose for several minutes!
the nurse care for a client with depression that states, "if I tell you something will you keep it a secret", what statement by the nurse is correct:
I cannot make that promise,I might have to tell your therapist
The nurse is reinforcing teaching to a client who has been prescribed peritoneal dialysis. What statement by the client indicates to the nurse that teaching was successful?
I will notify my primary healthcare provider if the peritoneal drainage is cloudy. The number 1 complication of peritoneal dialysis is infection. So, the client does need to monitor the drainage, which should be clear or straw-colored. If it is cloudy, that indicates infection and the primary healthcare provider should be notified.
Tinea corporis (ringworm)
I. Pathophysiology/highly contagious A. Infection transmitted from one person to another 1. Exposure to contaminated soil 2. Exposure to infected animals or people it can be transmitted from animal to a human B. Growth and transmission facilitating factors 1. Warm and moist environments (showers and pools) 2. Shared towels or clothing,bedding II. Signs A. Location: Glabrous skin (skin that is normally hairless) (excludes palms, soles, groin) B. Characteristics 1. *Round, erythematous, Scaling, pruritic Plaques* 2. Annular Lesion (hence the name Ringworm) a. Raised, advancing border b. *Plaque with central clearing* i. No central clearing after Corticosteroid use 3. Postinflammatory pigmentation changes III. Management A. Prevent re-infection (see pathophysiology above) B. Topical Antifungal applied twice daily for 2-3 weeks 1. Technique a. Apply to infected and normal skin 2 cm beyond affected area b. Continue for 7 days after symptom resolution 2. First line: Imidazoles (e.g. Clotrimazole) 3. Refractory cases: Naftin, Lamisil, Loprox, Mentax
patients with asthma and nasal polyps should not be taking
NSAIDS
What signs/symptoms does the nurse expect to see in a client who has ulcerative colitis? Select All That Apply 1. Abdominal cramping 2. Hematemesis 3. Diarrhea 4. Fever 5. Rebound tenderness 6. Rectal bleeding
Rationale 1., 3., 4., 5., & 6. Correct: Ulcerative colitis is an ulcerative inflammatory bowel disease in the large intestines. Common s/s include abdominal cramping, diarrhea, fever, rebound tenderness, and rectal bleeding.
The nurse is contribuiting to the plan of care for a client with gestational hypertension who is 32 weeks gestation. Which of the following is recommended be included in the plan of care? 1.monitoring in the client's urinary output 2.instruct the client to report any increase in fetal activity 3.instruct to use relaxation techniques to relieve headache 4.minimize the client's dietary intake of high calcium foods
1,2,3
What should the nurse document after a client has died? 1. Time of death 2. Who pronounced the death 3. Disposition of personal articles 4. Destination of body 5. Primary healthcare provider's prescriptions 6. Time body left facility
1., 2., 3., 4., & 6. Correct: All of these are correct options that should be documented. In addition to these things, the nurse should also document consideration of and preparation for organ donation, family notified and decisions made, and location of identification tags. 5. Incorrect: The primary healthcare provider's prescriptions do not need to be documented after a client dies.
The nurse is discussing obesity prevention with a group of parents who have 3 and 4 year old children. What should the nurse include? 1. Ensure at least 11 hour of sleep. 2. Do not put a TV in the child's bedroom. 3. Select a day care center that provides physical activity opportunities every 4 hours. 4. Limit 100% fruit juice to 6 ounces (180 mL) per day. 5. Walk after the evening meal while the child rides a bike or skates.
1., 2., 4., & 5. Correct: Children between the ages of 2 and 5 should get between 11-12 hours of sleep each night. Keeping TVs out of bedrooms, creates an environment that promotes naps and nighttime sleep. Establishing sleep routines are all important to promoting healthy sleep habits. Fruit juice should be limited to 4-6 ounces (120-180 mL) per day, as excess consumption can lead to excess weight gain. Preschoolers should be encouraged to drink water. Role modeling behaviors such as exercise and doing it with the child encourages activity and decreases sedentary time. 3. Incorrect: The Institute of Medicine (IOM) stresses the importance of giving young children plenty of opportunity to be active during the day. Several states now require day care centers to provide the opportunity for at least two hours of physical activity during an eight-hour day. Selecting a day care that limits TV time and encourages play will promote a healthy lifestyle. A growing number of preschool-age children are overweight or obese and greater efforts are needed to address the problem. One in 10 infants and toddlers and one in five children between the ages of 2 and 5 are overweight. Addressing the problem in very young children is critical because obesity-related conditions such as diabetes and high blood pressure are occurring with greater frequency among older children, teens, and young adults. The IOM has outlined strategies designed to reduce obesity by promoting healthy eating, exercise, and sleep habits among infants, toddlers, and preschoolers. Parents and caregivers can help prevent childhood obesity by providing healthy meals and snacks, daily physical activity, and nutrition education. Healthy meals and snacks provide nutrition for growing bodies while modeling healthy eating behavior and attitudes. Increased physical activity reduces health risks and helps weight management. Nutrition education helps young children develop an awareness of good nutrition and healthy eating habits for a lifetime. Children can be encouraged to adopt healthy eating behaviors and be physically active when parent's: focus on good health, not a certain weight goal; teach and model healthy and positive attitudes toward food and physical activity without emphasizing body weight; focus on the family. Involve the whole family and work to gradually change the family's physical activity and eating habits. Establish daily meal and snack times and eating together as frequently as possible. Make a wide variety of healthful foods available based on the Food Guide Pyramid for Young Children. Determine what food is offered and when, and let the child decide whether and how much to eat and plan sensible portions. Use the Food Guide Pyramid for Young Children as a guide. Studies show that insufficient sleep time is a risk factor for obesity. It is recommended that children age 2 and under get 12 hours or more of sleep each day and children between the ages of 2 and 5 get at least 11 hours of sleep. Education should include: Discourage eating meals or snacks while watching TV. Eating in front of the TV may make it difficult to pay attention to feelings of fullness and may lead to overeating. Buy fewer high-calorie, low-nutrient foods. Help children understand that sweets and high-fat treats (such as candy, cookies, or cake) are not everyday foods. Don't deprive children of occasional treats, however. This can make them more likely to overeat. Avoid labeling foods as "good" or "bad." All foods in moderation can be part of a healthy diet. Involve children in planning, shopping, and preparing meals. Use these activities to understand children's food preferences, teach children about nutrition, and encourage them to try a variety of foods. Make the most of snacks. Continuous snacking may lead to overeating. Plan healthy snacks at specific times. Include two food groups, for example, apple wedges and whole grain crackers. Focus on maximum nutrition - fruits, vegetables, grains, low-sugar cereals, lowfat dairy products, and lean meats and meat alternatives. Avoid excessive amounts of fruit juices, which contains calories, but fewer nutrients than the fruits they come from. A reasonable amount of juice is 4-8 ounces per day. Encourage physical activity. Participate in family physical activity time on a regular basis, such as walks, bike rides, hikes, and active games. Support children's organized physical activities. Provide a safe, accessible place outside for play. Limit the amount of time children watch television, play video games, and work on the computer to 1 to 2 hours per day. The average American child spends about 24 hours each week watching television. Reducing sedentary activities helps increase physical activity.
Which menu selection by the client diagnosed with nephrotic syndrome indicates that reinforcement of dietary teaching was understood? 1. Pancakes with whipped butter, syrup, bacon, apple juice 2. Scrambled eggs, sliced turkey, biscuit, whole milk 3. Grits, fresh fruit, toast, coffee 4. Bagel with jelly, hash browns, tea
2. Correct: Client needs low sodium and increased proteins. 1. Incorrect: This selection is too high in sodium and fats. 3. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine. 4. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine.
After obtaining vital signs, which prescribed medication should the nurse hold when caring for a client on the cardiac unit? Exhibit T - 98 ° (36.7°) P - 74 R - 20 BP - 88/50 1. Rosuvastatin 2. Enalapril 3. Digoxin 4. Clopidogrel
2. Correct: 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 is admitted to the LDR from the emergency department at 34 weeks gestation with profuse, painless, bright red vaginal bleeding. The priority action by the nurse is to prepare for which procedure? You answered this question Incorrectly 1. Sterile vaginal exam 2. Ultrasound exam 3. Amniocentesis 4. Contraction stress test
2. Correct: Painless, bright red vaginal bleeding is a sign of a placenta previa. Ultrasound can confirm this diagnosis with minimal risk to the mother and her fetus. This is the safest action for this client and best for fixing the problem. 1. Incorrect: If the placenta is over the cervix, a finger can go right through the placenta and cause hemorrhage and fetal death so vaginal exams would be absolutely contraindicated. 3. Incorrect: Amniocentesis is done for genetic analysis or to determine fetal lung maturity when delivery is likely. It is preferable to delay delivery until the fetus is term. It would not be safe to puncture the abdomen of a client that is already hemorrhaging. 4. Incorrect: Contractions can cause further detachment of the placenta from the cervix, which would also cause hemorrhage.
A nurse is working with community officials to decrease the incidence of violence in the community. Which primary preventive measures might the nurse suggest? 1. Provide a safe haven for victims of violence. 2. Provide educational programs about types of violence. 3. Form a neighborhood watch program. 4. Develop a media campaign identifying risk factors of potential abuse. 5. Provide for the immediate removal of a victim of violence from the home.
2. Provide educational programs about types of violence. 3. Form a neighborhood watch program. 4. Develop a media campaign identifying risk factors of potential abuse. Rationale 2., 3. & 4. Correct: These are all appropriate interventions for the nurse to suggest to the community. The key is prevention. The nurse is teaching ways to prevent violence before it occurs. Primary prevention is true prevention. Primary prevention aims to prevent disease or injury before it ever occurs. This is done by preventing exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury should exposure occur. Examples include: legislation and enforcement to ban or control the use of hazardous products (e.g. asbestos) or to mandate safe and healthy practices (e.g. use of seatbelts and bike helmets); education about healthy and safe habits (e.g. eating well, exercising regularly, not smoking); immunization against infectious diseases. 1. Incorrect: This is a true statement but is not a preventive measure. This does not prevent violence from occurring; it is an intervention to decrease the chance of future violence making it tertiary prevention. Tertiary prevention aims to soften the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries (e.g. chronic diseases, permanent impairments) in order to improve as much as possible their ability to function, their quality of life and their life expectancy. Examples include: cardiac or stroke rehabilitation programs, chronic disease management programs (e.g. for diabetes, arthritis, depression, etc.); support groups that allow members to share strategies for living well; vocational rehabilitation programs to retrain workers for new jobs when they have recovered as much as possible.5. Incorrect: This is not a primary preventive measure but a secondary preventive measure. Removing the victim is not preventing primary violence but additional violence. Secondary prevention aims to reduce the impact of a disease or injury that has already occurred. This is done by detecting and treating disease or injury as soon as possible to halt or slow its progress, encouraging personal strategies to prevent re-injury or recurrence, and implementing programs to return people to their original health and function to prevent long-term problems. Examples include: regular exams and screening tests to detect disease in its earliest stages (e.g. mammograms to detect breast cancer); daily, low-dose aspirins and/or diet and exercise programs to prevent further heart attacks or strokes; suitably modified work so injured or ill workers can return safely to their jobs. Primary prevention aims to prevent disease or injury before it ever occurs. Let's Talk: Before we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are community officials, decrease violence and primary preventive measures. You have to know what primary prevention is in order to select the correct options. Primary prevention aims to prevent disease or injury before it ever occurs. So let's look at each option. You have to know what primary This is a select all question so there will be 2 or more options correct. Also each option stands alone with the question. Remember client safety is always a priority. Option 1 Will this option prevent violence from occurring? False This is not a primary preventive measure but a secondary preventive measure. Removing the victim is not preventing primary violence but may prevent additional violence. Secondary prevention aims to reduce the impact of a disease or injury that has already occurred.This is not primary prevention because violence has already occurred. Option 2 Can educational programs prevent violence? True The key is prevention. The nurse is teaching ways to prevent violence before it occurs. Primary prevention is true prevention. Option 3 A neighborhood watch program brings citizens together to assist law enforcement by being their eyes and ears to potential problems in their community. This program empowers citizens to become active in their community. True Forming a neighborhood watch program can help to prevent violence from happening Option 4 To promote the neighborhood watch program a media campaign will initiated. Also street signs and window decals will be posted. True A media campaign will educate a vast number of people in a short period of time. Option 5 This is not a primary preventive measure but a secondary preventive measure. False Removing the victim is not preventing the primary violence but may prevent additional violence. Secondary prevention aims to reduce the impact of a the violence that has already occurred. This is a secondary prevention measure. Violence has already occurred.
What is the most important action for the nurse to take prior to a client having a liver biopsy? Choose One 1. Make certain the consent has been signed. 2. Obtain vital signs. 3. Check clotting study results. 4. Position client supine with right arm above head.
3. Correct: This is a priority question. All actions should be done by the nurse, however, the nurse better check the clotting study results. The client could hemorrhage if the clotting factors are too messed up.
What signs and symptoms does the nurse expect a client diagnosed with bacterial pneumonia to exhibit? 1. Asymmetrical chest expansion 2. Night sweats 3. Dyspnea 4. Tachypnea 5. Pleuritic chest discomfort 6. Increased tactile fremitus
3. Dyspnea 4. Tachypnea 5. Pleuritic chest discomfort 6. Increased tactile fremitus 3., 4., 5., & 6. Correct: The most common presenting signs and symptoms of pneumonia are cough, fever, chills, dyspnea, tachypnea, and pleuritic chest pain. If consolidation is present, increased tactile fremitus (vibration of the chest wall produced by vocalization) may be noted. 1. Incorrect: Asymmetrical chest expansion occurs if the client has a collapsed lung from a pneumothorax or hemothorax. 2. Incorrect: Night sweats is a common symptom of tuberculosis, not pneumonia. Pneumonia is an infection in one or both lungs. It can be caused by bacteria, viruses, or fungi. Bacterial pneumonia is the most common type in adults. The most common cause of bacterial pneumonia is Streptococcus pneumoniae. Chlamydophila pneumonia and Legionella pneumophila can also cause bacterial pneumonia. Pneumonia causes inflammation in the alveoli. The alveoli fill with fluid or pus, making it difficult to breathe. Pneumonia symptoms can be mild to life-threatening. The most common symptoms of pneumonia can include coughing that may produce mucus; fever, sweating, and chills; shortness of breath; and pleuritic chest pain. Other symptoms can vary according to the cause and severity of the infection, as well as the age and general health of the individual. Bacterial pneumonia may cause a fever as high as 105°F (40.55 C) along with profuse sweating, bluish lips and nails, and confusion. On physical examination, fine or coarse crackles may be auscultated over the affected region. If consolidation is present, bronchial breath sounds, egophony (a change in the sound of the voice of the client), and increased fremitus (vibration of the chest wall produced by vocalization) may be noted. Now let's look at the options. Option 1 is false. Do we worry about asymmetrical chest expansion with pneumonia? No. This occurs if the client has a collapsed lung from a pneumothorax or hemothorax. Option 2 is false. When do people have night sweats? When you see night sweats, think tuberculosis. Option 3 is true. After developing pneumonia, the client can experience irritation and inflammation within the lungs due to the presence of pathogens. When this occurs, the airways can narrow, making it harder for oxygen to flow into the lungs. This can cause clients to experience breathing difficulties, such as wheezing or shortness of breath, after developing pneumonia. Option 4 is true. Pneumonia can cause alterations in the heart rate as a symptom of infection. The pulse is faster than usual, which can be accompanied by symptoms of dizziness or headache. Why? To get more oxygenated blood circulating to the vital organs. Option 5 is true. Sharp or stabbing chest pain that gets worse when you breathe deeply or cough. Remember, there is inflammation and irritation of the pleural lining. Option 6 is true. Tactile fremitus is tremulous vibration of the chest wall during speaking that is palpable on physical examination. Tactile fremitus may be decreased or absent when vibrations from the larynx to the chest surface are impeded by chronic obstructive pulmonary disease, obstruction, pleural effusion, or pneumothorax. It is increased in pneumonia.
Which observation of a six month old infant would concern the nurse? 1. Able to sit unsupported for a few seconds. 2. Posterior fontanel is closed. 3. Head lags when pulled to sitting position. 4. Birth weight has doubled.
3. Head lags when pulled to sitting position. 3. Correct: At 6 months, the infant should be able to lift head when pulled to a sitting position. 1. Incorrect: Should be able to sit up at 6 months. 2. Incorrect: Posterior fontanel closes at 2 months.4. Incorrect: This is normal. Birth weight doubles at 5-6 months.
A nurse is at highest risk for blood-borne exposure during which situation? 1. When removing a needle from the syringe. 2. While placing a suture in the mechanical holder. 3. Prior to inserting an IM injection, the client moves causing a needle stick to the nurse. 4. A clean needle sticks the nurse through blood-soiled gloves.
4. Correct: A clean needle that moves through blood-soiled gloves to stick the nurse is a blood-borne exposure. All other answers are considered a clean stick. 1. Incorrect: This is considered a clean stick. 2. Incorrect: This is considered a clean stick. 3. Incorrect: This is considered a clean stick.
A neighbor of a client asks the nurse how the woman is doing with her respiratory problems. How should the nurse respond to the neighbor? 1. "That woman is doing well and she will be home soon." 2. "It is nice of you to be concerned." 3. "I can't tell you about her condition." 4. "I am sorry, but I can't say who is or is not on the unit."
4. Correct: The nurse cannot acknowledge who is a client on the unit. The client has a right to privacy. 1. Incorrect: The nurse would be violating the client's right of privacy if information were given to a neighbor. 2. Incorrect: With this response, the nurse is indirectly acknowledging that the client is on the unit. It does not state the limits to which the nurse is held. The nurse must maintain client confidentiality. 3. Incorrect: With this response, the nurse is acknowledging that the neighbor is a client at the hospital.
The parents of a preschooler have been told the child has primary tuberculosis. An LPN enters the room when the primary healthcare provider leaves to write prescriptions. The LPN knows what is the priority action? 1. Discuss the importance of dietary modifications. 2. Prepare child for immediate transfer to isolation. 3. Review important medications and respiratory aids. 4. Encourage parents to verbalize fears and concerns.
4. Correct: The unexpected diagnosis of a serious disease would definitely overwhelm most parents. As a professional, the LPN is aware that therapeutic conversation is the priority action at this time. 1. Incorrect: While diet is one of many topics the parents will need to understand, diet is not the first priority in this situation. 2. Incorrect: The question does not provide enough data to determine the need for isolation. Note also that the primary healthcare provider has not yet written prescriptions. 3. Incorrect: The parents will definitely need a review of administration of medications and respiratory treatments for the child. However, this is not the priority. A strategy you can draw on to help answer priority questions is to refer to basic guiding theories that are part of the foundation of nursing. Maslow's Hierarchy of Needs, the Nursing Process, Kubler-Ross's Theory of Death and Dying, Teaching/Learning Theory, Therapeutic Communication. Nurses need to use interviewing techniques to effectively communicate in a nonthreatening way with clients. Though the child has been diagnosed with primary tuberculosis, the parents are the clients in this question. Talk a moment to recall what you know about primary tuberculosis in children. Primary tuberculosis, caused by the mycobacterium tuberculosis, is spread from person to person from droplets in the air. Presenting symptoms include a chronic cough with blood-tinged mucus, fever, night sweats and fatigue. The resulting disease can settle into the lungs or pharynx, lead to lymphadenopathy and calcification of tubercles. Diagnosis can be determined with chest X-ray and a tuberculin test, which will then be positive for the child's entire life. The child may even develop other life threatening complications. Remember when reading the options that the parents have just been informed of this diagnosis. The LPN has entered the room and must determine the priority at this point. Consider the facts in this situation -what would the immediate priority be for the client(s)? Option 1: Not this one. Obviously there will be a great deal of reinforcemnet of teaching needed for the parents, including diet, activity, medications and respiratory treatments as well as follow up appointments. However, diet is not a priority topic at this time. Try again. Option 2: Not quite! Were you thinking about treatment in a hospital setting and the need for isolation? The question does not provide enough information, and you cannot assume! There is no data about whether the child's disease is currently active or whether the child even needs to be admitted. More importantly, notice that the primary healthcare provider has not yet written prescriptions! Not the priority. Option 3: No! Medications and respiratory treatments are definitely vital in the care of this child. However, immediately after the diagnosis is not the time to begin review. Picture yourself in such a situation. Do you think you would hear anything after the word "tuberculosis"? Reviewing is not priority at this moment. Option 4: Awesome! Right now, the parents have just been informed of a serious diagnosis for their child. Any reviewing provided at this time would most likely be too overwhelming. While the parents will need extensive education about TB and their child's needs, right now the LPN knows therapeutic communication techniques are the priority action.
The nurse is caring for an immobile client. Which complication is the nurse's priority? 1. Orthostatic hypotension 2. Urinary tract infection 3. Pressure ulcer 4. Deep vein thrombosis
4. Deep vein thrombosis 4. Correct: A venous thrombus has the potential to dislodge and travel to the lungs and heart: impairing circulation and oxygenation. A venous thrombus can be life threatening. 1. Incorrect: Orthostatic hypotension is low BP that occurs when going from lying or sitting position to standing position. It is not as life threatening as deep vein thrombosis. . Incorrect: Urinary tract infections can be painful and serious. They are treated with antibiotics. Urinary tract infections are not as life threatening as deep vein thrombosis.3. Incorrect: Prolonged pressure causes injury to the skin and underlying tissue. Most pressure ulcers heal with appropriate treatment. Pressure ulcer is not as life threatening as deep vein thrombosis.
When should the nurse tell the client to take Lispro insulin? 1. Thirty minutes before bedtime. 2. Twice daily in AM and PM. 3. One hour before meals. 4. With meals.
4. With meals. 4. Correct: Lispro is a rapid-acting insulin that should only be taken with food or within 15 minutes of a meal. 1. Incorrect: Lispro is a rapid-acting insulin and should not be taken without food. 2. Incorrect: Lispro is a rapid-acting insulin and should not be taken without food. 3. Incorrect: Lispro is a rapid-acting insulin and should not be taken without food. Giving an hour before eating is too early and would put the client at risk for hypoglycemia.
positive cytomegalovirus
A positive test for CMV IgG indicates that a person was infected with CMV at some time during their life, but does not indicate when a person was infected. This applies for persons ≥12 months of age when maternal antibodies are no longer present. Cytomegalovirus is a common herpes virus. Many people do not know they have it, because they may have no symptoms. But the virus, which remains dormant in the body, can cause complications during pregnancy and for people with a weakened immune system. The virus spreads through bodily fluids, and it can be passed on from a pregnant mother to her unborn baby. Also known as HCMV, CMV, or Human Herpes virus 5 (HHV-5), cytomegalovirus is the virus most commonly transmitted to a developing fetus.
In the event of a fire, the nurse must know:
Location of fire alarms Location of and how to use fire extinguishers Location of fire exits Use the mnemonic R.A.C.E. to remember what to do in case of smoke or a fire.
does a nurse need to sign a consent form
The physician should have obtained consent before the nurse has the patient sign a form. Nurses can offer what we do best—patient teaching, as we check patient understanding and obtain written consent. ... As much as possible, obtain consent in a quiet and calm setting, with time to answer questions.
The nurse is caring for a client with a chest tube. The client is confused and keeps attempting to pull out the chest tube. The nurse applies soft restraints on both of the client's wrists. Is the nurse acting appropriately?
Yes, the nurse should apply a restraint to protect the client from self-injury, and then must contact the HCP. Correct Response
Enoxeparin (Lovenox)
anticoagulant
Tiotropium (Spiriva) side effects
xerostomia capsules should not be swallowed
can a patient view medical their own medical records
yes
INR
0.8-1.1 CRITICAL VALUE=.5.5 (> THE VALUE THE LONGER IT TAKES TO CLOT)
The nurse is caring for a terminally ill hospice client. The client is currently reporting, "pain all over, worse than ever." The nurse assesses the client and records the following data: blood pressure 104/60 mm Hg, apical pulse 74 beats/minute, respirations 8 breaths/minute and shallow. Which intervention would the nurse implement? Notify the health care provider of the client's vital signs Turn and reposition the patient for comfort Reassess the client in about 30 minutes Administer the ordered pain medication
Administer the ordered pain medication Correct! The central theme of hospice care and palliative care is the belief that each of us has the right to die pain-free and with dignity. The hospice teams develops a care plan that meets the client's needs for pain management and symptom control. The best response by the nurse is to medicate the client according to the prescribed plan of care. Turning and repositioning the client may increase, not decrease, the pain. There's no need to notify the health care provider if there are orders in place for pain management. Reassessing the client in 30 minutes is not an appropriate intervention.
Gastroenteritis symptoms
Nausea Vomiting Abdominal cramping Diarrhea Dehydration Hyperactivity of the intestine produces high-pitched bowel sounds = borborygmi. Hyponatremia possible Hypokalemia possible Metabolic acidosis possible Metabolic alkalosis possible
Clopidogrel (Plavix) is
Platelet Aggregation Inhibitor used to prevent blood clot formation in clients with recent myocradial infarction,acute coronary syndrome,cardiac stents, stroke or peripheral vascular disease. It can cuase thrombocytopenia and increase the risk for bleeding
Enoxaparin administration
To ensure complete medication delivery, the air bubble should not be expelled prior to injection, the air bubble should not be expelled prior to administration.The injection site should be on the right or left side of the abdomen at least 2 in from the umbilicus. The needle should be inserted at a 90-degree angle into a pinched up area tissue.do not rub because this could cause bruising.
Garlic application
is used to cure skin infections like contact dermatitis and burns on th wrist
UAP tasks for Pain
• Assist with screening for pain and notify RN if patient expresses pain.• Take and report vital signs before and after pain medications are given.• Note and report if patient is refusing to participate in ordered activities such as ambulation (since this may indicate inadequate pain management).
"A schizophrenic client states, ""I hear the voice of King Tut."" Which response by the nurse would be therapeutic?
"""I don't hear the voice, but I know you hear what sounds like a voice.""
The nurse is caring for a 5-year-old client with autism. Which of the following client behaviors would be consistent with the diagnosis? 1.frequently trips or falls when ambulating 2.blinks and twitches extremities uncontrollably 3.tonic-clonic muscle contractions 4.speech and language delays
4
Prior to discharge, the client asks the nurse about including her 2 year-old and 12 year-old sons in the care of their newborn sister. Which would be an appropriate initial statement by the nurse? "Suggest that the father spend more time with the boys." "Ask the children what they would like to do for the newborn." "Tell each child what he can do to help with the baby." "Focus on your sons' needs during the first few days at home."
"Focus on your sons' needs during the first few days at home." Correct Response In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn, especially in the first few days after the baby is brought home. The key to answering this question is to focus on the word "initial." This would indicate that all of the options will be correct and appropriate, but one response will take precedence. Notice also the use of the words "sons" in both the question and the correct response.
The nursing supervisor overhears a conversation between the nurse and a client with a substance disorder. The client insists that no one can help him. Which of the following responses by the nurse should be of concern to the nursing supervisor? "I have extensive experience and will be able to help you overcome your addiction." "I am sensing you are discouraged with your current situation." "I would like to hear of your past experiences with treatment." "I have planned a conference with your physician and social worker to evaluate your current treatment."
"I have extensive experience and will be able to help you overcome your addiction." Correct! Countertransference is a risk for a nurse caring for a client with addiction. Patient behaviors may trigger overwhelming emotional reactions and result in the nurse being less effective in the therapeutic relationship. Reassuring the client that the nurse is the one who will be able to help may indicate that the nurse is responding to the emotional pressure presented by the client. The other options are therapeutic responses because they seek clarification, more information or involve further assessment.
"Which characteristics would the nurse expect to see in the client with schizophrenia?
"Loose associations, grandiose delusions, and auditory hallucinations"
A client with a terminal diagnosis is not eating or drinking. Her husband is very concerned. What is the nurse's best response? (Select all that apply.) "This is a normal part of the end of life." "An intravenous drip can be started for her." "A feeding tube can be inserted." "Pain is decreased with dehydration." "Feeding her may cause nausea."
"Pain is decreased with dehydration." Correct! "Feeding her may cause nausea." Correct! Lack of eating and drinking is an expected part of the dying process. The provision of intravenous hydration can have a negative impact on quality of life by increasing pulmonary secretions, urinary output, nausea, vomiting, and edema. Water deprivation increases the body's production of endogenous opiates that create a euphoric state and has been associated with a reduction in pain. Studies of patients who are dying have indicated that thirst and hunger are not a significant problem when patients decide to forgo nutritional support and hydration.
When reinforcing teaching, which client statements indicate to the nurse that discharge instructions about antibiotic administration have been successful?
"The instructions on the label should be followed exactly." . "It is necessary to finish all of my antibiotic medication."
A client calls the clinic and states to the triage nurse: "I had an upset stomach and took Pepto-Bismol and now my tongue looks black. What's happening to me?" What would be the nurse's best response? "This is a common and temporary side effect of this medication." "How long have you had an upset stomach?" "Come to the clinic so you can be seen by the health care provider." "Are your stools also black?"
"This is a common and temporary side effect of this medication." Correct Response The best response would be to explain that a dark tint of the tongue is a common and temporary side effect of bismuth subsalicylate (Pepto-Bismol). Although it may also turn stools a darker color, do not confuse this with black, tarry stools, which is a sign of bleeding in the intestinal tract. After addressing the client's initial concern and the reason for the call, the nurse can ask about the upset stomach and then ask the client to come to the clinic if necessary.
"A client is admitted to the psychiatric unit with a diagnosis of borderline personality disorder. The nurse expects data collection to reveal:
"unpredictable behavior and intense interpersonal relationships.
Schizoprenia return to clinic 2 weeks after recieving dose of haldol; important info for the nurse to obtain during this visit
- Current vital signs.
Culturally Competent Nursing Care
-Care must be sensitive to needs of individuals, families, or groups from diverse cultures -The healthcare system is a culture with customs, rules, values, and a language of its own -Nursing is the largest subculture of the healthcare system effective, individualized care that demonstrates respect for the dignity, personal rights, preferences, beliefs, and practices of the person receiving care while acknowledging the biases of the caregiver and preventing these biases from interfering with the care provided
Trimethoprim
-Inhibits bacterial dihydrofolate reductase. Bacteriostatic.Sulfonomide antibiotic/sulfa drug -Used in combination with other sulfonamides (trimethoprim-sulfamethoxazole [TMP- SMX]), causing sequential block of folate synthesis. Combination used for UTIs, Shigella, Salmonella, Pneumocystis jirovecii pneumonia treatment and prophylaxis, toxoplasmosis prophylaxis. -Toxicity: megaloblastic anemia, leukopenia, granulocytopenia. (May alleviate with supplemental folinic acid). TMP Treats Marrow Poorly. Contraindicated in pregnancy and breastfeeding drink 2-3 L of water
Pavlik harness teaching
-shirt under straps -check for red areas under strap several times a day -diaper should be placed under the straps, wear 3-5 months readjust every 1-2 weeks because of infant growth, done by HCP wear knee socks to prevent skin breakdown
INR
0.8-1.1 In healthy people an INR of 1.1 or below is considered normal. An INR range of 2.0 to 3.0 is generally an effective therapeutic range for people taking warfarin for disorders such as atrial fibrillation or a blood clot in the leg or lung. In certain situations, such as having a mechanical heart valve, you might need a slightly higher INR.
An LPN/LVN is preparing to transfer a client from the delivery room to the postpartum unit. Which statement by the client would cause the LPN/LVN to notify the charge nurse? 1. "I just felt something gushing." 2. "I feel like I am still having contractions." 3. "When I stand up I feel dizzy for several moments" 4. "My nipples hurt since I breastfed my baby."
1. "I just felt something gushing." 1. Correct. This could indicate postpartum hemorrhage and requires immediate assessment by the nurse. 2. Incorrect. This is normal postpartum contractions of the uterus to help dispel clots and to return the uterus to normal size. 3. Incorrect. This occurs after delivery because of the fluid loss that results. Teach safety measures. Not the priority here. 4. Incorrect. This is not the priority and can be dealt with on the postpartum unit.
Which task would be appropriate for the LPN/VN to accept from the charge nurse? 1. Collect data on a new client admit. 2. Administer ondansetron IVP to a two day post-op client. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. 5. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client.
1. Collect data on a new client admit. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. 5. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client. 1., 3., 4., & 5. Correct: All of these tasks are appropriate and within the scope of practice for the LPN/VN. The LPN/VN can collect data on a new admit, and the RN would verify and co-sign to complete the assessment. Bolus feeding by way of a gastrostomy tube and reinserting a nasogastric tube would be appropriate assignments for the LPN/VN also. A LPN/VN can monitor the PCA pain medication but cannot initiate or administer the medication. 2. Incorrect: Administering ondansetron IVP is out of the scope of practice for the LPN/VN. The PN cannot administer IV push medications.
Three hours after delivery of a client's newborn, the nurse monitors for bladder distention. What signs would the nurse note if the client's bladder is distended? 1. Fundus 3 cm above umbilicus 2. Excessive lochia 3. Voids 200 mL every 2 hours 4. Fundus in abdominal midline 5. Tenderness above symphysis pubis
1. Fundus 3 cm above umbilicus 2. Excessive lochi 5. Tenderness above symphysis pubis 1., 2., & 5. Correct: Monitor client for signs of distended bladder, such as fundal height above the umbilicus or baseline level, and/or fundus displaced from midline over to the side. Bladder that bulges above the symphysis pubis, excessive lochia, tenderness over the bladder area, frequent voiding of less than 150 mL (indicative of urinary retention with overflow) are also signs of a distended bladder. 3. Incorrect: Voiding every 2-3 hours should be encouraged to prevent possible displacement of the uterus and the development of atony. The clients ability to do this would prevent bladder distention. 4. Incorrect: Fundus in abdominal midline is what we want and is not a sign of bladder distention. We do not want it displaced over to the side from midline.
The nurse is assisting the client changing his gown. 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. 1. Correct: 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. 4. Incorrect: The client is trying to coerce the client, and this could be considered assault.
A nurse from the pediatric unit is transferred to the adult medical-surgical unit. Which client assignment should the nurse accept from the charge nurse? 1. Undergoing surgery for tonsillectomy and adenoidectomy. 2. Diagnosed with leukemia, hospitalized for induction of chemotherapy. 3. Prescribed IV heparin for left leg thrombosis. 4. Admitted with a cerebrovascular accident.
1. Undergoing surgery for tonsillectomy and adenoidectomy. 1. Correct: This is the most stable client to give to the nurse who was transferred from the pediatric unit. A pediatric nurse cares for postop T&As daily in this specialty area and can transfer this knowledge to the adult client. 2. Incorrect: This is not a good client for a pediatric nurse because knowledge of lab values, chemotherapy precautions, protective isolation and chemotherapy drugs is required for the RN in order to care for this client. 3. Incorrect: This is not the best client for a pediatric nurse because thrombosis problems are not commonly seen on the pediatric unit. Monitoring clotting factors and being aware of signs and symptoms of pulmonary emboli are essential for safe care of this client. 4. Incorrect: This client is very unstable and requires skilled observation and assessment using the Glasgow Scale. This client will require the skills of the RN
A young adult diagnosed with schizophrenia is admitted to the crisis center with exacerbation of psychotic behaviors. The client responds well to a medication regime of chlorpromazine three times daily. The nurse is reinforcing discharge instructions and knows teaching was successful when the client makes what statements? Select all that apply 1. "This medication will help me control my behavior." 2. "I should take this medication only if I feel anxious." 3. "I need to have blood levels checked periodically." 4. "My medication will eventually cure my disorder." 5. "I must apply sunscreen and wear a hat if outside."
1., & 5. CORRECT: Chlorpromazine is an antipsychotic medication used to control psychotic or hyperactive behaviors such as those noted in schizophrenia and attention deficit hyperactivity disorder (ADHD). If the medication regime is followed consistently, psychotic behaviors can be minimized. However, chlorpromazine also sensitizes the skin, making the client susceptible to sunburn even on cloudy days. Using sunscreen is vital at all times. 2. INCORRECT: Antipsychotic medications such as chlorpromazine cannot be stopped and restarted suddenly because of potential side effects. The medication must be taken consistently in order to control severe anxiety or agitated behaviors. 3. INCORRECT: While some psychiatric medications may need to have blood levels monitored frequently, chlorpromazine is not one of those drugs. 4. INCORRECT: There is no cure for schizophrenia. This disorder is because of alterations in normal brain chemistry, and although medications can alleviate or control the behaviors, the disorder can only be managed. 1. A strategy you can draw on to help answer priority questions is to refer to basic guiding theories that are part of the foundation of nursing. Maslow's Hierarchy of Needs, the Nursing Process, Kubler-Ross's Theory of Death and Dying, Teaching/Learning Theory, Therapeutic Communication. 2. Identify client-centered options. The focus of the nurse should be the client. Items that test your ability to be client-centered tend to explore client feelings, identify client preferences, empower the client, provide the client choices, or in some way put emphasis on the client. The client is the priority. Chlorpromazine is an antipsychotic medication used to control behaviors seen in disorders such as schizophrenia, bipolar disorder and ADHD. This medication may even be used for pre-surgical anxiety. Although chlorpromazine works well in controlling psychotic behaviors, there are many side effects, some quite serious, which need evaluated in relation to any positive benefits. Milder side effects include dry mouth, constipation, drowsiness and possible weight gain. However, a more serious, potential side effect is tardive dyskinesia in which the client develops erratic, uncontrollable and irreversible tremors. If this occurs, the client cannot control muscles, especially of the face, leading to constant jaw and tongue movements. These tremors make it extremely difficult to perform any ADL's. There are many restrictions with this medication, including using sunscreen, safety precautions when moving, and even dietary precautions. The nurse is looking for evidence the client understands the proper use of this medication at home. So what correct statements did the client make? Option 1: Excellent! The client is acknowledging the medication can help control psychotic behaviors or anxiety, as long as no doses are missed. Antipsychotic medications, whether oral or injectable, require consistent dosing in order to maintain control of the client's schizophrenia. This statement by the client indicates that teaching was successful. Option 2: Definitely not! An antipsychotic medication is not an "occasional use" drug for symptoms. These medications must be taken routinely and consistently for positive effects. It is also dangerous to suddenly stop such medications; therefore, a client needs the supervision of a primary healthcare provider to slowly taper off the drugs. Option 3: Not this one. It is not necessary to obtain periodic drug levels of chlorpromazine. Blood levels of the drug are not monitored; rather, specific behaviors are tracked to determine effectiveness. Option 4: So wrong! The cause of schizophrenia is not really known, but researchers believe this brain disease is a combination of genetics, brain chemistry and environmental factors. It is known that normal brain chemicals, such as dopamine and glutamate, become abnormal, contributing to the severity of schizophrenia. There are even structural differences in the brain and central nervous system. Therefore, no cure for this disorder exists. Option 5: Good choice! Chlorpromazine sensitizes the skin to ultraviolet light. The client would be instructed to use sunscreen and a wide-brimmed hat when outside, whether the sun is shining or not. Sunburns can be particularly severe for clients taking this drug.
In caring for a client exposed to radiation, the nurse knows that the type of damage due to radiation exposure depends on which factors? 1. Dose rate 2. Organs exposed 3. Technician 4. Time of day 5. Type of radiation
1., 2. & 5. Correct: The extent of damage due to radiation exposure depends on the quantity of radiation delivered to the body, the dose rate, the organs exposed, the type of radiation, the duration of exposure, and the energy transfer from the radioactive wave or particle to the exposed tissue. 3. Incorrect: The technician has no bearing on the type of damage due to radiation exposure. 4. Incorrect: The time of day has no bearing on the type of damage due to radiation exposure.
A client comes into the clinic for a routine check-up during the second trimester of pregnancy. The client reports gastrointestinal (GI) upset and constipation. The nurse reviews the client's medications. Which client medication is most commonly associated with GI upset and constipation? 1. Calcium supplement 2. Ferrous sulfate 3. Folic acid 4. Cetirizine
2. Ferrous sulfate 2. Correct: Ferrous sulfate commonly causes constipation and GI upset. These side effects can be diminished with proper diet instruction and taking medication with food.1. Incorrect: Calcium is essential for bone health, maintaining heart rhythm, and muscle function. It is crucial in growing new bone and maintaining bone strength. Calcium does not generally cause constipation.3. Incorrect: Constipation and GI upset are not generally associated with folic acid administration.4. Incorrect: Constipation is an adverse effect associated with cetirizine administration, since it is an antihistamine. Antihistamines dry you up, so the GI tract contents gets thicker, leading to constipation.
An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse respond to this? 1. Encourage the family to accept nursing home placement as the best option for their loved one. 2. Listen to the family's concerns and report those to the primary healthcare provider. 3. Determine what the client wants to do and tell the family to abide by the client's wishes. 4. Realize that the nurse does not need to be involved in this decision.
2. Listen to the family's concerns and report those to the primary healthcare provider. 2. Correct: The nurse should listen to the concerns of the family. The Asian culture tends to be opposed to nursing home placement and see it as their duty to care for their elders in the home. The nurse should listen and serve as an advocate. 1. Incorrect: The nurse should not impose personal values on the client and family. Cultures vary as to acceptance of nursing home placement. 3. Incorrect: The client may not be in a position to make this decision. 4. Incorrect: The nurse must serve as client advocate and intermediary between client/family and primary healthcare provider as decisions are made about this important issue.
The nurse is providing care to a 5 year old client who has been experiencing moderate pain. Which intervention is appropriate for the nurse to use with this client? 1. Encourage the client to talk about the pain. 2. Provide distraction by asking the client to sing with the nurse. 3. Suggest that the client try to relax. 4. Tell the client that the pain can be self controlled
2. Provide distraction by asking the client to sing with the nurse. 2. Correct: Distraction is a good technique to use with the toddler/preschooler. Other distractions might be to read a book, watch TV with the client, or look at pictures. 1. Incorrect: The client at this age does not have the cognitive abilities to discuss pain other than to report the presence and location of the pain. 3. Incorrect: Relaxation requires higher level of skills and attention than this child would have. 4. Incorrect: This child would not have the cognitive grasp of controlling pain.
therapeutic INR
2.0-3.0
Phosphorous levels
2.2-4.4 mg/dL
The nurse reinforces instructions regarding the use of warfarin sodium. Which statement indicates to the nurse that the client understands the possible food interactions which may occur with this medication? 1. "I'm glad I can still have my evening glass of wine." 2. "I told my daughter not to buy romaine lettuce for my salads." 3. "I will have to limit my intake of spinach, something that I really love." 4. "I am going to eat more canned tuna fish since it is healthy."
3. "I will have to limit my intake of spinach, something that I really love." 3. Correct: Clients taking warfarin sodium must watch their intake of vitamin K, which is present in leafy green vegetables such as spinach. 1. Incorrect: Alcohol affects the use of warfarin sodium. This combination can cause the client to bleed more easily. 2. Incorrect: Iceberg and romaine lettuce are considered low sources of vitamin K, so the client can eat them. 4. Incorrect: Canned tuna is a source of vitamin K, which can decrease the effectiveness of warfarin.
Which statement by an LPN/LVN student indicates to the nurse educator that teaching regarding witnessing consent signatures has been successful? 1. "Two people must witness a consent signature." 2. "An RN must witness a consent signature." 3. "Signing as a witness implies that the client willingly signed the consent." 4. "A witness must be over the age of 21."
3. "Signing as a witness implies that the client willingly signed the consent." 3. Correct: Signing as a witness implies that the witness has observed the client personally signing the consent form with no coercion. 1. Incorrect: Only one signature is required as a witness. 2. Incorrect: The witness does not have to be an RN. 4. Incorrect: A witness is required to be over the age of 18. Nurses are required to practice within the laws of the state and within federal laws, such as HIPAA.
The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a rehabilitation unit. Which nursing tasks would be most appropriate for the nurse to assign to the UAP? Select all that apply 1. Take initial vital signs on client receiving blood. 2. Insert an indwelling urinary catheter. 3. Assist a client to the bathroom during bladder training. 4. Transfer a client from wheelchair to bed. 5. Feed lunch to the client who gagged on food at breakfast.
3. Assist a client to the bathroom during bladder training. 4. Transfer a client from wheelchair to bed. 3. & 4. Correct: The UAP can assist client to the bathroom as part of bladder or bowel training. The nurse is responsible for the training but can delegate this part of the training. Transferring a client from bed to wheelchair and wheelchair to bed is within the scope of practice for the UAP1. Incorrect: The RN should take initial vital signs before administering blood. 2. Incorrect: The UAP cannot perform sterile procedures such as putting in a urinary catheter. It requires an RN or LPN.5. Incorrect: Clients who are at risk for aspirating are unstable and cannot be delegated.
Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 1. Check bladder for distension in client who had an indwelling catheter removed 4 hours ago. 2. Obtain BP of client with syncope in the lying, sitting, and standing positions. 3. Prepare a sitz bath for a postpartum client. 4. Monitor for grimacing in the client who has had a stroke.
3. Prepare a sitz bath for a postpartum client. 3. Correct. The UAP can assist clients with hygiene care, so it is within the scope of practice for the UAP to assist a client with a sitz bath for the postpartum client. 1. Incorrect. This is not within the scope of practice for the UAP. The nurse must collect data. Checking the bladder for distension is data collection. 2. Incorrect. This client is not stable if having episodes of syncope that could be related to orthostatic hypotension. Since the client is not stable, the UAP should not obtain the client's BP. 4. Incorrect. The nurse cannot ask the UAP to complete an assessment or evaluation task. This is beyond the scope of practice for the UAP.
A client with a history of congestive heart failure has an implantable cardioverter defibrillator (ICD) surgically implanted. What teaching points should the nurse reinforce with the client prior to discharge? 1. Avoid hot baths and showers. 2. Increase intake of leafy green vegetable products. 3. Avoid magnets directly over the site. 4. Notify primary healthcare provider whenever a shock is delivered by the ICD. 5. Driving is not recommended for 1 year after placement of an ICD.
3., & 4. Correct: Magnets can deactivate the defibrillator. Other transmitter devices should also be avoided. Most arrhythmias need only one shock, but the healthcare provider should be notified when a shock is delivered so that monitoring can increase. 1. Incorrect: Hot baths or showers are not contraindicated with ICDs. 2. Incorrect: Increase of leafy green vegetable products would have no relation to the ICD but should be avoided if the client is on warfarin. 5. Incorrect: The client cannot drive for 6 months after implantation of an ICD and cannot drive for 6 months after any shock therapy from the ICD.
Which client should the nurse see first? 1. A child whose colostomy bag is leaking 2. A three day post-op client requesting pain medication 3. A child admitted with failure to thrive, whose mother requested formula 4. A client with a blood pressure drop from 150/80 to 120/60
4. A client with a blood pressure drop from 150/80 to 120/60. 4. Correct: Assume the worst. This client's drop in BP is significant.1. Incorrect: This is a stable client. There is no indication of immediate distress. 2. Incorrect: This is a client 3 days post-operative. According to Maslow, pain is a less urgent need. 3. Incorrect: The client is not in immediate distress. Nutrition is not as high a priority as circulation.
The nurse is caring for a client diagnosed with schizophrenia who is admitted to the hospital for possible bowel obstruction. The client has a nasogastric tube (NG) and reports pain 8/10. What is the priority nursing action? 1. Decrease the stimuli and observe frequently. 2. Administer the prn sedative. 3. Call the primary healthcare provider immediately. 4. Administer the prn pain medication.
4. Administer the prn pain medication. 4. Correct: Small bowel obstruction has a clinical manifestation of crampy pain that is wave like and colicky due to persistent peristalsis above and below the blockage. The client reports pain 8/10. Nursing care of the patient includes pain management. 1. Identify key words in the stem that set a priority, such as first, initially, best, priority, safest, most. These words modify what is being asked. This question requires you to put a value on each option and then place them in rank order. If you are having difficulty ranking the options, eliminate the option that you believe is most wrong among the options. 2. Never delay treatment or choose an option that ignores client symptoms.
A client with cancer refuses treatment and asks about options for hospice home care. The client's daughter asks the nurse to talk the client into agreeing to cancer treatment. The nurse explains to the daughter that this violates which client right? 1. Advocacy 2. Ability to decline participation in experimental treatments. 3. Expectation of reasonable continuity of care. 4. To make decisions about the plan of care
4. Correct: Under the Patient Self-Determination Act (PSDA), healthcare institutions provide clients with a summary of their rights when making health care decisions as well as the facility's policies regarding recognition of advanced directives. The client is advised of the right to consent to or refuse treatment. Client rights refer to such matters as access to care, dignity, confidentiality, and consent to treatment. The competent adult client has the right to participate in the plan of care, to refuse a proposed treatment, and to accept alternative care and treatment. Documentation should be made that the client fully understands the risks and benefits of their decision. 1. Incorrect: The right to advocacy relates to the right to have another person present during interviews or examinations. This right would not be violated by the nurse if attempts were made to convince the client to have cancer treatment. 2. Incorrect: The right to decline participation in research or experimental studies is incorrect because no research or experimental treatment is proposed to the client. 3. Incorrect: The right to expect reasonable continuity of care appears to be a possible correct answer, but is incorrect because the client has not been transferred to hospice home care. Attempting to convince the client to agree to cancer treatment would not be pertinent to continuity of care in this situation. Under the Patient Self-Determination Act (PSDA), healthcare institutions provide clients with a summary of their rights when making health care decisions as well as the facility's policies regarding recognition of advanced directives. The client is advised of the right to consent to or refuse treatment or Self-determination. Client rights refer to such matters as access to care, dignity, confidentiality, and consent to treatment. The competent adult client has the right to participate in the plan of care, to refuse a proposed treatment, and to accept alternative care and treatment. Documentation should be made that the client fully understands the risks and benefits of their decision. Option 1. False: The right to advocacy relates to the right to have another person present during interviews or examinations. This right would not be violated by the nurse if attempts were made to convince the client to have cancer treatment. Option 2. False. The right to decline participation in research or experimental studies is incorrect because no research or experimental treatment is proposed to the client. Option 3. False. The right to expect reasonable continuity of care appears to be a possible correct answer, but is incorrect because the client has not been transferred to hospice home care. Attempting to convince the client to agree to cancer treatment would not be pertinent to continuity of care in this situation. Option 4. True. This is what self-determination is: the right to make decisions about one's own care.
The nurse is bathing a confused client in the acute care unit. The nurse talks with the client and explains each procedure. During the bath, the client becomes very agitated. What should the nurse do? 1. Complete the bath as quickly as possible. 2. Reassure the client and request them to stop acting out. 3. Continue bathing with assistance from an unlicensed assistive personnel. 4. Stop the bath, dress and reassure the client.
4. Stop the bath, dress and reassure the client. Correct: The nurse should not continue bathing if the client is becoming so distressed. Perhaps the bath can be completed at a later time. Safety is the priority. 1. Nurses need to use interviewing techniques to effectively communicate in a nonthreatening way with clients. 2. Client safety is always a priority. 3. Identify options that deny client feelings, concerns, and needs. Options that imply everything will be all right deny clients' feelings, change the subject raised by the client, encourage the client to be cheerful, or transfer nursing responsibility to other members of the healthcare team usually are distractors and can be eliminated from consideration
Coining
A practice among Southeast Asians in which a coin or other object is rubbed across the skin in a specific manner to treat various health concerns.
UAP tasks for Cast or Traction
• Position casted extremity above heart level.• Apply ice to cast as directed by RN.• Maintain body position and integrity of traction (after being trained and evaluated in this procedure).• Assist patient with passive and active ROM exercises.• Notify RN about patient complaints of pain, tingling, or decreased sensation in the affected extremity.
The client is in her first trimester of pregnancy. What major developmental task should the client accomplish during this stage of pregnancy? Accepting the loss of physical intimacy. Resolving any fears related to giving birth. Accepting physical changes related to pregnancy. Viewing the fetus as a separate and unique being.
Accepting physical changes related to pregnancy. Correct Response During the first trimester, the developmental focus is directed toward accepting the pregnancy and adjusting to pregnancy-related physical changes and discomforts. It is expected that the client will have some ambivalence during the first trimester, but the client can maintain physical intimacy with her partner if she wishes, including sexual intercourse. Looking at the fetus as a separate being and overcoming fears related to giving birth will occur in the third trimester, closer to the due date.
gentamicin
Aminoglycoside antibiotic that may cause nephro- and ototoxicity
Duloxetine (Cymbalta)
Antidepressant, Serotonin/Norepinephrine Reuptake Inhibitor Prescribed for major depressive disorders and to relieve diabetic neuropathy pain, and fibromyalgia has both analgesic and antidepressant properties it is used to relieve chronic pain that interfeeres with normal sleep.
20mcg/mL> level of theophyline
Associated with chronic toxicity include advanced age(60>),drug interaction(eg;alcohol,macrolide and quinolone antibiotics), and liver disease. SS of toxicity:headache, insomnia,seizures,nausea, vomiting,arrythmia
isoniazid
Avoid drinking alcohol Report yellowing of the skin and sclera Reprot numbness and tinglin of the extremities take vitamin B6 to prevent neuropathy avoid aluminum containing antiacids /Maalox withgin an hour of taking INH report changes in vision(blurred vision, vision loss) causess:hepatoxicity and peripheral neuropathy
A client asks about how various medications are prescribed to treat anxiety disorders. What is the best response by the nurse?
Benzos have established short-term effectiveness in the control of anxiety symptoms. They are the treatment choice for acute episodes of anxiety, such as during crisis
UAP tasks for DVT
• Reposition patients who are on bed rest at least every 2 hr.• Remind patients about the need to flex and extend the legs and feet every 2 hr while in bed.• Assist ambulatory patients to ambulate at least 4 to 6 times daily.• Assist patients with putting on elastic compression stockings.• Apply sequential compression devices.
Two members of the interdisciplinary team are arguing about the plan of care for a client. Which action could any one of the members of the team use as a de-escalation strategy? Interrupt, apologize for interruption, and change the subject Adjourn the meeting and reschedule when everyone has calmed down Tell the violators they must calm down and be reasonable Bring the communication focus back to the client
Bring the communication focus back to the client Correct Response Bringing the subject of the communication back to the client refocuses attention on the client's care, instead of the manner of communication. It is the most effective strategy because it is an example of collaboration. The other options are non-productive and may even make matters worse. Incorrect
UAP tasks for assessment and data collection
• Take and document vital signs.• Measure and document patient's height and weight.• Report abnormal vital signs to RN.• Report patient's subjective complaints to RN.
Digoxin
Cardiac Glycoside; Antiarrhythmic given for heart faliure myocardial contraction which increase cardiac output and increase circulation and tissue perfussion
After Thyroidectomy: Care
Care Includes: Position *LOW* or *semi - fowlers*, support the head, neck and shoulders.
A client at 42 weeks' pregnancy is admitted to the labor and delivery unit and started on an IV infusion of oxytocin. Which action should be included in the plan of care?
Carefully titrating the oxytocin based on the client's pattern of labor Explanation: Oxytocin may require titration to be effective; therefore, it should be titrated carefully based on the client's labor pattern. Maternal blood pressure, pulse, and respirations should be monitored every 30 to 60 minutes and with every increment of the oxytocin dose. Contraction pattern and uterine resting period should be monitored every 15 minutes. The client shouldn't be allowed to ambulate. The nurse should keep the client informed of labor progress and provide emotional support to the client and her labor partner.
The primary healthcare provider prescribes nafcillin 0.6 gram every 12 hours IM. Available is a vial labeled 200 mg per 1 mL. How many mL should the nurse give? Round your answer to the nearest whole number.
Changing 0.6 g to mg equals 600 mg. Then 200 mg : 1 mL = 600 mg : x mL 200x = 600 x = 3
UAP tasks for Cardiac Cath
• Take vital signs and report increases or decreases in heart rate or blood pressure to RN.• Report decreases in pulse oximetry to the RN.• Report patient complaints of chest pain, shortness of breath, and/or any other discomfort or distress to RN.• Assist with oral hygiene, hydration, meals, and toileting.
For a patient with cholelithiasis and acute cholecystitis
Cholelithiasis(gallstones) can obstruct the bile duct, causing acute inflammation of the gallbladder(cholecystitis) s/s:nausea,/vomiting and upper right quadrants pain that may radiate to the right shoulder. The gallbladder releases digestive enzymes in response to food. The highest priority for a client with cholecystitis and vomiting is to place in NPO to avoid gallbladder stimulation
UAP tasks for oxygen administation
• Use pulse oximetry to measure O2 saturation.• Report O2 saturation level to RN.• Assist patient with adjustment of O2 delivery devices (e.g., nasal cannula, face mask).• Report to RN any change in patient level of consciousness or complaints of shortness of breath.
Steps to collect a urine specimen from a foley catheter
Clean the collection port with an alcohol swab. Aspirate urine with sterile syringe Use an aseptic technique to transfer the specimen to a sterile specimen cup. Insert the needle gently into a Foley catheter (if the catheter is a self-sealing type) at a 45-degree angle, or if Luer-lock connection, twist on a sterile syringe to the port and slowly withdraw 20-30 mL of urine. 7. Remove the needle from a Foley catheter and push urine into the sterile specimen container. Cover container. A urine specimen is collected aseptically from the specimen port of an indwelling urinary catheter. Urine that has been collected from a bag does not yield accurate urinalysis and culture results/
oxytocin for induction of labor side effects
Common side effects of Pitocin include: redness or irritation at the injection site, loss of appetite, nausea, vomiting, cramping, stomach pain, more intense or more frequent contractions (this is an expected effect of oxytocin), runny nose, sinus pain or irritation, or memory problems. Tell your doctor if you experience serious side effects of Pitocin including: fast, slow, or uneven heart rate; excessive bleeding long after childbirth; headache, confusion, slurred speech, hallucinations, severe vomiting, severe weakness, muscle cramps, loss of coordination, feeling unsteady, seizure (convulsions), fainting, severe allergic reactions, abnormal heart beats, high blood pressure, and. rupture of the uterus. bleeding after child birth, shallow breathing or breathing that stops; or dangerously high blood pressure (severe headache, blurred vision, buzzing in your ears, anxiety, confusion, chest pain, shortness of breath, uneven heartbeats, seizure).
The nurse is contributing to the plan of care for a client with severe anxiety and new onset panic attacks following the loss of a spouse. Which factor is most important to recommend for the plan of care? 1. Available support system 2. Perception of the situation 3. Desire to return to work 4. Coping mechanisms
Coping mechanisms Correct. The plan of care for a client in crisis involves a complex combination of factors to achieve a positive outcome. However, the most important consideration is the client's own coping skills. Treatment and subsequent recovery is more successful when the client has the coping skills and is able to participate in the recovery process
Which home routines help reduce the risk for skin damage in a client with impaired sensation? Select all that apply 1. Using a hot water bottle to help warm up when first going to bed. 2. Hot water heater set at a temperature of 140 degrees. 3. Open flame heaters in the living areas of the home. 4. Testing the water with the back of the wrist and forearm before getting in the shower. 5. Wear shoes when out of bed.
Correctl 4. Testing the water with the back of the wrist and forearm before getting in the shower. 5. Wear shoes when out of bed. RationaleStrategies 4. & 5. Correct: This practice actually is a safeguard for skin damage from burns. Shoes will protect feet from injury.1. Incorrect: This client should not use a hot water bottle at bedtime because the client has impaired sensation and may not be able to determine that the water bottle is too hot.2. Incorrect: The water heater should be set at temperatures of about 120 degrees to decrease likelihood of skin burns.3. Incorrect: If clients have impaired sensation, burning of the skin is a risk with the use of open flame heaters. The client may sit too close to the heater and be unaware of a burn.
Risk factors for lithium toxicity
Dehydration Na+ Depletion ARF/CRF Thermal Stress Preeclampsia High Li dose Drug Interaction diuretics NSAIDs ACE-I ARB Levaquin flagyl tetracycline SSRIs
A nurse is reinforcing home care to the parents of a child with rheumatic fever. The nurse should make it a priority to emphasize which topic? Home schooling is preferred to classroom instruction The child may remain a strep carrier for years Difficulty breathing or swelling in the legs and feet should be reported. Most play activities will be restricted indefinitely
Difficulty breathing or swelling in the legs and feet should be reported. Correct! Rheumatic fever can cause damage to the heart valves resulting in signs of heart failure such as fatigue with activity, shortness of breath and fluid retention. These findings should be reported to the provider, as they may represent heart failure requiring medical treatment.
The nurse is assisting with the discharge of a client following a total hip arthroplasty. Which information should be emphasized during the discussion of home care with this client? Avoid climbing stairs for three months Sleep on your back Ambulate using crutches Do not cross your legs at any time
Do not cross your legs at any time Correct! To avoid dislocating the hip prosthesis, hip flexion should not exceed 60 degrees. To help narrow the options down, look at the the two that are the most similar but dissimilar. This would lead to options about the legs and not doing something. Then ask yourself which position would be contraindicated - climbing or crossing legs? (Still not sure? Cross your legs now and feel how the hip joint is a little stressed.)
Nurse colleagues are discussing their nursing practice during lunch. Which statement is correct? Each state has specific regulations for licensed registered nurses (RNs) and licensed practical nurses (LPNs) The employing agency is ultimately responsible to provide practice guidelines for licensed nurses The federal government ensures the safety of clients by defining the scope of nursing practice National nurses' associations work collaboratively to update the social policy statement for nursing
Each state has specific regulations for licensed registered nurses (RNs) and licensed practical nurses (LPNs) Correct! Boards of nursing are state governmental agencies that are responsible for licensing nurses in each state/jurisdiction and enforcing the rules and regulations of the nurse practice act (NPA). The NPA is enacted by the state legislature. The NPA and rules define the scope of practice and responsibilities for nurses. The scope of practice for nurses, especially LPN/VNs, varies from state to state.
The nurse is reinforcing education to a group of parents on how to treat accidental poisoning of children in the home. What information should the nurse include?
Empty the child's mouth of any poisonous substance still present. Emptying the mouth of the poison prevents any further ingestion. It should be done first to minimize further contact with and absorption of the substance. The parent should call the Poison Control Center before giving any treatment. Never induce vomiting unless instructed to do so by the Poison Control Center or a health care provider. The same applies for giving the child milk to drink because not all poisons are neutralized that way.
theme identification
Exploring overeaching or repeated topics: I've notice that you fear areas with crowds
hyperthermia and tinnitus
occurs in aspirin overdose
SIADH treatment
Fluid restriction,<1000mL/day oral salt tablets IV hypertonic saline, 3% conivaptan/tolvaptan, demeclocycline
Headache, agitation, and indigestion are symptoms that suggest mania in a client with a history
of bipolar disorder.
When a patient has crackles,JVD and peripheral edema, what medication do you expect to see
Furosemide /Lasix Monitor the client's blood presure as it can lower the blood pressure When excess fluid is removed through the kidneys by diuresis the heart will be able to pump more effectively, which will increase cardiac output
Which clients are nost at risk for hospital acquired MRSA
older adults supressed immune long antibiotiv use invasive tubes or lines ICU patients
Naproxen side effects:
GI bleeding Blood dyscrasias Tinnitus Headache Insomnia Vision changes Rash Angioedema Jaundice Tachycardia Back pain Nausea bleeding risk kidney injury hypertension and heart faliure
A client is diagnosed with rheumatoid arthritis (RA). Which types of drugs might the nurse expect to be ordered as a combination drug therapy regimen? (Select all that apply.) Glucocorticoids Biological-response modifiers Antimicrobial agents Diuretics Anti-inflammatory drugs
Glucocorticoids Correct! Biological-response modifiers Correct Response Anti-inflammatory drugs Correct! Rheumatoid arthritis is a chronic, systemic autoimmune disorder that results in symmetric joint destruction. Research shows that multiple drug therapy is most effective in protecting against further destruction and promoting function. Analgesics and anti-inflammatory drugs are used. Disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate help slow or stop progression of RA. Biological response modifiers are used to help stop inflammation. Glucocorticoids can also be used for severe RA or when RA symptoms flare to ease the pain and stiffness of affected joints. Because RA is not an infectious disease, antimicrobials are ineffective. Although there is swelling in the joints, it is not fluid, so diuretics are not part of the treatment plan.
Donn PPE before providing care to a patient in airborne transmission-based precautions
Hand hygiene Gown Mask or respirator Goggles or face Gloves
A client is been treated with suicidal ideation .What statement best indicates that the person is not currently at risk for suicide?
I plan to attend my grandaughter's graduation next month Clients who articulate long term goals and family milestones are less likely to commit suicide
Hypospadias - surgical repair
If hypospadias is not treated, it can result in: Abnormal appearance of the penis Problems learning to use a toilet Abnormal curvature of the penis with erection Problems with impaired ejaculation
A nurse is following the plan of care for a 75 year-old client with community-acquired pneumonia who is normally healthy and active. Which action should be most effective for the removal of pulmonary secretions? Increase oral fluid intake Perform chest physiotherapy twice a day Administer cough suppressants as ordered Maintain bed rest with bathroom privileges
Increase oral fluid intake Secretion removal is enhanced with adequate hydration, because it thins and liquefies secretions. In an older adult, the amount of fluid intake should be individualized based on the client's size, coexisting conditions and other factors because of the risk of fluid overload and normal fluid intake. Chest physiotherapy is beneficial but is not as important as hydration, and may not be needed in this client who is usually healthy and active. It would also be more effective after the secretions have thinned. You'll notice that two of the options (cough suppressants and bed rest) would not help remove pulmonary secretions; in fact, they may do the opposite. Inactivity would be beneficial only if hypoxia occurs with activity, and cough suppressants should be avoided, as they can prevent clearance of secretions by suppressing the cough.
what IV fluid should be ordered for hyperemesis?
Intravenous Fluids Intravenous(IV)fluids shouldbe provided to replenish the lost intravascular volume. Rehydration along with replacement of electrolytes is very important in the treatment ofhyperemesis. Normal saline or Hartmannsolutionare suitablesolutions; potassium chloride can be added as needed.
The nurse provides regular mouth care to the hospice client who is actively dying at home. The family wants to know why the doctor doesn't order an IV since the client's mouth seems so dry. What information can the nurse provide to the family that best answers their question. The client will need to be hospitalized if an IV is started The client will need to have a indwelling catheter inserted if an IV is started Intravenous hydration will increase episodes of delirium Intravenous hydration can delay death
Intravenous hydration can delay death Correct! Clients who are dehydrated may experience delirium and may benefit from IV therapy. However, intravenous hydration does not improve dry mouth and can even delay death. The nurse should explain that the client's comfort can be enhanced by providing frequent mouth care and that decreased oral intake is a natural and nonpainful part of the dying process.
The home health nurse is seeing a client diagnosed with type 2 diabetes. The client has a small foot ulcer that was debrided and requires daily dressing changes. Which intervention is most important for the nurse to implement to meet the goal of uncomplicated wound closure? Schedule regular visits to monitor wound healing. Evaluate the client's understanding of appropriate foot care. Arrange for referral to a diabetic educator. Involve the client in making decisions.
Involve the client in making decisions. Correct Response Although all these interventions may benefit the client, the involvement of the client in making health care decisions is the most important intervention to improve meeting desired goals and outcomes. The client will be more motivated to adhere to the nurse's recommendations if they are involved in the process of setting priorities and making decisions.
isotretinoin
Is an oral acne medication made from vitamin A.Due to teratogenic rsik and severity of side effects(Steve-Johnson syndrome,suicide risk) Is used to treat sever acne/and cystic acne not responding to other treatertements Exposure to this treatment during pregancu can cause birth defects Clients should enter web-based agreement PLEDGE and use two forms of contraceptions Taking vitamin A supplements along with isotretinion can cause vitamin A toxicity,which can cause increase intracranial pressure,GI upset,liver damage,and changes in skin and nail. Blood donation is prohibited during treatement and up to a month. Should not be taken with tetracycline ,can increase intracranial pressure.
A newly licensed nurse is concerned about time management. Which action should be most effective in the initial development of a time management plan? Set daily goals with the establishment of priorities Keep a time log for what was done during the hours worked Ask for additional assistance when necessary to complete tasks Complete each task before beginning another activity
Keep a time log for what was done during the hours worked
The nurse is in a crowded shopping area in an urban setting when a radiologic dispersal device (RDD) explodes scattering radioactive dust and material into the environment. What should the nurse instruct the victims in proximity to the explosion to do first? Stay out of any buildings until help arrives Lie down flat and cover the head with anything available Keep the nose and mouth covered Remove all exposed clothing right away
Keep the nose and mouth covered Correct! An RRD, or "dirty bomb," generates radioactive dust and smoke, which can be dangerous if inhaled. The nurse should initiate measures to limit contamination, instructing victims to cover their noses and mouths. Neither lying down or covering the head does anything to limit exposure. Victims should move into a building where the walls and windows have not been broken and then remove their outer layer of clothing (sealing them in a plastic bag, if available) to help minimize exposure.
A client with chronic kidney disease is admitted with pneumonia and pleurisy,the labs read: Hemoglobin 9.0 g/dL Platelets 267,000/mm3 WBC 14,500 /mm3 Creatine 2.8 mg.dL What prescription should you question? Ketorolac 15 mgI V every 6 hours, as needed for pain Levofloxacin 500 mg IV, once daily Epoetin alpha 15000 units SQ inj, weekly
Ketorolac Ketorolac(Toradol) highly potent NSAIDs often used for pain and available Highly potent and and antiinflamatory Available in IV form However indomethacin,ibuprofen,naproxen,ketorolac are nephrotoxic and should be avoided in clients with kidney disease. Clients should not be using two forms of NSAIDs (Ketorolac and naproxen) as this can be toxic to the stomach and kidneys.
listening techniques
Listening actively ,non verbal process that involves receiving and interpreting examples:Lead forward, nod appropriately,mantain eye contact
Acetylcysteine (Mucomyst)
Mucolyic agent. Breaks disulfide bond in mucos proteins. Topically available for filimentary keratits, dry eye, corneal burns. Inhalation prevents mucos build up so respiratory pts can breathe easier. Mucolytic Antidote for Tylenol poisoning Used in CF, pulmonary diseases w/ lots of secretions Can cause aspiration and bronchospasm (oral) Smells like rotten eggs (mix w/ syrupy drink) Via nebulizer For cystic fibrosis Not for asthma
A client being treated for hypertension returns to the clinic for a follow up visit. The client states to a nurse, "I know these water pills are important, but I just can't take them anymore. I drive a truck for a living and can't stop every 20 minutes to go to the bathroom." During a team meeting, which nursing diagnosis should the nurse suggest? Altered health maintenance related to occupation Knowledge deficit related to misunderstanding of disease state Noncompliance related to medication side effects Defensive coping related to chronic illness
Noncompliance related to medication side effects Correct! The client kept the appointment and stated a knowledge that the pills were important. The client is unable to comply with the regimen due to the side effects of the diuretics being in conflict with the occupation, not a lack of knowledge about the disease process or medication's importance. Correct!
Rosuvastatin (Crestor):
reduce LDL,cholesterol and tryglieride levels
What you should teach to clients taking opioids
to raise slowly
The nurse is assigned to care for a client who has seizures. Which nursing action is a priority for a client during a seizure? Protect the client from injury Suction the oropharynx Loosen restrictive clothing Observe the sequence of movements
Protect the client from injury Correct! The priority during a seizure is to protect the client. Next, it is a priority to observe, and then record what movements are seen during a seizure. The diagnosis and subsequent treatment often rests on the seizure description. Suctioning may be done after seizure activity, as well as loosening clothing. Remember that safety always takes "priority" when it is an option, and the question is about a priority action.
Aspirin is contraindicated in:
Pts under 18 years with chickenpox or flu-like symptoms may cause Reye's Syndrome thyroid storm If evidence of bleeding
The nurse performs an assessment on a client who reports abdominal pain. Based on the assessment findings, what problem does the nurse suspect?(Awake, alert, and oriented reporting diffuse abdominal pain rated 9/10. Skin warm and dry. Cullen's sign noted. Abdomen rigid with guarding. Temperature 101 degrees F (38.3 degrees C), BP 96/64, HR 102, RR 26.) Choose One 1. Cirrhosis 2. Pancreatitis 3. Peptic ulcer 4. Ulcerative colitis
Rationale 2. Correct: These s/s point to pancreatitis. Look at the big clues: Cullen's sign, rigid abdomen with guarding, and fever.
Which action should the nurse perform first when a chest tube is accidentally disconnected from the water-seal system? 1. Auscultate the lung sounds. 2. Re-connect the tubing. 3. Notify the primary healthcare provider. 4. Place the client on oxygen.
Re-connect the tubing. 2. Correct: You do whatever you can to re-establish the water seal. The water seal must be re-established to prevent tension pneumothorax. 1. Incorrect: Auscultating the lungs is important, but is not the first action to be taken. 3. Incorrect: The nurse should notify the primary healthcare provider after fixing the problem and monitoring the client. 4. Incorrect: Placing the client on oxygen does not fix the problem. The problem is that the chest tube became disconnected. Do whatever you can to re-establish the water seal.
Aldosterone memonic
S S P P Saves Sodium and Pushes Potassium out of the body
Benxtropine
treat of extrapyramidal side effects associated with antipsychotic medications and metoclopramide
A client comes to the ER after being bit by a bat. T he nurse observes 2 small non draining puncture wounds, resembling pin pricks on the finger tips. What actions should be implemented first?
Scrubbthe wound with povodine iodine solution or soap and water
A nurse is caring for a 2 year-old child. What should be understood as a major stressor for this child during hospitalization? Loss of control Fear of bodily injury Separation anxiety Fear of pain
Separation anxiety Correct! Note that a toddler will experience all of these listed stresses. However, separation from parents or the caretaker is the major stressor.
A client's wound has tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which transmission-based precautions should the nurse implement for the client?
Standard precaution and contact precautions Correct! Standard precautions are used for all clients, regardless of their diagnosis or presumed infection status. Transmission-based precautions provide additional precautions beyond standard precautions to prevent transmissions of pathogens. Contact precautions are used for infections such as MRSA that spread by skin-to-skin contact or contact with other surfaces.
UAP tasks for Alzheimers
• Assist patient to use the toilet, commode, or bedpan at frequent intervals.• Provide personal hygiene, skin care, oral care.• Help patients with eating.• Assist patients with daily activities.• Use bed alarms and surveillance to decrease risk for falls.
UAP tasks for Post-op PACU
• Assist with positioning of patients in the "recovery" position.• Obtain vital signs and pulse oximetry; report abnormal levels to RN.• Assist patient with elimination needs.• Assist in transfer of patient to clinical unit.
Triage
Triage is a French word that means "to sort." The nurse's role in a disaster is to triage or sort clients according to their injuries and chance for survival. The goal is to ensure that the most critical clients are treated first.By using triage, limited resources are utilized where they do the greatest good for the greatest amount of people. Simple triage and rapid treatment or S.T.A.R.T. is a triage method used during mass casualty events to quickly classify victims based on the severity of their injury. S.T.A.R.T. uses a red, yellow, green and black tag system.
steps in adminster continous enteral feeding
Use 2 identifiers Wash hands Elevate head of the bed > 30 degrees and keep elevayed 30 min after feeding Validate tube placement Check gastric residual volume Flush tube with 30 mL of water after checking residual volume every 4-6 hours duribg feeding, and after medication administration Adminster presribed parenteral feeding solution by connecting the tubing and setting the rate on the infusion pump
The nurse receives a telephone call from a health care provider who wants to give a telephone order. Which of the following actions should the nurse take? (Select all that apply.) Verify understanding by reading the order back to the provider before hanging up Ask a second nurse to listen on another extension while the order is being given Record the order word-for-word and sign the order Request that the order is signed by the provider before implementation Begin the order with the abbreviation "P.O." to indicate that it was a "phone order"
Verify understanding by reading the order back to the provider before hanging up Correct! Record the order word-for-word and sign the order Correct Response Reading the order back allows the provider to correct any misunderstanding and is a Joint Commission read-back requirement. The order should be immediately written and signed by the nurse. The order should clearly state "telephone order" as abbreviations can be misunderstood (P.O. could be interpreted as "by mouth"). Having a second person listen in on the conversation is not required unless the nurse cannot understand the health care provider. The order may be implemented right away, but it must be countersigned within the time limits set by the facility.
UAP for Pt receiving Bladder Irrigation
• Clean around catheter daily.• Record intake and output.• Notify RN if large amount of bright red blood in urine.• Report complaints of pain or bladder spasms to RN.
Cheyene-Stokes breathing
a distinct pattern of breathing characterized by quickening and deepening respirations followed by a period of apneastroke ,increased intracranial pressure and with the end of life
delusion of reference
a false belief that external events, such as other people's actions or natural disasters, relate somehow to oneself Clients experiencing delusion of reference will believe that songs, newspaper articles, and other events are personal and significant to them
Acetylsalicylic acid
a non narcotic analgesic that inhibits the cox-2 protective mechanisms to the gastric mucosa. This could make the ulcer worse. Clients are advised to avoid the use of NSAIDs and acetylsalicylic acid due to increased bleeding potential.
border line personality disorder
a personality disorder characterized by disturbances in identity, in affect, and in impulse control Negativity
balloon angioplasty
a procedure using a slender, hollow tube passed through a coronary artery in order to compress a blockage in the artery
MRI
a technique that uses magnetic fields and radio waves to produce computer-generated images that distinguish among different types of soft tissue; allows us to see structures within the brain
vaginal candidiasis
a vaginal infection caused by the yeast-like fungus Candida albicans; also known as a yeast infection itching and painful urination tick white, like curd and reddened vulva
social anxiety disorder
an anxiety disorder involving the extreme and irrational fear of being embarrassed, judged, or scrutinized by others in social situations,meeting unfamiliear people,eating or drinking in public, and giving a speech.The client might fear critizism,embarrassment,humilliation and rejection from unfamiliar people in unfamiliar situations,will exihibit sweating,palpitations,trembling,diarrhea and blushing
Postoperative hypotesnion can be a manifestation of
bleeding hypovolemia sepsis Changes in vital signs(eg; decrease systolic pressure, tachycardia, tachypnea) and cool pale skin can indicate decreased cardiac output and altered tissue perfussion
In a patient with COPD what is priority to report
breathing shallow(tachypnea)
UAP tasks for Post-op Clinical unit
• Monitor vital signs, pulse oximetry, and intake and output. Report abnormal levels to RN.• Assist patient with deep breathing and coughing exercises.• Report complaints of pain to RN or LPN/LVN.• Reposition and ambulate patients.• Provide hygiene, including oral care.• Assist with nutrition and elimination needs.
Diltiazem
calcium channel blocker decrease HR
Acute illnes may trigger release of stress hormones which lead to higher blood glucose and ketone leveks in
client swith type 1 DM Do not skip dose of insulin even if not eating check glucose q4h increase or decrease dose as needed based on blood glucose levels mantain adequate hydration test for urinary ketones frequently
for severe asthma attack(tachycardia HR 1>20,tachypnea (>30 /min), saturation (<90%) on room air, use of accesory muscles to breath, and peak expiratory flow (PEF) less than 40% of predicted or less (150L/min)
clinical manifestation of
Cytomegalovirus (CMV) precautions
contact precautions
UAP tasks for hypertension
• Obtain accurate BP readings in outpatient and inpatient settings.• Report high or low BP readings immediately to RN.• Check for postural changes in BP as directed.
ACE inhibitors('prils) and angiotensin receptor blockers)(''sartans")
create risk for hyperkalemia ACE inhibitors decrease excretion of aldosterone
Signs of hypovolemic shock include...
decreased BP, increased heart rate, decreased urine output
alprazolam side effects
dizziness, drowsiness; orthostatic hypotension; blurred vision,constipation, diarrhea, depression
Streptococcal Pharyngitis precautions
droplet
The nurse is taking care of a client with pertussis. Which following infection precautions should be implemented?
droplet and contact
therapeutic response of levothyroxine(synthroid)
elevayed mood higher energy blevels normal HR
ACE inhibitors are contarindicated with
end -pril pregnancy ACE inhibitors are teratogenic
aplastic anemia
failure of blood cell production in the bone marrow
Elder Abuse and Neglect
failure to provide for basic needs, food, hygiene, physical abuse, etc.
The licensed practical nurse (LPN) is caring for a client with an order that reads, "morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain." There are no other licensed persons working that shift. Which action should the nurse take?
holdmedication and call doctor
ACE inhibitors are contraindicted in patients with
hyperkalemia Clients receiving ACE inhibitors should be monitor for hyoerkalemia ,specially in the presence of renal insuffencvy.
clients with kidney disease are at risk for
hyperkalemia hyperphosphatemia
After thyroidectomy patients are at risk for
hypocalcemia, remember hypocalcemia is opposite of the prefix and anything to BP so tetany, parasthesia
Role of Unlicensed Assistive Personnel (UAP) in blood transfusion
• Obtain blood products from the blood bank as directed by the RN.• Take vital signs before the transfusion and after the first 15 min.
UAP taks for Neutropenia
• Obtain vital signs and report changes to the RN.• Assist the patient with oral care and personal hygiene.
A client with head trauma
is at risk for increased intracranial pressure due to inflammation and cerebral edema. IV nannitol is an osmotic should reduce cerebral edema by pulling water from the cerebral cells into the vasculature.
Urine Specimen Collection
is collected aseptiaclly,from the specimen port of an indewlling urinary catheter .Urine that has been collected fro a bag does not yield accurate urinalysis and culture results
Hepatitis B(HBV)
is highly contagious. it is spread through infected blood and body fluids. the virus is hardy and can live for 7 days or more on surfaces. The Infection Control precautions for hepatitis B are those of "Blood and Body Fluid Precautions" and those of "Universal Precautions". Gloves, preferably latex, are worn when there is to be contact with blood and body fluid.
ethical principle of veracity
is the concept of telling the truth without distressing , and overwhelm them
post op bowel resection client with absent bowel sounds
it can take 24-48 for perilstasis to return after surgery
LDL levels should be
less than 100
intial therapy for PE/pulmonary embolism
low molecular weight heparin eg; enoxeparin,dalteparin
short acting beta-agonist meterd-dose inhaler/with no spacer
may be used for some nonrespiratory conditions(eg;diabetes,analgesia) 1. Shake canister well for about 3-5 seconds. 2. Tilt head back slightly and exhale slowly for 3-5 seconds. 3. Hold canister mouthpiece aboit 1 1/2 inches infromt of open mouth;as an alternative,place the mouth piece in the mouth sealed around it. Holding it in front of an open mouth orevents impaction of the particles into the tonguw and sides of the mouth. 4. Compress canister while inhaling slowly through the mouth for about 3-5 seconds. 5. Hold breath for 10 seconds, if possible,before exhaling. 6. Wait at least 1-2 minutes before taking a second puff of a bronchodilator, if prescribed. The first puff of medication dilates the bronchiles and allows easy passage of the second puff.
What labs will be checked when taking Warfarin
prothrobin time INR
sicidal ideation interview what to assess:
psyc meds support form family , councelors, etc future goals and plans home and worj=k environmet risks overall affect , and level of energy possible access to weapons
in an event of air embolus position the client
should be lowered (Trendelenburg),and the client should be position on the left side
Ascending Stairs with Crutches
the patient usually uses a modified three-point gait. He or she stands at the bottom of the stairs and transfers body weight to the crutches. The unaffected leg is advanced between the crutches to the stairs. The patient then shifts weight from the crutches to the unaffected leg. Finally, he or she aligns both crutches on the stairs. The patient repeats this sequence until he or she reaches the top of the stairs. 1. Assume the tripod position and place bodyweight on the crutches while preparing to move the unaffected leg. 2. Place the unaffected leg onto the step 3. Transfer body weight from the crutches to the unaffected leg and then use the unaffected leg to rais the body up to the step. 4. Advance the affected leg and the crutches together up the step. 5. Realign the crutches with the unaffected leg on th step before repeating the process.
PT ,INR and enoxaparin are not affected
vit K rich food
The nurse is reinforcing discharge education to a client after a concussion. What should the nurse emphasize to report to the primary healthcare provider? Select all that apply 1. Difficulty waking up 2. Headache (3/10 on the pain scale) 3. Blurry vision 4. Achy feeling all over 5. Vomiting
1,2,3,5
An elderly client tells the nurse, "I noticed that my skin is drier". What should the nurse tell the client about skin changes associated with aging? Select all that apply 1. The oil glands don't work as effectively as one ages. 2. There is increased vascularity of the skin in the elderly making it appear red. 3. There is a loss of elasticity in the skin with advancing age. 4. One loses the fat under the skin as one ages. 5. Skin tears more easily as one gets older.
1the oil glands don't work as effectively as one ages. 3. There is a loss of elasticity in the skin with advancing age. 4. One loses the fat under the skin as one ages. 5. Skin tears more easily as one get 1., 3., 4. & 5. Correct. There is a decrease in sebaceous gland activity in the elderly. Elasticity of the skin decreases with aging. Subcutaneous fat diminishes as one ages resulting in sagging and wrinkling of the skin. The skin becomes fragile and tears easily in the elderly.2. Incorrect. There is a decreased vascularity in the aging individual leading to the appearance of pallor. The skin in the elderly does not have increased vascularity and does not appear red.
The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). Which of the following statements by the nurse would provide a UAP with the best directions about the assignment? 1."The client is at risk for infection. Take the vital signs and report back to me if the temperature is above 100.5° F (38.1° C)." 2."The client has hemiplegia. Assist the client to eat breakfast." 3."All the clients who have been assigned to you will need to have vital signs obtained and intake and output recorded." 4."The clients who had total knee replacements need to begin physical therapy. Plan the clients' care around the therapy."
2
what patient should be seen first? 1.has gastroenteritis is reporting nausea and vomited 100 mL of green liquid 2.has a long leg cast and is sitting in a chair with the casted leg elevated in a stool 3.had appendectomy 1 day ago and has a 0.8 (2cm) area of serosanguineous drainage on the incision dressing 5.had a thyroidectomy 2 days ago has muscle spasms in the wrist when the blood pressure is taken
5
Beers Criteria
A list of medications that are generally considered inappropriate when given to elderly people antipsychotics antihypertensives benzodiazepines diuretics opioids sliding insulin scales
A client admitted to a psychiatric facility is refusing all medications. The nurse notes the client appears to be responding to auditory hallucinations. What actions by the nurse would be appropriate?
Assign staff to stay with client. Frequently reorient client to reality. Auditory hallucinations, also called "paracusia", are extremely frightening. The client's intense fear may result in striking out at staff, visitor or other clients, and can even cause the client to do self-harm. Nurses must focus on safety by remaining with the client at all times in a quiet room. Reinforcing that feeling of being safe while frequently reorienting the client to reality are priority actions that may continue for hours until the client becomes calmer.
Assigments for UAP, for care of the clients with Alzeihmer's disease:
Assist with ADLs(toiletting,skin care,bathing, Assist with feedings,oral care,personal hygene) Report changes in the ability to eat or difficulty swallowing. Report changes in behavior. Place bed alarms to reduce risk for falls. UAP may report changes in behavior, remove or alter safety hazards
The nurse makes home visits for a client who has completed an inpatient substance abuse disorder program. Which behavior is most revealing about the client's commitment to continued sobriety?
Evidence of drug and/or alcohol use Correct Response Feeling full of self pity or crises may trigger a relapse. Missed appointments are a form of dishonesty, which is also a red flag for a relapse. But continued drug or alcohol use is the most revealing because it demonstrates a lack of commitment to the treatment program. However, since substance use disorder is a chronic disease, the nurse will understand that relapse can occur. Lapsing back to drug or alcohol use indicates that treatment needs to be reinstated or adjusted, or another treatment should be tried.
A client arrives at the clinic reporting a sharp pain, rated 10/10, radiating from the right flank around to the lower right abdomen. The client also reports nausea and vomiting. Based on this data, what problem does the nurse suspect?
Renal lithiasis
A nurse is reinforcing information to a child and parents about the medication phenytoin prescribed for seizure control. Which more common side effect should the nurse include in the discussion? Drowsiness Butterfly-shaped rash on the face Dizziness Gingival hyperplasia
Gingival hyperplasia Correct! Submit You will note that this question is asking for a specific side effect of phenytoin (Dilantin). Dizziness and drowsiness are common side effects of many different drugs, so these options can be eliminated right away. A butterfly-shaped rash on the face (lupus erythematosus) is a severe adverse effect associated with phenytoin and should be immediately reported to the health care provider. Swollen or any overgrowth of tender gums often occurs with the use of phenytoin. The effects can be minimized with good oral hygiene, such as brushing after each meal and flossing once a day, as well as regular visits to the dentist.
The nurse is reviewing the plan of care for a client admitted for the treatment of mania. Which interventions should the nurse implement?
Give one cigarette to client at a time. Have finger foods available at mealtime. Give high calorie fluids between meals. We need to protect this client from hazards in their environment. They have no control or awareness of these hazards. If they smoke, only give the client one or two cigarettes at a time, or the client will light a whole pack at once. Finger foods should be provided because the cleint is too busy to stop and eat. They are also too busy to drink, so they can become dehydrated. This is why we provide high calorie fluids for them throughout the day.
When a patient comes complaining of a headache and has sympomts like flat effect,drowsiness, confusion
It could be a sign of intracranial pressure, early sign late sign:Cushing triad(bradycardia,widening pulse,altered respiratory pattern)fixed dilated pupils and decrease motor function
The hospice nurse is caring for a terminally ill client at home. During one care encounter, the client and spouse voice concerns about "never doing everything we wanted to do." Which philosophy should the nurse use to help them best cope? Anticipate the worst and plan for it Plan for good times ahead Relive past pleasant memories Live each day to the fullest
Live each day to the fullest Correct! At the end of life, assisting patients and loved ones to focus on the present by living each day to the fullest is the most appropriate philosophy. Focusing on the past can interfere with living in the present. Expecting the worst makes focusing on the present difficult. With the uncertainty of the length of life with terminal illness, planning for the future is inappropriate.
After a heart catheterization, a client reports severe foot pain on the side of the femoral insertion site. The nurse notes pulselessness, pallor, and a cold extremity. What should be the nurse's first action? 1. Administer an anticoagulant. 2. Warm the room. 3. Increase intravenous fluids. 4. Notify the primary healthcare provider.
Notify the primary healthcare provider. 4. Correct: This is an emergency, and the primary healthcare provider (PHP) is the only one that can save this foot from ischemia. Don't delay. 1. Incorrect: The primary healthcare provider may treat with an embolectomy, bypass surgery, or a thrombolytic. Giving an anticoagulant could alter treatment options. 2. Incorrect: The cold extremity is caused by decreased arterial perfusion, not room temperature. 3. Incorrect: In theory, increasing blood volume increases blood flow, but this client has an arterial obstruction. Blood cannot get passed the occlusion.
risk for postpartum hemorrhage
PPH is usually defined as a maternal blood loss of >500mL after an SVD or 1000 mL after CS Uterine atony or soft boggy and poorly is the most common cause of PPH, (occurring 24 hours after birth). Delayed PPH (> 24 hours after birth) usually results from retained placental fragments associated with a long third stage of labor (ie; time form birth of baby to expulsion of placental, lasting >30 minutes) Risk factors for PPH include: Hx of PPH in a prior pregnancy Uterine distention due to: Multiple gestations Polyhydramnios (excessive amniotic fluid) Macrosomic infant( >8 lb 13 oz[4000 g Uterine fatigue (labor lasting 24 hrs High parity Use of certain medication Magnesium sulfate Prolonged use of Oxytocin during labor Inhaled anesthesia(ie; general anesthesia)
A nurse is caring for a client diagnosed with a subarachnoid hemorrhage after the client fell in the home. The computerized tomogram (CT) shows that the bleeding has stopped. Which aspect of the client's plan of care is most important for the nurse to implement? Arouse the client every one to two hours to collect data about the neurological status Restrain the client to avoid spontaneous movement Keep the door to the room closed Restrict visitors to the immediate family
Restrict visitors to the immediate family Correct Response Maintaining a quiet environment will assist in reduction of the risk for a reoccurrence of bleeding. All of the options are part of the plan of care, although arousing the client should only be as needed. The correct response most directly maintains a quiet in-room environment. With fewer visitors, the room will be quieter. You will notice that two options focus on reducing stimuli. The correct response of restricting visitors would be better than simply closing a door.
advantages of medical records
The benefits of electronic health records include: Better health care by improving all aspects of patient care, including safety, effectiveness, patient-centeredness, communication, education, timeliness, efficiency, and equity.
calcium channel blocker taken with grapefruit juice
can cause hypotension,
An 8 year old smiles when mom places the "B" paper on the refrigerator. Which Erikson developmental stage is this child displaying? 1. Autonomy vs. Shame and Doubt 2. Initiative vs. Guilt 3. Industry vs. Inferiority 4. Identity vs. Role Confusion
industry vs. Inferiority 3. Correct: Children need to cope with new social and academic demands. Success leads to sense of competence, while failure results in feelings of inferiority.1. Incorrect: This should be accomplished in early childhood, ages 2-3 years. Children need to develop a sense of personal control over physical skills and a sense of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt.2. Incorrect: This is preschool, ages 3-5 years. Children need to begin asserting control and power over the environment. Success in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt.4. Incorrect: This stage is for the adolescent, age 12-18 years. Teens need to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of self.
Naloxone (Narcan) is antidote for
reverse effects of opioids
UAP Chronic venous insufficiency
• Assist patients in elevating extremities to reduce edema and pain.• Apply elastic wraps or compression stockings, as directed by the RN.• Provide wound care for chronic venous ulcers (consider state nurse practice act and agency policy).
"(SELECT ALL THAT APPLY) A physician starts a client on the antipsychotic medication haloperidol (Haldol). The nurse is aware that this medication has extrapyramidal adverse effects. Which nursing measures should the nurse take during haloperidol administration?
"(2) Closely monitor vital signs, especially temperature. (3) Provide the client with the opportunity to pace. (5) Provide the client with hard candy.
"(SELECT ALL THAT APPLY) A physician prescribes lithium (Eskalith) for a client diagnosed with bipolar disorder. Which topics should the nurse cover in the client education for this drug?
"(2) Signs and symptoms of drug toxicity (5) The need to consistently monitor blood levels (6) Changes in his mood may take 7 to 21 days
"A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom?
"Tardive dyskinesia''
The nurse is using the SBAR technique to communicate with the health care provider. Which of the following phrases would be associated with "B-Background"? "Vital signs are..." "I would like you to..." "The client's treatments are..." "I'm not sure what the problem is, but the client's condition is deteriorating."
"The client's treatments are..." Correct Response The correct option gives the health care provider background information about the client, including age, primary diagnosis, treatments, etc. Stating that the client's condition is deteriorating is the situation (S). Stating, "I would like you to..." is the request or recommendation (R). Vital signs are part of the assessment (A). Using SBAR is an effective technique used to improve communication with other members of the health care team. This, in turn, helps to foster a culture of safety.
if a patient has allergis reactions to shellfish do you still insert a urinary catheter
-If pt is allergic to latex: "I will use a non-latex kit."-If pt is allergic to iodine/shellfish: "I cannot use the iodine to clean before catheter insertion, so I will have to use an alternative- swabs provided in plastic bag." Drop alternative swabs on sterile field after laying the drape & before putting on sterile gloves.
elbow restraint
-Rigid, padded, fabric splint -Minimizes movement of elbow joint -Helps with patients who pick on IV lines Prevents a patient from reaching head and face to dislodge tubes or dressings. A type of restraint that is used in the care of infants or small children to prevent flexing an arm to scratch or touch skin on the face or head, primarily during surgery <30 min
A 6 year-old child is admitted to the emergency department. The x-rays show a femur fracture near the epiphysis. What information does the nurse understand about long bone fractures in children?
Epiphyseal fractures often interrupt a child's normal growth pattern Correct Response The epiphyseal plate in children is where active bone growth occurs. Damage to this area may cause growth arrest in either longitudinal growth of the limb or in progressive deformity if the plate is involved. An epiphyseal fracture is serious because it has potential to interrupt and alter growth of the bone.
The nurse prepares to perform tracheal suctioning on a client who is a paraplegic. What is the reason for placing the client in a high-Fowler's position prior to suctioning? Maximize expansion of the client's lungs Suppress the client's cough reflex Prevent the client from aspirating gastric secretions Provide for better visualization of site
Maximize expansion of the client's lungs High or semi-Fowler's positions maximize lung expansion and allows for effective coughing to help facilitate the removal of lung secretions during the suctioning process.
A client is scheduled for a transesophageal echocardiogram (TEE). Prior to the procedure, which activity could be delegated to the unlicensed assistive person (UAP)? Assess the client's psychological state Provide basic instructions about the procedure Obtain a signed consent Remove the pitcher of water from the bedside table
Remove the pitcher of water from the bedside table Correct! Removing the water pitcher would be an appropriate task because the client would be NPO. The health care provider is responsible for instructions about the procedure and needs to address client questions or concerns. The nurse is typically responsible to obtain a signed consent form and to assess the client both physically and psychologically before the procedure.
when taking potassium-sparing(spironolactone, triamterene, eplerenone)diuretics avoid what foods
bananas oranges
ACE inhibitors during pregnancy are avoided why
because they can cause renal function, lung development problems and cause death
somatic delusions
believes that his body is changing in an unusual way, such as growing a third arm The doctor thinks I'm fine but I really have Cancer
grandeur delusion
believing that one is a very powerful or important person
atenolol
beta blocker
INR is
blood test used to check effectiveness of warfarin
horizontal violence
bullying, harrasment, desparing behaviors between coworkers belittle, gossip, using a hostile tone ignoring, eye rolling
itch is a common sign of what medication
common post surgery side effect of narcotics(generalized) and healing process(localized ) Generalized can indicate an allergic drug reaction and should be assessed. Localized itch may need ice packs and diphenhydramine
ECT
induces generalized seizure 15-20 seconds seizures have prove effiecient in treating mood disorders, and schizophrenia
A belt restraint is applied to a person in bed. Where should you secure the straps?
is applied to the waist and tied to the bed frame under the matress with straps using a quick-release knot.
orthopedic leg immobilizer
is used to restrict movement and mantain a client's extremity in proper aligment not a restrain
Advance directives include a...
medical power of attorney An advance directive encompasses all legal orders which concern your wishes surrounding future medical care. The document will come into play in the case of severe medical situations in which you're not able to communicate your wishes or make decisions. These may include such conditions as a coma, stroke or dementia The most common types of advance directives are the living will and the durable power of attorney for health care (sometimes known as the medical power of attorney). POLST DNR
codeine/acetaminophen
narcotic analgesic for cough supression depress cough reflexcan cause accumulation of secretion contrainicated in those with COPD
Vancomycin adverse effects
nephrotoxicity, ototoxicity, red man syndrome
Can an UAP evaluate pain level?
no
When respiratory rate is decreased
pC02 will increase creating respiratory acidosis, this will occur in response of primary metabolic acidosis
hemiplegia.
paralysis of one side of the body
After anesthesia a cleint has a oxygen saturation of 88% , what is the most appropriate initial intervention
perform head tilt and chin lift
discharge instruction on enoxaparin:
pinch skin 1 inch upward and insert the needle 90 degree angle. Continue to hold the skin this way through the injection process and then remove the needle at 90 degree angle. Mild bruising,pain, irritation, or redness is common Do not rub site Can use ice for comfort Avoid NSAIDs,aspirin,ginkgo biloba, vitamin K Monitor CBC for thrombocytipenia
Cupping
placing a heated cup on the skin to create a slight suction Used to remove ilness from the body
Statins are contraindicated in:
pregnancy,severe liver and muscle injury
Calcium Channel Blockers are for
prevention of angina
escharotomy
removal of burn scar tissue
priority for clients victms of domestic abuse is
remove the them from any sources of immediate danger, including suspected abusers Such clients should be questioned and assessed alone so that the suspected abusers do not guide their answers or intimidate themfrom provising truthful answers. Notify the social services of suspected abuse should occur with the client's permission after the immediate threats are removed and after any immediate threats are removed and after psychological needs are met.This could not be done in presence of any potential abuser.
Priority care in patients with anorexia nervosa:
restore caloric intake slow weight gain treating medical conditions caused by stravation
skin care in sedated infants
the icciput is the highest pressure point in infants due to increase weight of the head in proportion to the body sgearing may occur as the infant slides down the bed head of the elevated <30 degrees to reduce pressure on the head and prevent sliding Do not use donut pillows yse skin barriers do not use baby powder reposition pulse ox q4h
The nurse admnisters methylprenisone(Solu-Medrol) as a continous IV fusion to a male patient who has fractures of the cervical vertebrae. Which intervention would prevent or detect adverse effects of the medication?
the nurse should adminster PPI because they are at high risk for Gi erosion and bleeding. from the steroid.
when a patient refuse to give consent for a procedure
the patient has the right to refuse care, and this must be documented
carotid endarterectomy
the surgical removal of the lining of a portion of a clogged carotid artery leading to the brain
A client with carotid endarterectomy with a blood pressure of 160/88
this might triger hematoma formation,which can cause hemorrhaeg and airway obstruction Systolic pressure should be 100-150 These patients are at risk for ischemia and hemorrhage
Physical restraints are used MOST often....
to prevent client injury
prescription for physical restraints
to prvent falls , injury to self or others, or removal of medical devices. Eg; Belt restrain used for confused clients Soft ankle restraint to prevent bleeding
for inattentive ADHD
trouble trying holding attention on task or play activities have trouble getting organized task and activities get sidetracked or distracted can not give close attention to detail dislike tasks or assignments that require mental effort for a long period
tolterodine
used for overactive bladder, and urge urinary incotinence
The nurse and the UAP are caring for assigned clients. Which of the following activities should be assigned to the UAP? 1.vital signs with a patient with major depression 2.provide medication teaching to the client with schizophrenia 3.monitoring medications side effects of the patient with bipolar disorder 4.call the PHCP to report I/O of the patient with anorexia nervosa (AN)
vital signs with a patient with major depression
Objective information includes:
vital signs, physical exam, orders/results
For C.difficile
wash hands with soap and water before and after care
Hydrochlorothiazide
weak diuretic use in hypertension
Increased bicarbonate resorption
would produce metabolic alkalosis this will occur in compensation for primary respiratory acidosis (increased pC02 and low pH )
UAP tasks for Skin Care
• Assist patient with bathing.• Apply wet dressings to skin or add medications (such as oilated oatmeal) to patient baths (consider state nurse practice act and agency policy).• Report changes in skin appearance or patient complaints of discomfort to the RN.
UAP tasks for Diabetes Mellitus
• Check capillary blood glucose (CBG) levels (after being trained and evaluated in this procedure) and report values to the RN.• Report changes in patient vital signs, urine output, behavior, or level of consciousness to the RN.• In a community or home care setting, administer OAs and insulin to the stable diabetic patient (consider state nurse practice act and agency policy).
UAP tasks for Ostomy care
• Empty ostomy bag and measure liquid contents.• Place the ostomy pouching system for an established ostomy.• Assist stable patient with colostomy irrigation.
Preventing a DVT While Traveling
• Exercise the legs at least every 2-3 hours • Walk up and down the aisle of a coach, train, or plane • Wear loose fitting clothing • Keep hydrated • Wear compression stockings
UAP tasks for Acute Stroke
• Obtain vital signs frequently and report these to RN.• Measure and record urine output.• Assist with positioning patient and turning patient at least every 2 hr (as directed by RN).• Perform passive and active range-of-motion exercises (after being trained and evaluated in these procedures).• Place equipment needed for seizure precautions in patient room.
UAP tasks for Seizure Disorder
• Place suction equipment, Ambu bag, and O2 at the patient bedside.• Remove potentially harmful objects from the bedside and pad side rails.• Immediately report any seizure activity to the RN.• Observe and report events of the seizure to the RN.• Obtain vital signs during the postictal period.• Provide oropharyngeal suctioning after a seizure (after being trained and evaluated in this procedure).
UAP tasks for suctioning & trache care
• Provide oral care to patient with a tracheostomy.• Suction patient's oropharynx (after being trained and evaluated in this procedure).• Report increased need for oropharyngeal suctioning to the RN.
UAP tasks for Urinary catheters
•Provide perineal care around the catheter with soap and water.•Anchor the catheter in place (upper thigh in women and lower abdomen in men).•Notify RN about changes in skin condition, especially around meatus.
Clopidogrel (Plavix) adverse effects
◦ Bleeding ◦ GI bleeding and hemorrhagic stroke ◦ Enteric-coated tablets may not reduce the risk for GI bleeding Use with caution in combination with other drugs that promote bleeding New black box warning for CYP2C19 poor metabolizer- medication less active
Hypotonic IV solutions
0.45% NS Creates concentration gradients and shifts out of the intravascular compartment into the intertitial fluid and cells
lithium narrow therapeutic index
0.6 - 1.2 mEq/L
normal INR
0.8-1.2
The nurse is collecting data from a client who had percutaneous transluminal coronary angioplasty (PTCA) via the right femoral artery 2 hours ago. Which of the following findings would require immediate intervention? 1.diminished right dorsalis pedis pulse 2.nausea after drinking a cup of water 3.0.8 in (2 cm) area of serosanguineous drainage on the right groin dressing 4.right groin pain rated 3 on a scale of 0 (no pain) to 10 (severe pain)
1 PTCA is widely practiced and has risks, but major procedural complications are rare. The mortality rate during angioplasty is 1.2%.[4] People older than the age of 65, with kidney disease or diabetes, women and those with massive heart disease are at a higher risk for complications. Possible complications include hematoma at the femoral artery insertion site, pseudoaneurysm of the femoral artery, infection of skin over femoral artery, embolism, stroke, kidney injury from contrast dye, hypersensitivity to dye, vessel rupture, coronary artery dissection, bleeding, vasospasm, thrombus formation, and acute MI. There is a long-term risk of re-stenosis of the stented vessel.
Billroth II,
Billroth II, more formally Billroth's operation II, is an operation in which the greater curvature of the stomach is connected to the first part of the jejunum in end-to-side anastomosis. This often follows resection of the lower part of the stomach (antrum).
Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection? Select all that apply 1. Cleans perineum from front to back after newborn soils diaper. 2. Makes certain the umbilical cord remains dry with each diaper change. 3. Places the top of the diaper just above the umbilicus. 4. Wraps sterile petroleum gauze around umbilical cord. 5. Submerges newborn in warm water up to the chest for first bath.
1,2
Cyclosporine side effects
1-Nephrotoxicity:the mc and serious side effect. It manifest as acute azothemia or irreversible progressive renal disease 2. Gingival hypertrophy 3. HyperKalemia 4. Tremor
A client experiencing a manic episode tells the night nurse, "If you do not go to bed with me, I am going to have you fired." What is the nurse's best response? 1. "That is inappropriate behavior. You will have to go to your room if you say that again." 2. "You've got to be kidding! You can't get me fired for not sleeping with you." 3. "I don't want to hear that again! Don't ever say that again." 4. "I can see that you need attention, but this is not the way to get it."
1. "That is inappropriate behavior. You will have to go to your room if you say that again." 1. Correct: Set limits on manipulative behaviors. Explain what is expected and what the consequences are if limits are violated. The nurse needs to set limits on and control dangerous behavior. 2. Incorrect: Do not argue with the client. The behavior of a manic client is often aimed at decreasing the effectiveness of staff control. 3. Incorrect: This is confrontational and does not set appropriate boundaries or consequences. The manic client can elicit numerous intense emotions, even in the nurse caring for them. 4. Incorrect: Remember to set limits without demeaning the client, and do not encourage this behavior. Don't acknowledge that the client is seeking attention.
Which is a therapeutic technique that can be utilized by the nurse for clients with anxiety disorders? 1. Activity assignments 2. Careful monitoring 3. Goal setting 4. Relaxation techniques 5. Group activities
1. Activity assignments 2. Careful monitoring 3. Goal setting 4. Relaxation techniques 1., 2., 3. & 4. Correct: Therapeutic techniques that can be utilized by the nurse for clients with anxiety disorders include activity assignments, careful monitoring, goal setting, and relaxation techniques. Other therapeutic techniques include assisting clients to use "self-talk" to help deal with anxiety-provoking stressors.5. Incorrect: Group activities may increase anxiety.
Which data will provide the nurse with the most information regarding a client's neurologic function? 1. Level of consciousness 2. Doll's eyes reflex 3. Babinski reflex 4. Reaction to painful stimuli 5. Verbal ability
1. & 5. Correct: Yes, the most important and subtle changes are related to the client's level of consciousness, verbal ability, orientation, and ability to move to command. 2. Incorrect: No, only helps with the determination of brain death. 3. Incorrect: Identifies diseases of the brain and spinal cord. 4. Incorrect: This should be last resort. So we are looking for the assessments that will provide the MOST information about a client's neuro function. Notice the word most. Identify key words in the stem that set a priority, such as first, initially, best, priority, safest, most. These words modify what is being asked. This question requires you to put a value on each option and then place them in rank order. If you are having difficulty ranking the options, eliminate the option that you believe is most wrong among the options. Let's look at the options. Option 1, level of consciousness. If the client is alert and oriented, that indicates high brain functioning does it? Yes. As level of consciousness decreases, so is brain function. So do you agree that this is true? Yes, it is. Option 2. When do we check a person's eyes for the Doll's eyes reflex? When they are in a coma, right? It is a clinical sign for evaluating brainstem function in a comatose client. So it is reserved for client's who already have decreased brain function. Option 3, the Babinski reflex. Well first of all, what is the Babinski reflex? It is a reflex action in which the big toe remains extended or extends itself when the sole of the foot is stimulated. It is abnormal, except in young infants. When the Babinski reflex is present in a child older than 2 years or in an adult, it is often a sign of a brain or nervous system disorder. Option 4, reaction to painful stimuli? Well, clients who are awake and alert will withdraw from a painful stimuli. This is done as a last resort and only if the client does not respond to other stimuli. So the client is already in a decreased state of consciousness, right? Right. So this is false. Option 5, verbal ability? This is true. If the client can speak and answer questions appropriately, this indicates neuro function level versus incoherent speech or no speech at all.
Which signs/symptoms does the nurse expect to see in a client diagnosed with schizophrenia?
1. Auditory hallucinations 2. Grandiose delusions 3. Religious preaching all the time. 4. Flat affect Auditory hallucinations are commonly experienced by the client diagnosed with schizophrenia. Delusions of grandiosity like believing they are a famous person or religious figure is a false fixed belief experienced by the client. If the client is in the acute phase of schizophrenia, the person may be overwhelmed by anxiety and is not able to distinguish thoughts from reality. It is thought that delusions may develop to cope with the anxiety. Religiosity is common. The client may carry a bible all of the time and preach to everyone all of the time. The client may have an inappropriate affect, a flat affect, or a blunted affect.
A client who was hospitalized with a diagnosis of schizophrenia tells the nurse, "My veins have turned to stone and my heart is solid!" How would the nurse identify this statement? 1. Depersonalization 2. Echopraxia 3. Neologism 4. Concrete thinking
1. Depersonalization 1. Correct: Depersonalization, which is the unstable self-identity of an individual with schizophrenia may lead to feelings of unreality (the feeling that one's parts have changed or a sense of seeing oneself from a distance). 2. Incorrect: The client who exhibits echopraxia may purposelessly imitate movements made by others. 3. Incorrect: Neologism is the invention of new words by a psychotic client. 4. Incorrect: Concrete thinking, or literal interpretations of the environment, represents a regression to an earlier level of cognitive development.
What actions would be appropriate for the nurse to take when performing peritoneal dialysis on a client diagnosed with renal injury?
1. Dialysate is warmed to body temperature by allowing it to sit out for a short period of time. 3. Once infused, dialysate remains for prescribed dwell tiime. The dialysate should be warmed to body temperature by allowing it to sit out for a short period of time. The dwell time is the length of time that the dialysate stays in the peritoneal cavity. This allows for toxins to be drawn out of the blood and into the peritoneal cavity for removal. The dialysate is infused through the peritoneal catheter into the peritoneal cavity. Allow the dialysate to drain by gravity for 20-30 minutes. The nurse should turn the client from side to side if all the drainage does not come out of the peritoneum.
The nurse is reviewing the plan of care for a client admitted with a diagnosis of Alzheimer's Disease. What interventions should the nurse implement?
1. Encourage participation in light exercise. 2. Identify doors with pictures. 3. Monitor food intake. 4. Weigh weekly. t is important to keep the client as active as possible by participating in enjoyable things like light exercise, dancing, singing, simple games, and painting. Identify all doors with pictures or easily identifiable labels. Doors to rooms, closets, and bathrooms are especially important for the client to be able to recognize. Monitor food and liquid intake daily. The client can easily forget to eat and drink. This is one reason the client should be weighed weekly as well.
A client in the manic phase of bipolar disorder is constantly interrupting a group session. What should the nurse do? 1. Engage the client to walk with the nurse to make another pot of coffee 2. Ask the client to reflect on behavior to determine if it is appropriate 3. Ask the group to tell the client how they feel when interrupted 4. Instruct the client to perform jumping jacks and count aloud to get rid of some energy.
1. Engage the client to walk with the nurse to make another pot of coffee 1. Correct: Yes! Get them away and doing something purposeful. 2. Incorrect: The client is in the manic phase and feels invincible. This is not the time for the client to reflect on the disruptive behavior. 3. Incorrect: Sometimes this will be helpful during times of therapy, but the client is manic at this time, and probably will not believe them. 4. Incorrect: No. This, is getting the client active, but can the group continue with this attention seeking jumping, counting person? No. Get the client away from the activity.
The primary healthcare provider is preparing to drain a large abdominal abscess. The client has dementia and moves about on the bed frequently. Which personal protective equipment (PPE) should the nurse wear while holding the client for the procedure? Select all that apply 1. Face shield 2. Sterile Gloves 3. Gown 4. Mask 5. Regular exam gloves
1. Face shield 3. Gown 4. Mask 5. Regular exam gloves 1., 3., 4. & 5. Correct: The nurse should implement transmission-based contact precautions. During drainage of an abscess, the nurse may come into direct and indirect contact of the contaminated body fluids. The nurse needs the protection of a gown, mask, face shield, and regular exam gloves. Since the nurse is not directly assisting with the wound care, regular exam gloves are appropriate.2. Incorrect: Sterile gloves are not necessary since the nurse is holding the client and not directly assisting with the wound care procedure.
A client suffering from major depression spends all day in bed. Which nursing action should the nurse take? 1. Frequently initiate contact with client. 2. Frequently round at regular intervals. 3. Patiently wait for the client to come out of the room. 4. Ask client, "Why are you still in bed"?
1. Frequently initiate contact with client. 1. Correct: Be accepting and spend time with the client even though pessimism and negativism may seem objectionable. Focus on strengths and accomplishments and minimize failures. 2. Incorrect: The nurse should round at frequent irregular intervals so that the client does not know when to expect the nurse and can plan suicide attempt. 3. Incorrect: The nurse should seek out the client. The depressed client is not likely to come looking for someone. 4. Incorrect: Do not confront the client about why the client is not doing something. This will not promote trust and client may not know why.
What is normal for the nurse to see in a one year old child? 1. Gets to a standing position without help. 2. Able to say several single words. 3. Pulls toys while walking. 4. Builds a tower of 4 blocks.
1. Gets to a standing position without help. 1. Correct: A 1 year old should be able to get to a standing position without help. May stand alone. 2. Incorrect: Children at 18 months are able to say several single words. 3. Incorrect: Children at 18 months are able to pull toys while walking. 4. Incorrect: Children at 2 years of age can build a tower of 4 or more blocks.
In what position should the nurse place a client post intracranial surgery? 1. Head of bed elevated 30 degrees 2. Supine 3. Dorsal recumbent 4. Recovery position
1. Head of bed elevated 30 degrees 1. Correct: The goal after intracranial surgery is to keep the intracranial pressure (ICP) from rising while optimizing the cerebral perfusion pressure (CPP). The ideal position for this client is HOB elevated and the head in neutral position. 2. Incorrect: Placing the client in supine position may increase ICP. Supine position is achieved when the client is lying flat. 3. Incorrect: Dorsal recumbent position will increase ICP as this position will increase peripheral return. The client in dorsal recumbent position is lying flat with the knees flexed and separated. 4. Incorrect: The recovery position is side lying position with one knee flexed. This position can also increase ICP.
How should the nurse prepare a client for a paracentesis? 1. Place client in the Fowler's position. 2. Position client flat with right arm behind the head. 3. Ask the client to empty bladder. 4. Obtain client's vital signs every 4 hours. 5. Maintain NPO status for 4 hours pre-procedure.
1., & 3. Correct: The correct position is HOB elevated to allow fluid to pool in one spot for the paracentesis. The nurse knows this is a lower abdominal puncture and the bladder should be empty to avoid puncturing the bladder. 2. Incorrect: The optimal position is HOB elevated to allow the fluid to pool in one spot. If the nurse were to lie the client flat, the fluid would go everywhere. 4. Incorrect: Obtain a set of vital signs immediately prior to the procedure and immediately after the procedure. Vital signs every 4 hours will not give you needed data on the client's status. 5. Incorrect: This procedure does not require NPO status. NPO status is initiated when there is a risk of aspiration during or following the procedure.
The client is worried and distracted, and explains to the nurse that because of the direct admission from the primary healthcare provider's office, there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client? 1. I will speak to the charge nurse about your needs so a case manager can be notified to help you with your concerns. 2. I know how you feel. I will be sure to tell your night nurse in shift report that you will probably need something to help you sleep tonight. 3. An unexpected hospital admission can be very stressful. Is there anyone who I can call for you? 4. I can call your primary healthcare provider for you and ask if you could go home today, then schedule another date for your hospital admission.
1. I will speak to the charge nurse about your needs so a case manager can be notified to help you with your concerns. 1. Correct: The charge nurse will notify the case manager. The case manager should be involved in coordinating the client's care from the date of admission in order to help the client navigate unexpected situations like a last-minute hospital admission. The ability to make telephone calls to notify family and friends will help to decrease the client's sudden sense of isolation from normal daily life, loss of control, and anxiety. 2. Incorrect: Although sleeping medication may be warranted for this client, the nurse neglects to offer a viable solution to the client's problem. The nursing interventions should focus on assisting the client to explore their feelings. 3. Incorrect: Although this is a helpful response, this answer does not include notifying the case manager. The nurse should forward this request to the case manager who can identify client needs. 4. Incorrect: Calling the primary healthcare provider is inappropriate, as the client requires hospitalization now. The primary healthcare provider will determine if the client should be hospitalized. 1. Identify client-centered options. The focus of the nurse should be the client. Items that test your ability to be client-centered tend to explore client feelings, identify client preferences, empower the client, provide the client choices, or in some way put emphasis on the client. The client is the priority. 2. Identify options that deny client feelings, concerns, and needs. Options that imply everything will be all right deny clients' feelings, change the subject raised by the client, encourage the client to be cheerful, or transfer nursing responsibility to other members of the healthcare team usually are distractors and can be eliminated from consideration.
The nurse is caring for a client who is drowsy and has an elevated PCO2 level. What are some common medications that can cause this elevated level? 1. Narcotics 2. Diuretics 3. Steroids 4. Antiemetics 5. Hypnotics
1. Narcotics 4. Antiemetics 5. Hypnotics 1., 4. & 5. Correct: Narcotics sedate and decrease the respiratory rate, which increases CO2 retention. Always monitor respiratory rate. Some antiemetics (such as promethazine) are very sedating and will decrease the respiratory rate while increasing CO2 retention. Hypnotics can cause sedation to the point of hypoventilation, which leads to CO2 retention. Always monitor respiratory rate. 2. Incorrect: Diuretics do not affect breathing patterns. 3. Incorrect: Steroids do not affect breathing patterns.
Which nursing intervention is most important for the nurse to perform prior to the administration of diltiazem?
1. Note the rate and character of the apical pulse. 1. Correct: Diltiazem is used to treat hypertension, angina, and certain heart rhythm disorders. So prior to giving this medication, the nurse should monitor blood pressure and pulse. Diltiazem causes systemic vasodilation and suppresses arrhythmias.2. Incorrect: This medication is to treat hypertension, so check the BP. Breath sounds do need to be monitored prior to administration. This would be a complication of diltiazem administration. So monitor for this after administration. 3. Incorrect: Diltiazem is a calcium channel blocker, but the total serum calcium concentration is not affected by it.4. Incorrect: A decrease in output would be an indicator of heart failure which is a complication of diltiazem administration. This would be monitored after giving the medication.
What is the priority nursing action for a client that was admitted with tingling of the toes and feet after having the flu for several days when the client begins to have numbness in the legs and hips? 1. Notify the primary healthcare provider 2. Monitor for paresthesia in the fingers and hands 3. Insert an indwelling urinary catheter 4. Assist the client with performing passive range of motion
1. Notify the primary healthcare provider 1. Correct: Symptoms are classic for Guillain-Barre. The possibility of rapid progression and respiratory failure make this a medical emergency. The nurse's priority action is to notify the healthcare provider. 2. Incorrect: The nurse should continue to monitor for paresthesia in the upper body and arms. The first priority in this situation is to notify the primary healthcare provider of the potential life threatening situations. 3. Incorrect: Urinary retention is a possible complication with Guillain-Barre, and the client may require an indwelling urinary catheter, but the immediate priority is to notify the primary healthcare provider. 4. Incorrect: Passive range of motion is performed to prevent complications of immobility, but this is not the priority at this time. The client is presently able to move their extremities. Passive range of motion is not the priority at this time. Option 1 is true. A client that has numbness and tingling in the lower extremities that advances upwards, especially after having a viral infection, has clinical manifestations characteristic of Guillian-Barre Syndrome. The primary healthcare provider must be immediately notified of the change because the disease is progressively paralytic and must be treated before paralysis of the respirator muscles occurs.
The nurse walks into a client's room and finds the client exposed while the unlicensed assistive personnel (UAP) is giving the bath. After covering the client with a sheet, what should the nurse do first? 1. Tell the UAP to keep the client covered at all times. 2. Talk with the UAP about providing appropriate care for all clients. 3. Provide teaching to the UAP about privacy for clients. 4. Use the call light to ask for additional assistance in the room.
1. Tell the UAP to keep the client covered at all times. Correct: A comment should be made about keeping the client covered. This instruction is the first action after covering the client.
What action should the nurse take when a client receiving 40 mL/hr of enteral feedings has a gastric residual volume of 250 mL? 1. Recheck gastric residual volume in 1 hour. 2. Reduce the infusion rate and reevaluate residual volume in 4 hours. 3. Change the feeding schedule from continuous to intermittent delivery. 4. Discard the 250 mL and continue the feedings at the same rate.
1. Recheck gastric residual volume in 1 hour. 1. Correct: The action is to recheck gastric residual in 1 hour. This may be a sign of intolerance. Reasons for delayed gastric emptying must be determined if 250 mL or more remains on 2 (1 hour apart) checks. 2. Incorrect: Reducing the rate does not fix the problem. There is a reason for delayed gastric emptying. Four hours is too long to recheck residual volume. 3. Incorrect: Changing the feeding schedule does not fix the problem. To change from continuous to intermittent will not address the concern of the 250 mL of gastric residual volume. 4. Incorrect: Do not discard residual volumes. Discarding residual volumes can disrupt a client's fluid and electrolyte balance. Standard practice is to give it back. When you have high residuals, the client should be rechecked in 1 hour to determine if delayed gastric emptying is present.
A client with sleep apnea has been ordered a Continuous Positive Airway Pressure (CPAP) machine. Which action could the nurse assign to an unlicensed assistive personnel (UAP)? 1. Reminding the client to apply the CPAP at bedtime 2. Obtaining oxygen saturation levels every three hours 3. Teaching the client how to turn on the CPAP machine 4. Assessing for fatigue or depression caused by poor sleep
1. Reminding the client to apply the CPAP at bedtime 1. Correct: It is appropriate delegation for a UAP to remind the client to do a previously taught intervention. The UAP cannot perform actual teaching because this is outside the scope of practice, but reminding the client about what was taught may help with compliance. 2. Incorrect: This is an assessment function and may be outside the UAP's scope of practice in some states. Since oxygen saturation requires every three hour monitoring, it is best not to assign this to the UAP. The nurse should be the one to check the oxygen saturation levels every three hours because additional assessment of the client status may be warranted. 3. Incorrect: Initial teaching about the CPAP machine is the responsibility of the RN. The LPN can reinforce this teaching, but teaching is outside the UAP's scope of practice. 4. Incorrect: Assessment is outside the UAP's scope of practice. Independent assessment requires additional education and skills and should be carried out by the RN.
meter dose inhaler steps:
1. Shake the MDI and attach it to the spacer 2. Exhale completely 3. Place lips tightly around the mouthpiece 4. Deliver a single puff of medication into the spacer 5.Take a slow deep breath and hold it for 0 seconds to allow for effective medication distribution 6. Rinse mouth with water to remove any leftover medication from oral mucous membranes
Which finding indicates to the nurse that a client is at risk for skin breakdown? 1. Weakness requiring assistance to move in bed. 2. Daily intake of at least 85 percent of food offered. 3. Occasional forgetfulness. 4. Continent of bowel and bladder.
1. Weakness requiring assistance to move in bed. 1. Correct: Immobility or weakness puts a client at risk for skin breakdown, particularly if combined with other indicators such as inadequate nutrition, confusion, incontinence, or limited sensory perception. 2. Incorrect: This level of intake is considered adequate, as the client seems to be consuming protein, dairy, fruits, and/or vegetables. 3. Incorrect: Occasional confusion should not put the client at risk for skin breakdown. If the client was confused and did not keep skin dry, move about, or have adequate nutrition, the client would be at greater risk. 4. Incorrect: Moisture presence and feces on the skin from incontinence place the client at risk for skin breakdown. If the client is continent of urine and feces, there is no increased risk for skin breakdown. 1. The nurse must be aware of risk factors that cause diseases. If the test taker does not know the correct answer, think about which body system the question is asking about may help rule out or rule in some of the options. 2.. Identify clues in the stem. Generally, the stem is short and contains only the information needed to make the question clear. A clue is the use of a word or phrase that leads you to the correct answer. The clue shows a relationship to a word or phrase in the correct answer.
Which client statements indicate to the nurse that discharge instructions about antibiotic administration have been successful? Select all that apply 1. "I will take the antibiotic until I feel better but save some in case the infection returns." 2. "The instructions on the label should be followed exactly." 3. "I will double the dose for two days so I will get better sooner." 4. "If I miss a dose, I will double the dose the next time the antibiotic is due." 5. "It is necessary to finish all of my antibiotic medication."
2. & 5. Correct: Instruct the client to follow the instructions and finish the whole prescription. 1. Incorrect: Not taking the whole prescription can lead to resistance of the organism and cause a relapse of the infection. 3. Incorrect: Medication doses should never be doubled, even if one dose is missed. 4. Incorrect: Medication doses should never be doubled, even if one dose is missed.
The nurse is teaching a group of clients how to decrease the risk of developing osteoarthritis (OA). What should the nurse include? 1. Control blood sugar. 2. Use largest, strongest joints for lifting. 3. Do intense aerobic exercise, daily. 4. Maintain a healthy weight. 5. Wear joint padding with playing sports.
1., 2., 4., & 5. Correct: High glucose levels speed the formation of certain molecules that make cartilage stiffer and more sensitive to mechanical stress. The client should use the largest and strongest joints and muscles. Use both arms when lifting or carrying an object. By using the largest and strongest joints, less stress occurs on single joints or weaker areas of the body. Excess weight is one of the biggest risk factors for osteoarthritis. Although injuries aren't always avoidable, it pays to protect joints. If playing sports, wear protective gear, such as joint padding for soccer or hockey. And make sure any baseball field uses break-away bases. 3. Incorrect: Physical activity is one of the best ways to keep joints healthy. As little as 30 minutes of moderately intense exercise five times a week helps joints stay limber and strengthens the muscles that support and stabilize the hips and knees. However, it does not have to be daily or intense. Osteoarthritis (OA) was once considered a disorder in which joints simply wore out, the unavoidable result of a long and active life. But research has shown that OA is a complex process with many causes. It is not an inevitable part of aging, but rather the result of a combination of factors, many of which can be modified or prevented. Excess weight is one of the biggest risk factors for osteoarthritis. Extra pounds put additional pressure on weight-bearing joints, such as the hips and knees. Each pound gained adds nearly four pounds of stress to the knees and increases pressure on the hips six-fold. Over time, the extra strain breaks down the cartilage that cushions these joints. But mechanical stress is not the only problem. Fat tissue produces proteins called cytokines that promote inflammation throughout the body. In the joints, cytokines destroy tissue by altering the function of cartilage cells. When a person gains weight, the body makes and releases more of these destructive proteins. Unless a person is very overweight, losing even a few pounds can reduce joint stress and inflammation, cutting their risk of OA in half. The latest research suggests that diabetes may be a significant risk factor for osteoarthritis. That's because high glucose levels speed the formation of certain molecules that make cartilage stiffer and more sensitive to mechanical stress. Diabetes can also trigger systemic inflammation that leads to cartilage loss. The newly discovered connection between diabetes and joint damage may help explain why more than half of Americans diagnosed with diabetes also have arthritis. Physical activity is the best available treatment for OA. It's also one of the best ways to keep joints healthy in the first place. As little as 30 minutes of moderately intense exercise five times a week helps joints stay limber and strengthens the muscles that support and stabilize the hips and knees. Exercise also strengthens the heart and lungs, lowers diabetes risk and is a key factor in weight control. Walking, gardening, even scrubbing floors, counts. But the greatest results come with a consistent and progressive exercise program adjusted for the client's age, fitness level and the activities enjoyed most. No matter what type of exercise the client chooses, listening to the body is important. If pain occurs after a workout that persists more than an hour or two, do less next time and take more breaks. To avoid injury, go slow until the body adjusts to a new activity and don't repeat the same exercise every day. Because cartilage doesn't heal well, an injured joint is nearly seven times more likely to develop arthritis than one that was never injured. Fractures, dislocations, even ligament tears and strains, can significantly increase the risk of OA, which occurs in about 50 percent of people who experience a traumatic injury. Although injuries aren't always avoidable, it pays to protect the joints. If playing sports, wear protective gear, such as joint padding for soccer or hockey. And make sure any baseball field has break-away bases. At home or work, use the largest, strongest joints for lifting and carrying and take breaks when needed. After an injury, maintaining a healthy weight can help guard against further joint damage. Ultimately, the best defense against any disease, including OA, is a healthy lifestyle. The way a person eats, exercises, sleeps, manages stress and interacts with others, and whether the client smokes or drinks can have a tremendous influence not just on overall health, but also on the health of joints.
A client with a history of schizophrenia was admitted with abdominal pain and has been undergoing diagnostic tests. When the nurse enters the room, the client is alone and looking at the wall and states "Why should I hurt them?" What would be an appropriate intervention by the nurse? Select all that apply 1. Directly ask the client "Are you hearing voices?" 2. State "Tell the voice that you do not want to hurt anyone." 3. Focus on reality based topics of conversation. 4. Observe for signs of increasing anxiety in the client. 5. Tell the client "You know that you are not being told to hurt someone." 6. Inquire about what the client believes he or she is being told to do.
1., 3., 4., & 6. Correct: Did you pick up on the cues that this client is experiencing auditory hallucinations? The most obvious cues that this client is hallucinating are the verbal response when there is no one present and the client is looking at the wall when responding. When you think a client is hallucinating, you should directly ask the client about the hallucination by asking such questions as: "Are you hearing voices?" In order to intervene with a client who is experiencing a hallucination, you should focus on reality-based diversions including reality-based topics of conversation. Also, hallucinations can be anxiety producing for clients, so you should observe for any signs of increasing anxiety, which can be a sign that the hallucinations are increasing. The nurse can explore the hallucination experience with this client by asking directly "What are the voices telling you to do?" Another way to specifically explore the hallucination with this client is to ask if they are being told to do something that would cause harm to someone. 2. Incorrect: You never want to react to the client's hallucinations as if they are real. In this case, you would not tell the client to talk back to the "voices" and argue with them or discuss things as if the voices are real. 5. Incorrect: You do not want to negate the client's hallucination experience, but you do offer your own perception that you do not hear the voices. Telling the client that they are not being told something would only escalate their anxiety and perhaps cause them to become irritable or upset. The voices are "real" to the client. You were able to identify that the client was having auditory hallucinations because of the response being made by the client. Other cues that can indicate a client is hallucinating include eyes darting around the room, muttering, or looking at a vacant area of the room. In this case, the client was looking at the wall and talking. Interventions with a client who is hallucinating include directly asking the client about the hallucination by using such phrases as: "Are you hearing voices?" "What are the voices saying to you?" "Are the voices instructing you to do something?" "Are the voices telling you to not tell anyone what you are hearing?" However, when talking with the client, you never want to react to the client's hallucinations as if they are real. In this case, you would not tell the client to talk back to the "voices" and argue with them or discuss things as if the voices are real. However, you should focus on reality-based diversions including reality-based topics of conversation. One way to do this is to encourage the client to try not to listen to the voices and to try to concentrate on what you are talking about. You could pick a topic of interest to the client to discuss. Being aware of increasing anxiety in the client can give you an indication that the hallucinations may be increasing as well. You do not want to tell the client that they are not hearing voices, but you do offer your own perception that you do not hear the voices. You can also voice concern by telling the client that you understand it can be very upsetting for them to be hearing these voices telling them to do something. However, challenging the client by saying that they are not being told something would only escalate their anxiety and perhaps cause them to become irritable or upset. The voices are "real" to the client. Additional interventions for clients with hallucinations would be helping the client to develop strategies for coping with the hallucinations when they occur. Some suggested activities could include: reading aloud, engaging in physical activity, and seeking additional help when needed.
The nurse is providing teaching for a client who is being scheduled for outpatient 24 hour electrocardiogram monitoring using a Holter monitor. What should the nurse tell the client to avoid while monitoring is in progress? 1. Taking a shower or bath 2. Performing daily exercises 3. Working around high voltage equipment 4. Being screened at airport security 5. Eating foods that are sources of potassium
1., 3., and 4. Correct: The nurse should teach this client to continue the usual activities while wearing the monitor with a few exceptions. The monitor should be kept dry to ensure that it functions properly. The client should avoid taking a shower or bath or swimming while wearing the monitor. The electrodes could also become detached from the skin if they get wet, which would also interfere with the accuracy of the reading. The client should be advised to not work around high voltage equipment because areas of high voltage can interfere with the function of the electrocardiogram monitoring. In addition, magnetic fields, such as those used for airport screenings, can interfere with the function of the Holter monitor and should be avoided. 2. Incorrect: This client should be encouraged to continue regular routine unless otherwise directed by the primary healthcare provider. The client can perform the usual daily exercise, but should be advised to avoid activities that may cause excessive perspiration that could lead to the electrodes becoming loosened from the skin. 3. Incorrect: There are generally no dietary restrictions while wearing the Holter monitor unless otherwise prescribed by the primary healthcare provider.
What information should the nurse give a pregnant client who comes to the clinic reporting hemorrhoids and constipation? 1. Increased rectal pressure from the gravid uterus may result in hemorrhoids. 2. Hormones decrease maternal GI motility, resulting in constipation. 3. More fluid and fiber is needed in the diet. 4. Use a mild laxative to alleviate constipation. 5. Increase daily fluid intake.
1.. Increased rectal pressure from the gravid uterus may result in hemorrhoids. 2. Hormones decrease maternal GI motility, resulting in constipation. 3. More fluid and fiber is needed in the diet. 5. Increase daily fluid intake. 1., 2., 3. & 5. Correct: As pregnancy progresses, the enlarging uterus increases abdominal and rectal pressure. GI motility slows due to hormonal influences. Pregnant clients may benefit significantly from dietary changes including adequate hydration and increased fiber intake.4. Incorrect: Medications, including laxatives, should not be taken by pregnant women unless prescribed by the primary healthcare provider. If needed, the primary healthcare provider may prescribe a stool softener but a laxative is not typically recommended because of possible fluid and electrolyte shifts.
Which client data should the nurse anticipate when caring for a client with acute cholecystitis? Select all that apply 1. Chills 2. Fever 3. Nausea and vomiting 4. Increased appetite 5. Rigidity of upper right abdomen
1.Chills 2. Fever 3. Nausea and vomiting 5. Rigidity of upper right abdomen 1., 2., 3. & 5. Correct: Many clients with acute cholecystitis present with acute onset of right upper quadrant pain associated with nausea and vomiting. Epigastric pain may also be present as well as fever, chills, and anorexia. A physical examination often reveals rigidity of the upper right abdomen that may radiate to midsternal area or right shoulder. Rebound and guarding are present in some cases. 4. Incorrect: The client with cholecystitis will have nausea and vomiting which usually results in a decreased appetite. In order to get this question correct, you need to know what acute cholecystitis is. The gallbladder is an organ that sits below the liver. It stores bile, which your body uses to digest fats in the small intestine. Acute cholecystitis occurs when bile becomes trapped in the gallbladder. This often happens because a gallstone blocks the cystic duct, the tube through which bile travels into and out of the gallbladder. When a stone blocks this duct, bile builds up, causing irritation and pressure in the gallbladder. This can lead to swelling and infection. So let's look at our options. Option 1: True. Any disease process ending in "itis" may present with fever and chills. So knowing that will make Option 2...True. Option 3: N/V? True. Many clients with acute cholecystitis present with acute onset of right upper quadrant pain associated with nausea and vomiting. Option 4: False. If you have nausea and vomiting, do you want to eat? No. You would not want to eat, so anorexia is seen. Option 5: True. A physical examination often reveals rigidity of the upper right abdomen that may radiate to the midsternal area or right shoulder. Rebound and guarding are present in some cases.
A nurse working in a long term care facility observes a resident who is eating in the dining hall. Suddenly, the resident crosses her hands at her neck. What action should the nurse perform first? 1. Forcefully hit the resident between the scapula with an open hand. 2. Ask the resident if she can speak. 3. Apply 5 abdominal thrusts quickly and firmly. 4. Sweep back of mouth with crossed fingers.
2. Ask the resident if she can speak. 2. Correct: If the client can speak or cough, then the nurse should allow the client to try to expel the object herself. If the client cannot speak or cough, then the client is getting no air, and intervention must be given. 1. Incorrect: The proper procedure is to perform abdominal thrusts. 3. Incorrect: Checking to see if the client can speak or cough is first. Then 6-10 abdominal thrusts should be attempted. 4. Incorrect: While the client is conscious, sweeping the mouth may actually push the object further down the airway. 1. Maintaining a client's airway is always a priority if it is applicable. 2. Identify key words in the stem that set a priority, such as first, initially, best, priority, safest, most. These words modify what is being asked. This question requires you to put a value on each option and then place them in rank order. If you are having difficulty ranking the options, eliminate the option that you believe is most wrong among the options.
Which findings does the nurse expect to find when monitoring a client admitted with left sided congestive heart failure? 1. Ascites 2. Bibasilar crackles 3. Orthopnea 4. Hepatomegaly 5. Anorexia
2. Bibasilar crackles 3. Orthopnea 2. & 3. Correct: Bibasilar crackles that do not clear with coughing occur with left sided heart failure. Fluid backs up into the lungs. Orthopnea occurs in left sided heart failure when the client lies flat, because fluid backs up into the lungs. 1. Incorrect: Ascites is seen with right sided heart failure because fluid backs up into the systemic venous circulation, causing stasis in the abdominal organs. 4. Incorrect: Hepatomegaly is seen with right sided heart failure because of the venous engorgement and stasis in the liver. 5. Incorrect: Anorexia is seen in right sided heart failure due to venous engorgement and venous stasis within the abdominal organs.
Which findings does the nurse expect to find when monitoring a client admitted with left sided congestive heart failure? 1. Ascites 2. Bibasilar crackles 3. Orthopnea 4. Hepatomegaly 5. Anorexia
2. Bibasilar crackles 3. Orthopnea 2. & 3. Correct: Bibasilar crackles that do not clear with coughing occur with left sided heart failure. Fluid backs up into the lungs. Orthopnea occurs in left sided heart failure when the client lies flat, because fluid backs up into the lungs.1. Incorrect: Ascites is seen with right sided heart failure because fluid backs up into the systemic venous circulation, causing stasis in the abdominal organs.4. Incorrect: Hepatomegaly is seen with right sided heart failure because of the venous engorgement and stasis in the liver.5. Incorrect: Anorexia is seen in right sided heart failure due to venous engorgement and venous stasis within the abdominal organs
What should the nurse tell a client to increase antioxidant benefits? 1. Avoid harmful substances such as tobacco smoke and radiation. 2. Take a multivitamin daily and eating a balanced diet. 3. Engage in regular exercise and physical activity. 4. Maintain a normal body weight.
2. Correct: Several vitamins such as A, C, E, β-carotene, selenium, and lycopene are just some of the antioxidants found in a multivitamin and a balanced diet rich in colorful fruits and vegetables. Antioxidants capture the free radical, an electron emitted as part of the cellular process of oxidation, thus limiting cellular damage. 1. Incorrect: While avoiding harmful substances is a beneficial lifestyle goal, it does not answer the question directly. 3. Incorrect: Exercising regularly is a beneficial lifestyle goal, but it does not answer the question directly. 4. Incorrect: Maintaining a normal body weight is a beneficial lifestyle goal, but it does not answer the question directly.
ACE inhibitors ending in -pril
are given to patient who are diabetic with hypertension or proteinuria
Immediately following a below-the-knee amputation (BKA), the nurse positions the client to prevent complications. What intervention related to position of the residual limb is a priority at this time? 1. Flat on the bed 2. Elevate foot of the bed 3. Position of comfort 4. Dependent position
2. Elevate foot of the bed 2. Correct: It is normal to experience post-operative swelling after a BKA. Immediately after surgery, the foot of the bed should be elevated to reduce swelling. An ACE compression bandage will be used to reduce swelling and prevent hemorrhage. The other positions would not be as appropriate since swelling is an issue after a below the knee amputation. 1. Incorrect: Flat on the bed will not relieve swelling. Post-operatively for a BKA, hemorrhage and swelling are the biggest concerns immediately following surgery. 3. Incorrect: Position of comfort may increase swelling. Immediately following a BKA, elevating the foot of the bed and the ACE compression wrap are used to prevent hemorrhage and swelling. Positioning for comfort is not appropriate. 4. Incorrect: Placing in a dependent position will increase swelling. Swelling post-operatively is a normal occurrence, and elevating the foot of the bed along with the use of an ACE wrap will help prevent swelling.
A client is scheduled for an electroencephalogram (EEG). Which intervention should the nurse implement? 1. Keep NPO and hold medication. 2. Hold sedatives, but allow client to have breakfast and other medicines. 3. Administer meds, but hold anticonvulsants. 4. Give additional fluids and some caffeine prior to the test.
2. Hold sedatives, but allow client to have breakfast and other medicines. 2. Correct: Yes, prior to an EEG we want the client to eat so the glucose level does not drop. In addition, they should take medications except sedatives prior to the EEG. 1. Incorrect: No, give them food, and give them their meds except sedatives. 3. Incorrect: No, give all meds including anticonvulsants unless specifically ordered. 4. Incorrect: No, the client does not need extra fluid. They will just have to stop and urinate, and caffeine will increase the electricity in the brain and interfere with the test.
Which suggestion should the nurse provide to a client reporting frequent episodes of constipation? 1. Take a stool softener. 2. Increase intake of fruit in the diet. 3. Monitor elimination habits for the next week. 4. Rest after each meal.
2. Increase intake of fruit in the diet. 2. Correct: Fruit is high in fiber. Increased fiber intake may help to establish regular elimination habits by promoting the movement of material through the digestive system and increasing stool bulk. 1. Incorrect: Not the best initial suggestion. It's better to promote health maintenance routines than to just go with a medication, which could be a temporary fix. 3. Incorrect: The nurse should make a suggestion that will assist the client with normal elimination. This option does not suggest a way to fix the problem. 4. Incorrect: Increased activity is likely to result in more normal elimination. Resting after meals would not increase elimination frequency.
Which data collected by the nurse would support a client history of chronic emphysema? 1. Atelectasis 2. Increased anteroposterior (AP) diameter 3. Breathlessness 4. Use of accessory muscles with respiration 5. Leans backwards to breathe 6. Clubbing of fingernails
2. Increased anteroposterior (AP) diameter 3. Breathlessness 4. Use of accessory muscles with respiration 6. Clubbing of fingernails 2., 3., 4., & 6. Correct: Emphysema is described as a permanent hyperinflation of lung beyond the bronchioles with destruction of alveolar walls. Airway resistance is increased, especially on expiration. Inspection reveals dyspnea on exertion, barrel chest (anteroposterior diameter is equal to transverse diameter), tachypnea, and use of accessory muscles with respiration. Clubbing of fingernails is due to chronically decreased oxygen levels. 1. Incorrect: Atelectasis is collapse of alveolar lung tissue, and findings reflect presence of a small, airless lung. This condition is caused by complete obstruction of a draining bronchus by a tumor, thick secretions, or an aspirated foreign body, or by compression of lung. 5. Incorrect: Client tends to sit up and lean forward to relieve or prevent orthopnea and uses accessory muscles of respiration to breathe. If you know the signs and symptoms of emphysema, then you can answer this select all that apply question correctly. So what is emphysema? Emphysema is one of the diseases that comprises COPD. Emphysema involves gradual damage of lung tissue, specifically thinning and destruction of the alveoli or air sacs, making it progressively difficult to breath. Emphysema is usually accompanied by chronic bronchitis, with almost-daily or daily cough and phlegm. Cigarette smoking is the major cause of emphysema. People with emphysema experience shortness of breath with activities. It is not curable, but there are treatments that can help the client manage the disease. Look at the options now. Option 1: Atelectasis. Atelectasis is the collapse of part or, much less commonly, all of a lung. So this is false. Option 2: Increased AP diameter. This is true. It occurs because of chronically hyperinflated lungs and loss of lung elasticity. Option 3: Breathlessness is true. We just said that emphysema destroys the alveoli, making it progressively difficult to breath. Look at option 4, use of accessory muscles to breathe. True. Accessory muscles of respiration are typically only used under conditions of high metabolic demand (e.g. exercise) or respiratory dysfunction (e.g. an asthma attack, or emphysema). Option 5: Lean backwards to breathe. This is false. This client tends to lean forward (orthopnea) and uses accessory muscles of respiration to breathe. Now option 6. Clubbing of fingernails. True. This is due to chronically decreased oxygen levels. Think about it, the alveoli are destroyed so gas exchange is impaired. Oxygen levels decrease.
The nurse is caring for a client reporting intense headaches with increasing pain for the past month. An MRI is prescribed. In reviewing the client's information, which piece of information is of concern to the nurse? 1. Allergy to iodine 2. Internal cardiac defibrillator 3. Diabetic 4. Stroke a year ago
2. Internal cardiac defibrillator 2. Correct: If a client with a cardiac pacemaker and internal defibrillator has an MRI, the pacemaker is turned off and the client could die. The MRI uses a magnet. Magnets turn off pacemakers. This needs to be reported to the primary healthcare provider. 1. Incorrect: No, there is no dye involved with MRI. Magnetic resonance imaging (MRI) is a test that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body. 3. Incorrect: Diabetics can have an MRI without being made NPO or withholding medications prior to the test. This test should not affect the client's blood glucose in any way. 4. Incorrect: MRI is not contraindicated with stroke. This is not an invasive procedure and does not place the client at increased risk for complications related to having had a stroke.
The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action? 1. Is confused and disoriented. 2. Is scared and lonely and grabs the nurse's hand for comfort. 3. Would like to talk with the nurse. 4. Would like to reminisce with the nurse.
2. Is scared and lonely and grabs the nurse's hand for comfort. 2. Correct: This elderly client with no visitors is most likely scared and lonely. The touch of the nurse's hand is comforting for the client. 1. Incorrect: There is no indication of confusion or disorientation. 3. Incorrect: Grabbing the nurse's hand indicates more than just a desire to talk. This is indicative of needing comfort and personal touch. 4. Incorrect: There is no indication of a desire to reminisce from the information in the question. 1. Identify clues in the stem. Generally, the stem is short and contains only the information needed to make the question clear. A clue is the use of a word or phrase that leads you to the correct answer. The clue shows a relationship to word or phrase in the correct answer. 2. Identify the global option. This is the most comprehensive and general option. The global option may incorporate the more specific option.
A new nurse has a prescription to insert a feeding tube. The new nurse has never performed the procedure, but learned how to do it while in nursing school. What would be the best action by this new nurse? 1. Ask to observe another nurse perform the procedure. 2. Look up how to perform the procedure in the policy and procedure manual. 3. Tell the charge nurse that someone else will have to insert the feeding tube. 4. Insert the feeding tube as learned in nursing school.
2. Look up how to perform the procedure in the policy and procedure manual. 2. Correct: The best action for the nurse is to look up how the procedure is done in the agency policy and procedure manual. The nurse could then discuss the procedure with a fellow nurse and ask that nurse to observe during the procedure. 1. Incorrect: This is passive and will not give the new nurse the experience needed. The best action would be to look up how to do the procedure. Then the new nurse could discuss with another nurse, and have that nurse observe the insertion of the feeding tube by the new nurse. 3. Incorrect: This is not the best option. The new nurse needs to learn how to insert a feeding tube. This will not help the new nurse learn. Actually doing the procedure after checking the policy and procedures manual will give the new nurse the experience needed. 4. Incorrect: Nursing school knowledge is needed but also check agency policy and procedure manuals. Then the new nurse can discuss the procedure with a fellow nurse and ask that nurse to observe the feeding tube insertion.
Which finding would indicate to a nurse that a client receiving chemotherapy may have difficulty maintaining proper nutrition? 1. Fatigue 2. Mucositis 3. Neutropenia 4. Diarrhea
2. Mucositis 2. Correct: Mucositis is pain and inflammation of the body's mucous membranes along the gastrointestinal tract. Ulcerations in the oral cavity can make it difficult to chew food or be intolerant to certain foods due to discomfort and pain. Intake may be inadequate as a result of this. 1. Incorrect: Fatigue may make the client tire easily, but pain and inflammation in the oral cavity will be the primary reason for not wanting to eat. 3. Incorrect: Someone with neutropenia has an unusually low number of neutrophils, a type of white blood cell. Neutropenia leads to infection. This does not alter intake. 4. Incorrect: Diarrhea may need to be treated by making diet changes. However, the maintenance of nutrition should be focused on intake. The impact of the mucositis should be considered first for maintaining proper nutrition.
Which tasks can the LPN/LVN assign to an unlicensed assistive personnel (UAP)? 1. Tell a female client who has recurrent urinary tract infections how to wipe after urinating. 2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 3. Collect a urine specimen from a foley catheter tubing. 4. Document the intake and output of a client in acute renal failure. 5. Irrigate the foley catheter of a client who has had transurethral resection of the prostate (TURP). 6. Perform perineal care of a client who has urinary incontinence.
2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 4. Document the intake and output of a client in acute renal failure. 6. Perform perineal care of a client who has urinary incontinence. 2., 4., & 6. Correct: These are all tasks that can be performed by the UAP. The UAP has received training for completing these tasks. 1. Incorrect: The UAP cannot teach. 3. Incorrect: This is out of the scope of practice for a UAP. 5. Incorrect: The UAP does not have the knowledge and skill to irrigate catheters of any kind.
The nurse is providing care for a client admitted with a diagnosis of myasthenia gravis. Which nursing interventions should the nurse include in order to decrease the risk of aspiration? 1. Provide thin liquids such as water with meals. 2. Offer small bites of food. 3. Allow client to rest between each bite of food. 4. Offer small meals in the morning and larger meals in the evening. 5. Provide meals 30 minutes before administration of cholinesterase inhibitor medication.
2. Offer small bites of food. 3. Allow client to rest between each bite of food. 2., & 3. Correct: Offer the client small bites and instruct to chew well, eat slowly, swallow after each bite, and swallow frequently. Allow the client to rest while chewing and in between bites to restore strength. 1. Incorrect: Provide thickened liquids that are easy to swallow. Thin liquids are more likely to cause aspiration. 4. Incorrect: Offer large meals in the morning and small meals in the evening. The client is more fatigued as the day progresses, so a smaller meal is best in the evening. 5. Incorrect: Adjust the client's eating schedule to optimize medication efficacy. Typically, meals should be taken during periods of optimal strength (such as during the earlier part of the day, 30 minutes after administration of cholinesterase inhibitor medications, or after rest periods).
Which task would be appropriate for the nurse to assign the unlicensed assistive personnel (UAP)? 1. Assess any pressure ulcers noted on clients. 2. Report if any client indicates pain. 3. Monitor amount of chest tube drainage. 4. Demonstrate coughing and deep breathing exercises to post-op clients.
2. Report if any client indicates pain. 2. Correct. It is within the scope of practice for the UAP to ask the client if they are experiencing pain. The nurse will then assess the pain. The nurse can delegate, assess, develop a plan of care and evaluate. 1. Incorrect. This is an RN task. The UAP does not have the appropriate education to assess a pressure ulcer. This is not within their scope of practice. 3. Incorrect. The UAP cannot assess or evaluate. This is an RN task. Monitoring the amount of chest tube drainage is an appropriate action for the nurse. The UAP cannot monitor the amount of chest tube drainage. 4. Incorrect. The UAP cannot teach. This is an RN task. The nurse cannot delegate teaching or demonstrating to the UAP.
The nurse assigned feeding of a client to the unlicensed assistive personnel (UAP). Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. What should the nurse do first? 1. Feed the client after warming the food. 2. Speak to the UAP to determine what happened with the feeding. 3. Pick up the tray and tell the UAP the task was not done. 4. Provide a between meal supplement to the client.
2. Speak to the UAP to determine what happened with the feeding. 2. Correct: Communication is important in assigning tasks, as is follow-up. There may be a good reason that the tray was not served. The key word in the stem is first. The other options may be correct but are not the best first action. 1. Incorrect: The client does need to have food; however, there is another action that should be performed first. The reason for the UAP not feeding the client needs to be determined. 3. Incorrect: The nurse retains the responsibility for the delegated task. The nurse should not assume that the UAP just did not do their job, but needs to ascertain the reason for not feeding the client. 4. Incorrect: The concern here is the client being fed their meal. Speak to the UAP first and then decide if a between meal supplement is needed.
Which findings will direct the nurse towards determination that a client is experiencing normal grief? 1. Anhedonia is prevalent. 2. The client states, "I am having fewer bad days". 3. Smiles at the nurse while talking about life. 4. Dysphoria is noted. 5. The client states, "I have been crying less".
2. The client states, "I am having fewer bad days". 3. Smiles at the nurse while talking about life. 5. The client states, "I have been crying less". 2., 3. & 5. Correct: A client going through a normal grieving process will experience a mixture of good and bad days. The client is able to experience moments of pleasure and cries less. 1. Incorrect: Anhedonia is the inability to experience pleasure, which is seen in clinical depression. 4. Incorrect: Dysphoria is a mood of general dissatisfaction, restlessness, depression, and anxiety. This is often seen in clinical depression.
When arterial blood gases (ABGs) are drawn by lab personnel, which information is important for the nurse to document? 1. That the client had not been NPO prior to the test. 2. The client was on 2 L of oxygen by nasal canula. 3. Lung sounds are wet. 4. Client is in semi fowler's position.
2. The client was on 2 L of oxygen by nasal canula. 2. Correct: The fact that the client is on 2 Liters of oxygen will affect the analysis of the ABG results.1. Incorrect: Oral intake will not affect the evaluation of the ABG results.3. Incorrect: Although the presence of wet lung sounds is important, this data is not specific to the interpretation of ABGs. 4. Incorrect: The client's position will not affect the evaluation of the ABG results.
Which nursing actions would indicate proper sterile technique? 1. Using clean gloves, the nurse removes sterile forceps from package and places on sterile field. 2. The nurse does not allow any sterile item to get within one inch of the drape border. 3. The nurse's arms stay above the waist. 4. When adding sterile saline to a sterile bowl, the nurse places the inside of the bottle cap up. 5. The nurse discards a package that becomes wet.
2. The nurse does not allow any sterile item to get within one inch of the drape border. 3. The nurse's arms stay above the waist. 4. When adding sterile saline to a sterile bowl, the nurse places the inside of the bottle cap up. 5. The nurse discards a package that becomes wet. 2., 3., 4. & 5. Correct: This is a correct procedure. Because the edge of a sterile towel, drape, or tray touches an unsterile surface, such as a table, the edges of the drape are considered contaminated (1 inch). A sterile object or field out of the range of vision or an object held below the waist is contaminated. The inside of the bottle cap is considered sterile. Placing the cap up will keep the cap sterile. When a sterile surface comes into contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action .1. Incorrect: Sterile can touch sterile only. If the nurse touched sterile forceps with clean gloves, the forceps would become contaminated. Further teaching would be needed.
Prescribed orthopedic immobilizers and protective devices
are used temporarily and without authorization
A client is hospitalized for chronic renal failure. The nurse will need to notify the primary healthcare provider concerning which findings? 1. Sodium 135 mEq/L (135 mmol/L) 2. Potassium 5.8 mEq/L (5.8 mmol/L) 3. BP 100/70 4. No weight loss 5. Calcium 8.0 mg/dL (2 mmol/L)
2., 5. Correct: Normal K 3.5-5.0 mEq/L (3.5-5.0 mmol/L); Normal serum Ca 9.0-10.5 mg/dL (2.25-2.62 mmol/L). The abnormal lab results need to be reported. Hyperkalemia is a serious electrolyte disorder associated with chronic renal failure due to decreased excretion of potassium from the kidneys. Progressive decrease in kidney function affects mineral and bone metabolism. The low calcium needs to be reported. 1. Incorrect: Normal sodium 135-145 mEq/L (135-145 mmol/L). This is a normal finding and does not need to be reported. 3. Incorrect: Hypertension is a potential complication of chronic renal failure. A BP of 100/70 is not an abnormal finding and does not need to be reported. 4. Incorrect: The desired outcome for clients with chronic renal failure is no rapid increases or decreases in weight. This finding does not need to be reported.
The nurse is caring for a client on the psychiatric unit. The client is prescribed fluphenazine 10 mg. The drug is available as an elixir: 2.5 mg / 5 mL. How many mL will the nurse give to the client? Round answer to the nearest whole number.
2.5 mg : 5 mL = 10 mg : x mL 2.5 mg/x mL = 50 mg/mL 2.5 mg/x mL = 50 mg/mL x = 20 mL
The nurse recognizes that treatment has been successful in resolving fluid volume excess based on which findings? 1. Continued lethargy 2. Heart rate 112/min 3. Decreasing shortness of breath 4. BP 114/78 5. Increased thirst
3. & 4. Correct: Urinary output should increase with decreasing shortness of breath as the FVE is corrected, and BP should be normal. 1. Incorrect: Level of consciousness (LOC) should improve with perfusion to the brain. 2. Incorrect: Heart rate should decrease if FVE is corrected. 5. Incorrect: Thirst is a sign of FVD, rather than FVE, so increased thirst would not be pertinent for FVE.
A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What information is essential for the nurse to emphasize concerning safe needle disposal? 1. Syringes are placed in a garbage bag. 2. A hospital issued biohazard container must be used. 3. Any hard plastic container with a screw-on cap may be used. 4. The needles must be taken to the nearest hospital for disposal.
3. Any hard plastic container with a screw-on cap may be used 3. Correct: At home, needles, syringes, and sharps may be disposed of in a hard plastic container placed into the regular trash. Clients should follow their community guidelines for sharps container disposal. This protects the sanitation engineers from becoming injured by the sharps .1. Incorrect: Syringes must be placed in a safe container in order to protect others from becoming injured by sharps. The syringes should be placed in a hard plastic container. 2. Incorrect: The hospital's biohazard container is not required for sharps disposal in the home. A hard plastic container with a screw on cap is an acceptable container to dispose of needles. 4. Incorrect: The hospital need not be involved in sharps disposal in the home. The client can dispose of needles safely at home in a hard plastic container with a screw on top.
The nurse is caring for a diabetic client. The client's glucose level at 0700 is 265. What is the nurse's best action? 40 units NPH insulin every AM Regular Insulin per Sliding Scale both AC and HS Sliding Scale: Blood glucose < 200: 0 units Blood glucose 200-249: 2 units Blood glucose 250-299: 4 units Blood glucose 300-349: 6 units Blood glucose 350-399: 8 units Blood glucose 400 or >: Call primary healthcare provider 1. Hold the NPH and regular insulin 2. Give 8 units of regular insulin and hold the NPH 3. Give the NPH and 4 units of regular insulin 4. Give 40 units of NPH and hold the regular insulin
3. Correct: According to the prescription and sliding scale, the client will need 40 units of NPH and 4 units of regular insulin for a glucose level of 250-299. 1. Incorrect: According to the prescription and sliding scale, the client will need 40 units of NPH and 4 units of regular insulin for a glucose level of 250-299. 2. Incorrect: According to the prescription and sliding scale, the client will need 40 units of NPH and 4 units of regular insulin for a glucose level of 250-299. 4. Incorrect: According to the prescription and sliding scale, the client will need 40 units of NPH and 4 units of regular insulin for a glucose level of 250-299.
A client returns to the room post appendectomy. In what position should the nurse place the client? 1. Sims' 2. Prone 3. Semi-fowler's 4. Right lateral
3. Correct: After any major abdominal surgery, the position of choice is to elevate the head of the bed 35-45 degrees. This will decrease pressure on the abdomen and suture line.
A client's vital signs, following a bowel resection are: BP 116/74; heart rate 102 and regular; respirations 26 and shallow. The ABGs are: pH 7.48; PCO2 30; HCO3 24. What disorder do these findings indicate? 1. Metabolic alkalosis 2. Metabolic acidosis 3. Respiratory alkalosis 4. Cardiovascular shock
3. Correct: With increased respiratory rates more PaCO2 is exhaled (blown off) decreasing the PCO2 level. PCO2 is an acid. If the client is blowing off CO2, an acid, this leaves them alkaline inside. In this case Respiratory alkalosis because the lungs are the problem. 1. Incorrect: The bicarbonate is normal. In metabolic alkalosis the bicarbonate will be increased. A pH of 7.48 is alkalosis. 2. Incorrect: Normal pH is 7.35-7.45. Anything less than 7.35 is acidosis. Anything greater than 7.45 is alkalosis. 4. Incorrect: In cardiovascular shock the BP is decreased well below 116/74.
What method should the nurse tell the client about the detection of prostate cancer? 1. Abdominal x-rays to detect the presence of lesions and masses. 2. A serum calcium test to detect elevated levels, which may indicate bone metastasis. 3. Digital rectal exam (DRE) and prostate-specific antigen (PSA) test to evaluate the prostate. 4. A magnetic resonance image (MRI) study to detect tumors and other abnormal growths.
3. Digital rectal exam (DRE) and prostate-specific antigen (PSA) test to evaluate the prostate. 3. Correct: Prostate cancer is the second most common type of cancer and the second leading cause of cancer death in men. Early detection improves outcome. DRE and PSA should be offered annually beginning at age 50 to men who have a life expectancy of at least 10 years and at age 45 in high-risk groups. The DRE estimates the size, symmetry, and consistency of the prostate gland while the PSA measures for elevated levels consistent with prostatic pathology, although not necessarily cancer. Declining PSA levels are useful in determining efficacy of treatment for prostate cancer. 1. Incorrect: Radiologic studies are not screening tools for this disease. Abdominal xrays can show the size, shape and position of abdominal organs. 2. Incorrect: Hypercalcemia may indicate cancerous bone involvement, but it's not a screening tool. Hypercalcemia is a condition in which the calcium level in the blood is above normal. 4. Incorrect: MRI is a diagnostic tool, not a screening tool. MRI is a test using magnetic fields to produce images of body structures.
The nurse overhears two nursing students talking about a client in the cafeteria. What should the nurse do first? 1. Report the incident to the nursing supervisor. 2. Write up a variance report about the incidence. 3. Instruct the students that this is a violation of HIPAA. 4. Notify the students' faculty regarding the violation.
3. Instruct the students that this is a violation of HIPAA. 3. Correct: The students should first be told of their violation of HIPAA and that they should stop immediately. Then the nurse should follow policy as to whether anyone else should be notified. 1. Incorrect: The students should be reminded about HIPAA violations, and instructed to not talk about clients. Yes, this should be reported per policy, but this should not be the first action. 2. Incorrect: The nurse variance report is to be completed according to the health care institution's policy. But this is not done first. Stop the violation from occurring first. 4. Incorrect: Yes, this is an appropriate action, but it should not be the first action. Stop the violation from occurring first. 1. Nurses are required to practice within the laws of the state and within federal laws, such as HIPAA.
A client is returned to the surgical unit following gastric/esophageal repair of a hiatal hernia, with an IV, NG tube to suction, and an abdominal incision. To prevent disruption of the esophageal suture line, what is most important for the nurse to do? 1. Monitor the wound for drainage. 2. Give ice chips sparingly. 3. Maintain the patency of the NG tube. 4. Monitor for the return of peristalsis.
3. Maintain the patency of the NG tube. 3. Correct: Maintain the patency of the NG tube. On ANY post-op client, the nurse is responsible for preventing disruption of the suture line. (Disrupture of any suture line, since disruption could be life-threatening.) The nurse is responsible for keeping the NGT patent to prevent accumulations of gastric secretions and blood in the stomach. Accumulation of fluid in the stomach can cause pressure on the suture line and places the client at risk for disruption of the suture line and hemorrhage. The nurse knows NEVER to allow pressure or stretching on suture lines. 1. Incorrect: Monitoring the wound for drainage is important, but when there is something more life-threatening, that is the priority answer. Disrupting the sutures is more life-threatening. 2. Incorrect: This person is ABSOLUTELY NPO. Giving ice chips is contraindicated as it could disrupt the suture lines. 4. Incorrect: It is important to monitor for return of peristalsis, but this is not life-threatening.
The nurse is admitting a client with a fifteen year history of poorly controlled diabetes mellitus. During the initial data collection, the client reports experiencing "numb feet." What is the nurse's first action? 1. Check blood glucose level. 2. Check for proper shoe size. 3. Observe the client's feet for signs of injury. 4. Test sensory perception in the client's feet.
3. Observe the client's feet for signs of injury. 3. Correct: Clients with decreased peripheral sensation are at risk for injury to the extremity. They may sustain an injury and be unaware the injury has occurred. In addition to this, diabetics are at risk for poor wound healing (related to impaired circulation) and infection (related to elevated glucose levels). This is the option that should be performed first and takes priority. 1. Incorrect: Checking a fasting blood glucose level is important, but it is not the FIRST action to be taken. Checking the blood glucose level does not fix the problem. The problem is potential risk for injury. 2. Incorrect: Diabetics need well-fitting shoes because the nerves and vessels that go to the feet can be damaged by poorly controlled blood sugar. Check the client first. 4. Incorrect: Checking the sensation in the feet is not fixing the problem. It will be done later but risk for injury is the priority because the client has numbness of the feet. Option 1 can be ruled out because it is not focusing on the feet. Option 2 can be ruled out because the client should be checked first. Option 3 is the initial data collection that should be performed. What are you worried about when a client cannot feel? Injury. That is the worst possible problem here, so it takes priority. Option 4 can be eliminated because the stem told the test taker that the client has "numbness in the feet".
A client returns to the room post appendectomy. In what position should the nurse place the client?
3. Semi-fowler's 3. Correct: After any major abdominal surgery, the position of choice is to elevate the head of the bed 35-45 degrees. This will decrease pressure on the abdomen and suture line.
The nurse is performing morning care on a client on the medical unit. What should the nurse do after changing a client's bed linen? 1. Hold the linen close to the body while transporting it to the dirty utility room. 2. Wear a gown and gloves to transport the linen to the biohazard container. 3. Place the linen into a leak proof container sitting outside the room. 4. Place the linen in a pillow case and set it on the floor until client care is completed.
3. Place the linen into a leak proof container sitting outside the room. 3. Correct: Soiled linen should be placed in a leak proof container for transport off the unit to the laundry. Make sure the linen bags are not overfilled which would prevent complete closure. 1. Incorrect: Linen should be held away from the body to prevent contamination of the nurse's clothes. The linens should be handled as little as possible to avoid possible contamination of air, surfaces, and persons. 2. Incorrect: Gloves should always be worn when handling soiled linen. A gown is not necessary. Soiled linen should be carried away from the body with minimal handling to prevent contamination. 4. Incorrect: Soiled linen should not be placed on the floor. All linens should be handled and transported in a way that will minimize contamination and maintain a clean environment for the client, healthcare workers, and visitors.
A nurse is caring for a client who was brought into the ED with a gunshot wound to the chest. There is an occlusive dressing in place and the client is receiving high flow oxygen. The nurse notes a deviated trachea, asymmetrical chest wall movement and decreased breath sounds bilaterally. What action should the nurse take first? 1. Elevate the head of the bed. 2. Initiate CPR. 3. Remove the occlusive dressing. 4. Notify the primary healthcare provider.
3. Remove the occlusive dressing. 3. Correct: The client has developed a tension pneumothorax as evidenced by these signs/symptoms. This developed as a result of the placement of an occlusive dressing over the chest wound. By removing the occlusive dressing the pressure pushing to the opposite side of the chest should stop. Dressings over "sucking chest wounds" should be taped down on 3 sides only to allow air to escape but not re-enter. A needle decompression may be required as an emergency measure. 1. Incorrect: Although elevating the HOB typically helps ease the effort of respirations, in this case, it will not fix the tension pneumothorax. 2. Incorrect: It is not necessary to start CPR at this point. The client has not arrested. The client needs emergency relief measures such as removal of dressing and possible needle decompression to prevent further deterioration and possible cardiopulmonary arrest. 4. Incorrect: Call the primary healthcare provider after removing the occlusive dressing. This is an emergency situation. Attempts to resolve the issue are crucial to prevent further deterioration of the client's condition. 1. Never delay treatment or choose an option that ignores client symptoms. 2. Identify clues in the stem. Generally, the stem is short and contains only the information needed to make the question clear. A clue is the use of a word or phrase that leads you to the correct answer. The clue shows a relationship to word or phrase in the correct answer. Clues indicate that the client has a tension pneumothorax due to the occlusive dressing over the chest wound.
A client is diagnosed with a duodenal ulcer due to Helicobacter pylori (H Pylori). In addition to antibiotic therapy, the nurse anticipates that the client will also receive what class of pharmacologic agents? Select All That Apply 1. Miotic inhibitor 2. Serotonin antagonist 3. H2 antagonist 4. Acetylsalicyclic acid 5. Proton pump inhibitor
3., & 5. Correct: H2 antagonist or receptor blockers are used to decrease excess stomach acid seen with ulcers. Antisecretory agents like proton pump inhibitors are indicated for the treatment of peptic ulcer disease. Antisecretory agents decrease the secretion of gastric acids. Protein pump inhibitors, a combination of antibiotics and bismuth salts are most commonly used for treatment of H Pylori.
Which task would be most appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Obtain a sterile urine specimen from an indwelling catheter. 2. Insert an in-and-out catheter on a postpartum client. 3. Take vital signs on a client 12 hours postpartum. 4. Remove an indwelling catheter on a postpartum client. 5. Perform perineal care on a client with an episiotomy.
3., & 5. Correct: Taking vital signs is within the scope of practice for the UAP, but the nurse is responsible for reviewing the vital signs. Performing perineal care is within the scope of practice for the UAP. The nurse is responsible for assessing the episiotomy and confirming that perineal care is done properly. 1. Incorrect: Invasive procedures are not appropriate tasks for UAP (obtaining sterile specimen from indwelling catheter). 2. Incorrect: Invasive procedures are not appropriate tasks for UAP (inserting catheter). 4. Incorrect: Invasive procedures are not appropriate tasks for UAP (removing indwelling catheter).
The nurse, caring for a client on the medical unit, receives a primary healthcare provider prescription for penicillin 100,000 units IM. The drug label reads penicillin 300,000 units/mL. How many mL of this medication should the nurse administer? Round answer using two decimal points.
300,000 units : 1 mL = 100,000 units : x mL 300,000 x = 100,000 x = 0.33
the nurse is caring for a client sustained a closed -head injury.Which of the following findings would requiere immediate intervention? 1.echymotic area over the left temple 2.Glasgow coma scale score of 23 3.blood pressure of 136/76 4.headache that worsen with coughing
4
During a conversation with a client on a psychiatric unit the client tells the nurse, "Everyone here hates me." Which response by the nurse is best? 1. "No, they do not hate you." 2. "What did you do to make others not like you?" 3. "Just don't pay attention to what others think of you." 4. "I can't speak for the other people, but I don't hate you."
4. "I can't speak for the other people, but I don't hate you." 4. Correct: Here the nurse is speaking only for the nurse. The nurse cannot legitimately speak for anyone else. The nurse must model the process of not speaking for anyone else. The response also lets the client know that the nurse cares about the way the client feels. 1. Incorrect: This is arguing and defending which are non-therapeutic communication techniques. The nurse does not know how the others on the unit feel about the client, so this may not be a true statement. Arguing with a client's belief can further upset or anger the client and leads to mistrust of the nurse. 2. Incorrect: This is agreeing with the client that everyone hates the client. It also puts the client on the defense by implying that the client is at fault for doing something that made everyone hate the client. This response reinforces the client's false belief. 3. Incorrect: This is using denial. This is where the nurse denies that a problem exists and blocks the discussion with the client. This avoids helping the client identify and explore the problem. This also dismisses the client's feelings.
A client's surgeon discusses the option of surgery, related benefits and risks with the client. Which statement by the client demonstrates understanding of the right to make decisions regarding treatment? 1. "The surgeon says that I need this operation, so I guess I had better go ahead and have it." 2. "I am not so sure that I want to have minor surgery, but my family will not even talk about other options." 3. "I am afraid to tell my surgeon about my hesitation to have this operation. The surgeon will think I am foolish, so I didn't mention it." 4. "The surgeon explained the risks and benefits of the operation to me, but the decision to have the surgery or to explore other options is mine."
4. "The surgeon explained the risks and benefits of the operation to me, but the decision to have the surgery or to explore other options is mine." 4. Correct: A client has the right to make decisions regarding recommended treatment options and the proposed plan of care. 1. Incorrect: Ultimately the decision is the client's to make, not the client's primary healthcare provider or the client's family members. 2. Incorrect: Ultimately the decision is the client's to make, not the client's primary healthcare provider or the client's family members. 3. Incorrect: The decision should be made after careful consideration of the risks and benefits.
What is the priority nursing intervention for a client with carbon monoxide poisoning? 1. Connect to an O2 saturation monitor. 2. Hyperventilate with an ambu bag. 3. Send to radiology for a ventilation/perfusion scan. 4. Administer 100% O2 per nonrebreather mask.
4. Administer 100% O2 per nonrebreather mask. 4. Correct: How do you treat carbon monoxide poisoning? It is treated with 100% oxygen. 1. Incorrect: Treatment is not monitoring. Do something. Yes, we want to monitor the client's O2 sat, but remember to start the oxygen first. Additionally, what will the O2 sat reading look like? It will look good because it is just telling us that something has attached to the hemoglobin. But what is attached here? Carbon monoxide. We will need ABGs. 2. Incorrect: Hyperventilation is used when there is acidosis. We have not been told the client's respiratory rate. 3. Incorrect: This procedure may be appropriate for emboli in the lungs and pneumonia but not for carbon monoxide poisoning.
The charge nurse is making client assignments. Which assignments are appropriate for a licensed practical nurse to perform? 1. Assessment of newly admitted diabetic. 2. Prepare discharge planning for a client diagnosed with Parkinson's disease. 3. Provide care to client requiring multiple blood transfusions. 4. Care for a one day post op mastectomy client. 5. Insert an indwelling urinary catheter for the client scheduled for surgery.
4. Care for a one day post op mastectomy client. 5. Insert an indwelling urinary catheter for the client scheduled 4. & 5. Correct: The LPN can care for stable clients with predictable outcomes and can insert an indwelling urinary catheter.1. Incorrect: The RN is ultimately responsible for the assessment of a newly admitted client.2. Incorrect: The RN cannot delegate parts of the nursing process including planning of care: discharge planning.3. Incorrect: RNs need to care for complicated, unstable clients requiring IV medications, IVPs, blood transfusions, etc...
Which observation by the nurse would demonstrate normal development of an infant during a well child clinic visit? 1. Eight month old infant who requires support to maintain a sitting position. 2. Twelve month old infant who can only say 2 words 3. Four month old infant who is fearful and cries when the nurse approaches. 4. Eleven month old infant who can only stand by holding onto the walls.
4. Correct: It is normal for 11 month old infants to "cruise" by holding onto furniture and walls. Children have until 22 months to walk independently. 1. Incorrect: By age 8 months, an infant should be able to sit securely without any additional support. This is a major developmental milestone and should be noted. 2. Incorrect: By 12 months of age, an infant should be able to say two words other than "ma-ma" and "da-da". The words should be used with meaning. 3. Incorrect: By six months, infants are aware of the difference between people who regularly care for them and strangers. By age 7 months, infants begin to show obvious fear of strangers.
Which food choice by a client taking isonizid indicates to the nurse that teaching has been successful? 1. Salad with Blue Cheese dressing 2. Smothered liver with onions 3. Smoked salmon 4. Pear salad
4. Correct: Pears are acceptable fruit. 1. Incorrect: Foods high in tyramine such as salads with Blue Cheese dressing can result in severe reactions when client is taking isonizid. Other foods high in tyramine: aged cheese, red wine, soy sauce, yeast extracts. 2. Incorrect: Foods high in tyramine such as smothered liver with onions can result in severe reaction when client is taking isonizid. Other foods high in tyramine: aged cheese, red wine, soy sauce, yeast extracts. 3. Incorrect: Foods high in tyramine such as smoked salmon can result in severe reactions when client is taking isonizid. Other foods high in tyramine: aged cheese, red wine, soy sauce, yeast extracts.
A nurse enters a client's room to find the client on the floor having a grand mal seizure. What action should the nurse take? 1. Wrap the client tightly in a blanket as a restraint. 2. Insert a padded tongue blade in the client's mouth. 3. Assist the client back into the bed. 4. Place a towel or sheet under the client's head.
4. Correct: Placing a towel or sheet under the client's head prevents further injury to the client.1. Incorrect: Restraining the client may cause further injury to the client. 2. Incorrect: Forcing an object into the client's mouth can result in choking the client or injuring the client's teeth and mouth.3. Incorrect: Lifting the client may cause injury to the nurse and client.
The nurse is caring for a client who has been in Russell's traction for four days. Which finding would require immediate action by the nurse? 1. Absence of indentations in the popliteal space. 2. Hypoactive bowel sounds to all abdominal quadrants. 3. Bilateral pedal pulses with doppler. 4. Report of sharp pain to right upper anterior chest wall.
4. Correct: Report of sharp pain to the chest is one sign of pulmonary embolus and should be investigated immediately. A pulmonary embolism is the blockage of a major blood vessel in the lung caused by a blood clot. Pulmonary embolism can be life-threatening. 1. Incorrect: Checking the popliteal space for signs of pressure from the sling such as redness, indentations, abrasions, or pain is essential but not immediate. 2. Incorrect: Immobility can lead to hypoactive bowel sounds. They may indicate that digestion and gastrointestinal activity has slowed down. This does not take priority over the potential embolus. 3. Incorrect: Bilateral pedal pulses heard with Doppler is a normal finding and would not require action by the nurse.
Post cataract removal, a client reports nausea and severe pain in the operative eye. Which nursing intervention takes priority? 1. Administer morphine and ondansetron. 2. Reposition client to non-operative side. 3. Massage the canthus to unblock the lacrimal duct. 4. Notify the primary healthcare provider.
4. Correct: Severe pain and nausea indicate an increase in intraocular pressure and must be reported at once. Eye damage can result if not resolved quickly. The primary healthcare provider may prescribe medications or take the client back to surgery. 1. Incorrect: This is not the priority, as severe pain and nausea indicate an increase in intraocular pressure and must be reported at once. 2. Incorrect: Repositioning will not fix the problem. Severe pain with nausea indicate an increase in intraocular pressure and must be reported at once. 3. Incorrect: The problem is an increase in intraocular pressure which needs to be reported to the primary healthcare provider.
When preparing a client for surgery, the nurse realizes the operative permit has not been signed. The client verbalizes to the nurse understanding of the procedure, but the client had received preoperative medication approximately 10 minutes ago. What would be the appropriate action by the nurse? 1. Have the client sign the permit, as understanding was verbalized. 2. Witness the form after having the client sign it. 3. Have the spouse sign the form as she witnessed his statement that he understands. 4. Call the surgical area and explain that the surgery will have to be cancelled.
4. Correct: The client must sign the operative permit or any other legal document prior to taking preoperative drugs that can affect judgment and decision-making capacity. 1. Incorrect: The client's verbal understanding does not override the fact that medication had been received that can alter thought processes and decision-making. 2. Incorrect: Witnessing would not make this document legal. The consent would not be valid because the client has already received the pain medication that could alter the thought process. 3. Incorrect: When a client is of legal age (unless an emancipated minor) and of sound mind, it would be inappropriate for the spouse to sign the form for surgery. In order to be valid, it must be the client who signs it, unless there is a legal power of attorney, durable power of attorney, or healthcare surrogate. Do not choose an option that violates a client's rights, a stated policy, or a federal legislation, such as HIPAA.
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 of 440 ml over previous 8 hour shift. 4. Heart rate 56/min
4. Correct: This is a beta blocker. 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. 1. Incorrect: If the client's BP drops below 90/60 this beta blocker should be held and the primary healthcare provider notified. 2. Incorrect: This is a normal glucose level. If the client is a diabetic, beta blockers can mask the signs of hypoglycemia. 3. Incorrect: Urinary output is adequate. Beta blockers do not alter renal function.
The primary healthcare provider has prescribed KCL 20 mEq by mouth once a day. The pharmacy has dispensed KCL 8 mEq/5 mL. How many mL will the nurse administer? Round answer using one decimal point.
8 mEq : 5 mL = 20 mEq : x mL 8 x = 100 x = 12.5
An LPN/VN from the maternity unit is pulled to the medical-surgical unit for the first four hours of the shift. When the LPN/VN is receiving assignments from the charge nurse, which client assignment would be considered inappropriate? 1. Client with rheumatic fever 2. Client scheduled for an appendectomy 3. Client one day post cardiac catheterization 4. Client diagnosed with Methicillin-Resistant Staphylococcus Aureus
4. Correct: This client is contagious and should not be delegated to the maternity nurse. The nurse will be going back to the maternity unit after four hours and will be a potential agent for spreading the infection. Client safety could be compromised. 1. Incorrect: Rheumatic fever is an inflammatory disease that can develop later as a complication of untreated or inadequately treated Group A beta hemolytic strep infections such as strep throat and scarlet fever. It is not contagious at this point, so the maternity nurse could be assigned to this client. 2. Incorrect: The maternity nurse should have the knowledge and skill needed to provide preop care to a client scheduled for a routine appendectomy. This nurse routinely cares for preop surgical clients on the maternity unit. 3. Incorrect: Since the client who had a cardiac catheterization is one day post procedure, the client is stable and could be appropriately assigned to the maternity nurse if needed. In this question, a maternity nurse is pulled to a medical surgical unit for four hours and will then return to the maternity unit. This nurse specializes in maternity nursing, so consider her a brand new nurse on the med surg unit. Do not assign this nurse unstable clients. Also, keep in mind that the nurse will be going back to care for new moms and babies. Think safety and infection control! Let's look at the options. Option 1 is a client with rheumatic fever. Fever scared you, didn't it? But is this disease contagious? No. Rheumatic fever is an inflammatory disease that develops as a complication of untreated or inadequately treated Group A beta hemolytic strep infections such as strep throat and scarlet fever. It is not contagious at this point, so the maternity nurse could be assigned to this client. Option 2 is a client scheduled to have an appendectomy. The maternity nurse should have the knowledge and skill needed to provide preop care to a client scheduled for a routine appendectomy.This nurse routinely cares for preop surgical clients on the maternity unit. Option 3, a client one day post cardiac cath? Since the client who had a cardiac catheterization is one day post procedure, the client is stable and could be appropriately assigned to the maternity nurse if needed. Look at option 4, the client diagnosed with MRSA? Are you going to assign the maternity nurse to this client for four hours then send her back to moms and newborns? I hope not. This client is contagious and should not be delegated to the maternity nurse. The nurse will be going back to the maternity unit after four hours and will be a potential agent for spreading the infection. Client safety could be compromised.
A client with Bell's palsy is having difficulty eating. Which action will be most helpful? 1. Respect her desire for privacy and leave her alone while she eats. 2. Provide a liquid diet high in protein and calories that she can easily swallow. 3. Assure the client that it does not bother others to observe her while she eats. 4. Teach the client to chew her food on the unaffected side of her mouth for better control.
4. Correct: This will decrease the risk of aspiration. 1. Incorrect: The nurse knows a client at risk for aspiration should NOT be left alone when eating. 2. Incorrect: Liquids are difficult for the client to manage as lip closure and chewing are impaired. 3. Incorrect: Focuses on other clients not on the client identified in the question.
The unlicensed assistive personnel (UAP) reports to the nurse that a client with Alzheimer's disease has been walking into rooms on the unit and stating, "This is my room, so get out!" What is the best instruction the nurse can give to the UAP? 1. Calmly sit with the client and have the client repeat the room number at frequent intervals. 2. Have the client remain in own room so the client can become familiar with it. 3. Place a sign on the client's door with the client's name. 4. Hang a familiar object on the door to enhance room recognition.
4. Hang a familiar object on the door to enhance room recognition. 4. Correct: A client with Alzheimer's is likely to recognize a familiar object before reading the name on the door. 1. Incorrect: You can make the client repeat the room number over and over, but he or she will not remember it, particularly since it is short-term current memory. This is the part of memory that goes first with the Alzheimer's client. 2. Incorrect: Stay in your room until you get used to it? No, this is non-therapeutic for a client with Alzheimer's and could increase their confusion and moody behavior. 3. Incorrect: This seems like an appropriate answer, but clients with Alzheimer's may not recognize their own name or take the time to read.
Which dietary consideration is most important for the nurse to reinforce to a client with hypothyroidism? 1. Increase carbohydrate intake. 2. Decrease fluid intake. 3. Avoid shellfish. 4. Increase fiber.
4. Increase fiber. 4. Correct: A symptom of hypothyroidism is constipation due to the decreased mobility of the intestinal tract. Client's with hypothyroidism should increase their dietary fiber to prevent constipation.
A client has returned to the burn unit after an escharotomy of the forearm. What is the priority nursing intervention? 1. Roll sterile q-tip over the wound 2. Elevate the affected arm 3. Ask the client to rate pain level 4. Monitor bilateral radial pulses
4. Monitor bilateral radial pulses 4. Correct: An escharotomy is an incision of the eschar of a burned arm to decrease the tension in the proximal tissue. This will result in increased circulation to the proximal tissue. The monitoring of bilateral radial pulses needs to be done to check for adequate circulation. 1. Incorrect: Removal of air or fluid by rolling a sterile q-tip over the wound would be an appropriate action for a client with a graft on the forearm. This is not appropriate for the incision of the burned arm. 2. Incorrect: After an escharotomy, elevating the affected arm is an appropriate intervention. Monitoring of the circulation in the arm should be performed first. Circulatory checks are priority. 3. Incorrect: Pain is also an indicator of adequate circulation. Monitoring of distal pulses first will provide a more concise assessment of the circulation in both arms.
The nurse notes continuous bubbling in the water seal chamber of the chest tube system. What should be the nurse's initial action?
4. Notify the healthcare provider. 4. Correct: Continuous bubbling in the water seal chamber indicates that there is an air leak in the system. The healthcare provider should be notified. The healthcare provider may prescribe for the tube to be clamped at intervals along the tube for only a few seconds to determine the location of the air leak, but clamping of the tube should never be done without a prescription.
Which client must the nurse assign to a private room? 1. Primiparous client who delivered twins at 28 weeks gestation two days ago 2. Postpartum client on IV Ampicillin and Gentamicin for chorioamnionitis 3. Postpartum client whose 2 hour old infant is being worked up for sepsis 4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C)
4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C) 4. Correct: A temperature of 100.5° F (38.05° C) or greater in a client more than 24 hours postpartum is likely an indication of infection. This client should be kept separate from other mothers and babies. 1. Incorrect: The preterm twins are in the NICU and not in their mother's room (a client with term twins would need a private room because of space considerations). 2. Incorrect: Chorioamnionitis is not contagious. 3. Incorrect: The infant may have an infection and will remain in the NICU. The mother is not infected. 1. Client safety is always a priority. 2. The test taker would need basic knowledge about postpartal care to answer this question easily, but some clues may be found in the stem. 3. The nurse must be aware of risk factors that cause diseases. If the test taker does not know the correct answer, think about which body system the question is asking about may help rule out or rule in some of the option
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 and 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 to the client between meals.
4. Provide high protein, high calorie snacks to the client between meals. 4. Correct: 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 during the manic phase. 1. Incorrect: The client in the acute phase of mania may have difficulty sitting still long enough to eat a meal. By offering finger foods or foods that can be eaten on the run, the client's food intake may increase. Also the word "all" is too limiting. 2. Incorrect: The client's diet should include the client's food preferences, but not just those foods. The word "only" is too limiting. 3. Incorrect: The client will be easily distracted when manic. Eating in the dining room with other clients may decrease the amount of food intake.
After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse collect data on first? 1. Admitted 3 hours ago post appendectomy with small amount of drainage on dressing. 2. Diagnosed with early onset of Alzheimer's disease with confusion. 3. Post operative internal fixation of the femur with crust forming on the Steinman pins. 4. Receiving treatment for dehydration, and is now picking at bedding and IV tubing.
4. Receiving treatment for dehydration, and is now picking at bedding and IV tubing. 4. Correct: Being restless is an early sign of hypoxia, so oxygen may be necessary. Remember oxygenation takes priority over the other issues with these clients. The client may also be exhibiting manifestations of fluid volume deficit (FVD) 1. Incorrect: This is a stable client, so no indication of immediate distress is indicated. A small amount of drainage on the dressing of a client who had a appendectomy 3 hours ago would not be assessed first. 2. Incorrect: This is a stable client because confusion is part of Alzheimer's disease. Safety issues for a confused client should be evaluated. The client with dehydration is exhibiting possible manifestations of decreased oxygen level and/or fluid volume deficit (FVD) and should be assessed first. 3. Incorrect: This is a stable client with no indication of immediate distress. Crust forming on the Steinmann pins should be removed from the pin insertion site. However, this client would not be given priority over the client with dehydration.
A client asks the nurse, "What causes hypermagnesemia?" The nurse should reinforce to the client that hypermagnesemia can occur secondary to what health problem? 1. Peripheral vascular disease 2. Dehydration 3. Liver failure 4. Renal insufficiency
4. Renal insufficiency 4. Correct: Magnesium is excreted primarily through the kidneys. When the client experiences renal insufficiency, magnesium is held. The incidence of hypermagnesemia is rare in comparison with hypomagnesemia, and it occurs secondary to renal insufficiency. 1. Incorrect: Peripheral vascular disease does not lead to hypermagnesemia 2. Incorrect: Dehydration leads to the electrolyte imbalance of hypernatremia, it does not cause hypermagnesemia. A client who has become dehydrated due to excessive urination may experience hypomagnesemia. 3. Incorrect: Liver failure does not lead to hypermagnesemia. Magnesium is regulated by GI absorption and renal excretion.
The nurse has been talking with a depressed client at an outpatient clinic. When asked how the client feels to live alone, the client simply stares straight ahead. How should the nurse respond? 1. Ask, "Why won't you answer me?" 2. Leave the client alone for awhile. 3. Tell a joke to lighten the mood. 4. Use therapeutic silence.
4. Use therapeutic silence. 4. Correct: Use of silence allows the client time to think over what he or she wants to say and gives the client a chance to collect thoughts. 1. Incorrect: This is not therapeutic and appears aggressive and confrontational. 2. Incorrect: This is not therapeutic. Depressed clients may need extra time to formulate their thoughts. 3. Incorrect: This is not therapeutic and demonstrates disregard for the client's feelings. 1. Nurses need to use interviewing techniques to effectively communicate in a nonthreatening way with clients. 2. The nurse must deliver care in a nonjudgmental manner.
side effects of oxytocin
Hypotension, tachycardia, chest pain/coronary artery spasm, cardiac dysrhythmias, hypertension
strategies
Identify key words in the stem that set a priority, such as first, initially, best, priority, safest, most. These words modify what is being asked. This question requires you to put a value on each option and then place them in rank order. If you are having difficulty ranking the options, eliminate the option that you believe is most wrong among the options.
Tiotropium
Spiriva COPD
Aspirin toxicity symptoms
Tinnitus bruising Melena
"The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is appropriate ?
"Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.
The parent of a toddler who is being treated for suspected poisoning asks, "Why is activated charcoal used?" What is the best response by the nurse?
"Activated charcoal binds with the poison to limit absorption in the digestive tract." Correct Response Treatment with activated charcoal is a method for removing ingested poisons from the gastrointestinal (GI) tract. Activated charcoal is an inert substance that adsorbs drugs and other chemicals. Because charcoal particles cannot be absorbed into the blood, adsorption of poisons into the charcoal prevents toxicity. The charcoal-poison complex is eliminated in the stool. Clients should be advised that charcoal will turn the feces black.Activated charcoal has the consistency of a fine powder and is mixed with water (or juice) for oral administration. The adult dose is 25 to 100 gm. Pediatric doses range from 25 to 50 gm. When administered within 30 minutes after poison ingestion, charcoal can adsorb about 90% of the dose. However, if given 60 minutes after poison ingestion, the amount adsorbed decreases to only 37%. Therefore, charcoal should be given as soon as possible after poison exposure.
A 17 year-old male seeking treatment at a clinic reports having fever and chills for several days. The client states that every time he gets sick, his mother sends him to the clinic because she thinks he has human immunodeficiency virus (HIV). What is an appropriate response by the nurse? "Are you concerned that you may have HIV?" "She's just worried about you." "Have you ever given her a reason to think that way?" "Are you sure that's what your mother says?"
"Are you concerned that you may have HIV?" Correct! All the nurse knows is what the client is reporting. The nurse does not know if, in fact, the client's mother is actually concerned about HIV. The most therapeutic response is to ask the client if he is concerned about HIV. Asking an open-ended question should encourage the client to express his feelings and concerns. The nurse should also reassure him that even though he is a minor, any information he discloses is confidential and will not be shared without his consent or without legal justification. Should the client disclose that he is concerned that he has HIV, the nurse will need to determine more information about the client's sexual relationship(s) and if they might involve abuse.
The nurse cares for a client diagnosed with pneumonia. During the admission interview, the client explains that her husband died a few months ago and states, "I don't seem to be able to sleep or eat now. I'm not sure I have anything to live for." Which of the following reflects an appropriate nursing response? (Select all that apply.) "Are you thinking of ending your life?" "Your loss is devastating and each person experiences grief differently." "You are grieving and if you don't feel better in another month, you should seek help for depression." "I'd like to know more about how you are doing and what you have used for support after your husband's death." "I need to pass medications, but I will call your daughter to come and talk to you."
"Are you thinking of ending your life?" Correct Response "Your loss is devastating and each person experiences grief differently." Correct! "I'd like to know more about how you are doing and what you have used for support after your husband's death." Correct! A client who has experienced the recent death of a spouse will express symptoms of grief that are similar to symptoms of depression. The nurse may not have the expertise or time to differentiate between grief and depression but, based on the client's statement, the nurse should recognize there's a potential for suicide; the nurse should directly ask the client if she is contemplating suicide. Using therapeutic communication and offering of self, the nurse should acknowledge the client's feelings. Offering to call a social worker or family member may be a part of a conversation (and plan of care) after the nurse has engaged in a therapeutic exchange with the client.
The hospice nurse is orienting a new unlicensed assistive person (UAP) about the care of dying clients. Which statement by the UAP indicates an understanding of hospice care? "To help clients conserve energy, I will perform as much care as possible for my clients." "I should discourage clients from talking about their lives." "Developing personal relationships with clients is an important part of my role." "Even if the client requests it, I will not withhold health care information from the hospice team."
"Even if the client requests it, I will not withhold health care information from the hospice team." Correct Response The UAP should encourage clients to be as independent as possible, for as long as possible. Clients should be encouraged to discuss their life because it may help clients accept their death. Establishing and maintaining a professional relationship (as opposed to a personal relationship) is important in any health care setting, including hospice. There should be no secrets. If the UAP has information that may potentially help the hospice team provide appropriate client care, then it needs to be shared with the team.
"A 62-year-old male client with paranoid schizophrenia tells a nurse that he sexually molests his cousin. He tells the nurse that he's never told anyone and begs her to keep his secret. Which action should the nurse take?
"Document the details of the conversation and notify the nursing supervisor.
"A client, age 36, with paranoid schizophrenia believes the room is bugged by the Central Intelligence Agency and that his roommate is a foreign spy. The client has never had a romantic relationship, has no contact with family members, and hasn't been employed in the last 14 years. Based on Erikson's theories, the nurse should recognize that this client is in which stage of psychosocial development?
"Trust versus mistrust"
An adolescent client is being treated for polysubstance abuse. The client states, "I don't need to give up marijuana because it is legal and doesn't harm me." Which of the following statements is the most appropriate response? "Evidence shows that marijuana has negative effects in the brain, heart and lungs." "Some people may not experience health problems from marijuana." "Marijuana smoking is unhealthy, but not as harmful as smoking cigarettes." "It will depend upon how much marijuana is smoked."
"Evidence shows that marijuana has negative effects in the brain, heart and lungs." Correct! Marijuana's active ingredient THC binds with the opioid mu (μ) receptor in the brain and blocks dopamine reuptake. Not only is marijuana addictive, its use results in impaired ability to form memories, recall events and shift attention. Due to the same carcinogens as tobacco, smoking marijuana has negative cardiovascular and respiratory effects. Imparting factual knowledge to the adolescent is the first step in opening a discussion about marijuana use. While many people who smoke marijuana do not experience immediate major health problems, there is increasing evidence that adolescents are more vulnerable to the harmful effects than adults. Therefore, minimizing the risk is not an appropriate response. While the amount of smoking may make some difference, the response that equivocates the effects of marijuana on adolescents is not an accurate nursing response.
How should the nurse respond to a pregnant client who asks, "How will I know when it is time to go to the hospital?" 1. "Go to the hospital immediately if your membranes rupture." 2. "You should leave for the hospital as soon as you lose your mucus plug." 3. "Go to the hospital when you have a burst of energy followed by a backache." 4. "You need to go to the hospital when contractions are 2 minutes apart."
"Go to the hospital immediately if your membranes rupture." 1. Correct: Yes! This is the appropriate information. A gush or trickle of fluid from the vagina should be evaluated regardless of whether contractions are occurring. Infection and compression of the umbilical cord are possible complications. 2. Incorrect: No. The mucus plug is lost prior to the beginning of active labor, so too early to go to the hospital. Some women lose their mucus plug weeks before labor begins, others lose it right as labor starts. 3. Incorrect: Nesting? That's too early and not specific enough. This is not labor. 4. Incorrect: The client should go when contractions are 5 minutes apart, for 1 hour if it is her first pregnancy. Labor may be faster for the woman who has given birth before than for the nullipara. Multiparas are instructed to go to the hospital when contractions are regular, 10 minutes apart, for 1 hour.
The nurse is providing care for a client who was recently diagnosed with end-stage heart failure. The client does not have advance directives in place. Which of the following statements by the nurse would be appropriate? (Select all that apply.)
"Have you discussed your wishes regarding resuscitation with your health care provider?" Correct! "What does your family know about your condition and prognosis?" Correct "Have you thought about what you want done as your disease progresses?" Correct! Approximately half of all deaths from heart failure are sudden and without warning. It is important to assist the client and family in planning for the possibility of sudden cardiac death at home. The nurse should discuss advance directives with the family and encourage them to develop a plan of action that addresses the client wishes. Although heart transplants are an option for clients with heart failure, discussions about treatment options (including a transplant) are the responsibility of the health care provider, not the nurse. Asking the client about their current understanding of the disease will help the nurse determine what additional education might be needed. Although it might be helpful for family members to know how to perform CPR, it is not appropriate for the nurse to request CPR certification.
The nurse is providing care for a client who was recently diagnosed with end-stage heart failure. The client does not have advance directives in place. Which of the following statements by the nurse would be appropriate? (Select all that apply.) "Someone in your family needs to learn how to do cardiopulmonary resuscitation (CPR)." "Have you thought about your options for a heart transplant?" "What does your family know about your condition and prognosis?" "Have you thought about what you want done as your disease progresses?" "Have you discussed your wishes regarding resuscitation with your health care provider?"
"Have you thought about what you want done as your disease progresses?" Correct! "Have you discussed your wishes regarding resuscitation with your health care provider?" Approximately half of all deaths from heart failure are sudden and without warning. It is important to assist the client and family in planning for the possibility of sudden cardiac death at home. The nurse should discuss advance directives with the family and encourage them to develop a plan of action that addresses the client wishes. Although heart transplants are an option for clients with heart failure, discussions about treatment options (including a transplant) are the responsibility of the health care provider, not the nurse. Asking the client about their current understanding of the disease will help the nurse determine what additional education might be needed. Although it might be helpful for family members to know how to perform CPR, it is not appropriate for the nurse to request CPR certification.
The LPN/VN is collecting health assessment data from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider? 1. "When I was 8 years old I had chickenpox." 2. "I had rheumatic fever when I was 10 years old." 3. "There is a strong history of gastric cancer in my family." 4. "I have pain in my hip with any movement."
"I had rheumatic fever when I was 10 years old." 2. Correct: After having rheumatic fever, a client would need to be pre-medicated with antibiotics prior to any surgical or dental procedure to prevent the development of infective endocarditis. 1. Incorrect: Chicken pox would have no implications on this surgery. 3. Incorrect: Cancer history in the family would have no implications for this surgery. 4. Incorrect: Pain in the hip is likely the reason for the surgery.
A severely injured client is moved into an examination area of the emergency department. The family member who accompanied the client to the ED is screaming at the nurse, saying that someone better start doing something right away. What is the best response by the nurse? "I need you to go to the waiting area. You can come back when you're more in control." "I'm going to give you a few minutes alone so you can calm down." "I can't think when you are yelling at me. Talk to me in a normal voice." "I know you are upset. But please control yourself and sit down. Otherwise I will have to call security."
"I know you are upset. But please control yourself and sit down. Otherwise I will have to call security." Correct! Most violent behavior is preceded by warning signs, such as yelling or swearing. The challenge for nurses is to apply interventions that de-escalate a person's response to stressful or traumatic events. The keys to effective limit setting are using commands to express the desired behavior and providing logical and enforceable consequences for noncompliance. Nurses should acknowledge the agitated person's feelings and be empathetic, reminding him or her that they are there to help.
"Every day for the past 2 weeks, a client with schizophrenia stands up during group therapy and screams, ""Get out of here right now! The elevator bombs are going to explode in 3 minutes!"" The next time this happens, how should the nurse respond?
"I know you think there are bombs in the elevator, but there aren't."
The nurse is providing education to a client who has been prescribed disulfiram for management of chronic alcohol use. Which of the following statements indicate that the client is a good candidate for disulfiram (Antabuse)? (Select all that apply.) "I must take the drug at bedtime if it makes me drowsy." "I will have to remember to take the drug within four hours of my last alcoholic drink." "I will take disulfiram for six months when I have completed supervised treatment." "I will need to wear medical identification to alert emergency personnel that I am taking this drug." "I will need to keep appointments for follow-up blood tests while I am taking this drug." "I am so glad that it will stop my cravings for alcohol."
"I must take the drug at bedtime if it makes me drowsy." Correct! "I will need to wear medical identification to alert emergency personnel that I am taking this drug." Correct! "I will need to keep appointments for follow-up blood tests while I am taking this drug." Correct Response\ Disulfiram is an inhibitor of aldehyde dehydrogenase, which blocks the oxidation of alcohol and allows acetaldehyde to accumulate. If clients use alcohol, they will experience flushing, tachycardia, nausea, and vomiting; this is why clients should wear or carry medical alert identification. Clients taking disulfiram may notice drowsiness when taking this medication and should take it at bedtime. There should be at least twelve hours between the last alcohol ingestion and taking disulfiram. Follow up blood tests for cardiac, liver and kidney functions are indicated. Disulfiram does not stop cravings for alcohol. Supervised disulfiram therapy may continue for months or even years.
The nurse has reinforced discharge instructions for a client diagnosed with glomerulonephritis. What statement by the client would indicate to the nurse that further teaching is needed?
"I should keep a record of the headaches I experience over 3 months." The client should report headaches sooner than 3 months to their primary healthcare provider. The headaches are related to the fluid retention due to the decreased filtration of the glomerulus. The retention of fluid will result in hypertension. This client will require additional discharge instructions.
A health care provider has written a discharge order and a prescription for a transdermal nitroglycerin patch for a client diagnosed with angina. Which statement by the client indicates an understanding about how to correctly use the medication? "I can remove the patch if my ankles swell." "I should put on a second patch if I have chest pain." "I will apply the patch to a non-hairy area of the body." "I will remove the patch when swimming or bathing."
"I will apply the patch to a non-hairy area of the body." Correct! The patch may be applied to any non-hairy area on the body. Contact with water, such as swimming or bathing, will not affect a transcutaneous medication system. Because two of the options involve removing the patch, you can eliminate these, leaving two options containing information about applying the patch. You should realize that it would be incorrect for someone to apply more than one patch at a time.
The outpatient sleep clinic nurse is reinforcing information about sleep for a client diagnosed with insomnia. Which of the following client statements indicate that the client understands the information? (Select all that apply.) "If I awaken during the night, I will stay in bed until I fall back asleep." "I will exercise a few hours before my bedtime to make me tired so I can sleep." "I will avoid drinking alcoholic beverages too close to bedtime." "I will keep a sleep log and to track my sleep and awake hours daily." "I will decrease my caffeine intake during the day and avoid coffee in the evening." "I will start a set of bedtime rituals that I will consistently use to help me fall asleep."
"I will avoid drinking alcoholic beverages too close to bedtime." Correct! "I will keep a sleep log and to track my sleep and awake hours daily." Correct! "I will decrease my caffeine intake during the day and avoid coffee in the evening." Correct Response "I will start a set of bedtime rituals that I will consistently use to help me fall asleep." Correct! Nurses can provide essential information to clients regarding symptom relief for insomnia. The client should use a sleep log, decrease caffeine intake overall and not drink caffeinated beverages in the evening, and establish a bedtime ritual. An increase in daily exercise is recommended; however, exercise within six hours before bedtime interferes with falling asleep and is not considered a part of good sleep hygiene. If the client awakens during the night, the client should get up and engage in a quiet, non-stimulating activity such as reading. Alcohol may speed the onset of sleep, but it disrupts sleep later in the night.
A client has received a prescription for nitrofurantoin to treat a urinary tract infection. Which of the following statements made by the client indicates the need for additional teaching about the medication?
"I will spend extra time in the sun to get plenty of vitamin D." Clients taking nitrofurantoin should avoid exposure to sunlight while taking the medication. Exposure to sunlight while taking this medication can lead to damage to the skin. A client planning to spend extra time in the sun while taking nitrofurantoin should be informed of the dangers of sun exposure and counseled to avoid sun exposure while taking the medication.Client statements reflecting the importance of taking the complete course of antibiotics, notifying the health care provider if a rash develops and taking the medication with food demonstrate correct understanding of important considerations while taking this antimicrobial therapy.
The nurse is caring for a 68 year-old client who had a total hip replacement three days ago. Which assessment finding requires the nurse's immediate attention? "I have to use the bedpan to pass my water at least every hour." "I have bad muscle spasms in my lower leg, below the incision." "I've been having a lot of trouble breathing for the past few minutes. I have a really bad feeling about this." "It seems that the pain medication is not working as well today."
"I've been having a lot of trouble breathing for the past few minutes. I have a really bad feeling about this." Correct! The nurse would be concerned about all of these comments, however the most life threatening is the respiratory focus (think ABCs). Clients who have had hip or knee surgery are at risk for developing pulmonary embolism. Sudden dyspnea, tachycardia and a feeling of impending doom are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Frequent urination may indicate a urinary tract infection, particularly since the client likely had an indwelling urinary catheter during surgery. Although the thought that medication is not effective requires further investigation, it is not life-threatening.
A client is admitted to an inpatient psychiatric unit for the purpose of alcohol detoxification. The client asks the nurse, "When will I be finished with my detox? I need to go home tomorrow and feed my dogs." Which of the following is a priority nursing response? "If withdrawal is uncomplicated, it will take two to four days for the physical symptoms to resolve." "You need to accept the program that your doctor has recommended for you." "If you have a seizure or start seeing things, it is best for you to be here where we can control you." "Let's see if you can get a pass to go out to feed your dogs."
"If withdrawal is uncomplicated, it will take two to four days for the physical symptoms to resolve." Correct Response In this situation, the nurse should respond factually to the client's request for information about the time period for treatment - that he should expect to be hospitalized for two to four days (if the withdrawal is uncomplicated). After that information is provided, subsequent conversations can take place about the client's animals. Advising the client to accept the program is not therapeutic. While it is true that a seizure or delirium tremens may necessitate interventions, not all clients experience these effects of alcohol withdrawal and the word "control" may alarm the client. Getting a pass to go home in the first 24 to 48 hours is not a correct response.
After talking with her partner, a client voluntarily admits herself to the substance abuse unit. The next day the client states to the nurse, "My partner told me to get treatment or we would have to get divorced. I don't believe I really need treatment, but I don't want my partner to leave me." Which response by the nurse would be of assistance to the client? "In early recovery it's quite common to have mixed feelings. I didn't know you had been pressured to come." "In early recovery it's quite common to have mixed feelings. Unmotivated people can't get well." "In early recovery it's quite common to have mixed feelings. Perhaps it would be best to seek treatment on an outpatient basis." "In early recovery it's quite common to have mixed feelings. Let's discuss the benefits of sobriety for you."
"In early recovery it's quite common to have mixed feelings. Let's discuss the benefits of sobriety for you." Correct! Submit Only the correct option focuses on the client and the client's problem (alcohol). This is the best response because it gives the client the opportunity to decrease ambivalent feelings by focusing on the benefits of sobriety. The other options are not therapeutic and do not have the client's best interests at heart. The option about being pressured to come might encourage clients to project blame for their behavior on someone else. The option of outpatient care might be a goal for this client, but it is inappropriate to suggest outpatient counseling at this time. To label the client's behavior as "unmotivated" might simply reinforce the client's ambivalence about treatment.
Michael, the nurse, worked the night shift and is giving a change of shift report to the oncoming nurse. Mr. Evans approaches the two nurses and asks, "What kind of place is this? My partner has had his call light on for 30 minutes and needs help to go to the bathroom - NOW!"Mr. Evans then says, "It's a good thing I got here when I did because who knows how long you would have made him wait! If he gets up without help and falls, you better believe that I'm suing this place!"
"Mr. Evans, thank you for coming and letting me know the situation. I'm sorry your partner has waited so long for someone to help him. I can understand your frustration. The CNA or I will be right over." Correct! It is important that the nurse manage the conflict by acknowledging the family member's concern and frustration. Give a timeframe regarding when the client's needs will be addressed (e.g., "a few minutes"). The next steps might involve the nurse offering to help the client and family discuss their concerns with the manager or charge nurse to make sure they feel as though their concerns were addressed appropriately. It is important not to respond defensively or take the family member's comments personally. An aggressive response will only escalate the problem. Using hospital policy as a justification or blaming others will not solve the problem and may contribute to the family member's sense that no one cares about the client.
The nurse is discharging a client who is at risk for venous thromboembolism (VTE). The client is prescribed enoxaparin. Which instruction should the nurse provide to this client?
"Notify your health care provider if your stools appear tarry or black." Correct! As with any anticoagulant, enoxaparin carries the risk of bleeding. Clients should be instructed to report the presence of tarry stools, bleeding gums, hematuria, ecchymosis or petechiae to their HCP. PTT monitoring is not required for this medication. This type of heparin is administered subcutaneously, not intravenously. Massaging the site will cause bruising and decrease effectiveness of the drug.
The client is diagnosed with an anxiety disorder. During a psychiatric interview, the client asks the nurse whether religious practices would decrease the symptoms of anxiety. Which response is the most therapeutic? "Studies have shown that spiritual practices and religious beliefs help people cope with stress and anxiety." "We are not allowed to discuss religion with clients in this facility." "Perhaps you can try out some different churches when you are discharged." "We have a wonderful chaplain and I will ask him to speak with you today."
"Studies have shown that spiritual practices and religious beliefs help people cope with stress and anxiety." Correct! Scientific studies have demonstrated that religious and spiritual practices enhance the immune system and increase a sense of well-being in people; they are also associated with decreased mental and physical illness. Nurses should respond honestly to client's questions and provide them with evidence-based information, rather than refuse to discuss the subject. Suggesting church attendance or assuming that the client wants to speak with the chaplain deflects the client request for information from the nurse.
The nurse in a primary care provider's office is collecting data on lifestyle choices and activities of daily living (ADLs) from an older adult client. Which of the following statements by the nurse would be appropriate? (Select all that apply.)
"Tell me what you eat on a typical day." Correct! How many glasses of alcohol do you drink per day or per week?" Correct! "How do you spend your time on a typical day?" Correct! Data collection on ADLs and lifestyle choices measures a client's ability to provide self-care and maintain their health and should be done in a way that positively reinforces what the client is doing correctly. It also collects general information on the client's overall health status. It should be done in a clear, non-judgmental manner. Asking if someone feels unsafe can be unclear. The nurse should use open-ended questions to obtain as much information as possible.
"The nurse is caring for a client with schizophrenia. Which outcome should prompt a revision to the client's plan of care?
"The client spends more time by himself.
A home health nurse is providing care for a client. Which client statement should the nurse report immediately to the client's health care provider? "I just didn't sleep well the last few nights. I keep having sad thoughts running through my mind." "My neighbors just don't visit me anymore since I came home from the hospital." "When I emptied my urine catheter drainage bag it looked like rusty-colored water." "I really don't want home-delivered meals any longer. I am just not hungry."
"When I emptied my urine catheter drainage bag it looked like rusty-colored water." Correct Response The change in the color of urine to "rusty" suggests blood, a potential sign of an infection or other urinary-renal complication. This requires immediate reporting, documentation and further assessment. The other statements do not require immediate interventions, but should also be addressed as they could indicate depression, social isolation or an underlying, undiagnosed physical problem.
A client experiences hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client's partner asks to stay a few hours beyond the visiting time in the client's private room. What would be the best response by the nurse? "Yes, would you like to spend the night when the client's behavior indicates a potential to be frightened?" "It would be best if you brought the client some reading material that could be read at night." "No, your presence may cause the client to become more anxious." "Yes, staying with the client and orienting the client to the surroundings may help to decrease the anxiety."
"Yes, staying with the client and orienting the client to the surroundings may help to decrease the anxiety." Correct! Encouraging a family member or a close friend to stay with the client in a quiet surrounding can help increase orientation and minimize confusion and anxiety. Remember to use the information in the question to help you select the best response. There are two options that indicate the client's partner can stay, but only one option indicates that the partner can "stay a few hours beyond the visiting time..."
A client diagnosed with depression is scheduled for electroconvulsive therapy treatments (ECT). One hour before the first treatment is scheduled, the client becomes anxious and states, "I do not want to go through with this!" Which statement by the nurse is most appropriate? "You have the right to change your mind. You seem anxious about the treatment. Can we talk about it?" "I'll call the health care provider and let him know that you have changed your mind about the treatment." "I'll go with you and will be there with you during the treatment." "You'll be asleep and won't remember anything."
"You have the right to change your mind. You seem anxious about the treatment. Can we talk about it?" Correct! This response indicates acknowledgment of the client's rights and the opportunity for the client to clarify and ventilate concerns. Further exploration or assessment would need to be done prior to notification of the health care provider.
A client has responded positively to a series of electroconvulsive treatments (ECT), but reports concerns about on-going memory loss. What is the most appropriate response by the nurse?
"You seem very concerned about your memory." The nurse/client relationship is collaborative and nonjudgmental with the goal of facilitating the client's emotional growth. Open-ended statements or questions encourage the client to express feelings and continue verbalizing. This comment by the nurse is open-ended and acknowledges the client's concerns.
"A client with schizophrenia tells the nurse he hears the voices of his dead parents. To help the client ignore the voices, the nurse should recommend that he:
"listen to a personal stereo through headphones and sing along with the music."
Prednisone
's classification is a corticosteroid. Client's with nephrotic syndrome leak protein from the blood into urine. Prednisone action is to reduce the inflammation of the kidneys, and results in decrease proteinuria. The prescription of a corticosteroid is applicable
Medications given to mom after placenta is out
*PIT in bag of LR* *Methergine if she is still bleeding profusely so she doesn't hemmorhage* *Any mother who were inducted with PIT are at risk for hemmorhage*
Dexamethasone (Decadron)
*class*: antiasthmatics, corticosteroids *Indication*:Manage cerebral edema, assess for Cushing's Disease *Action*: Suppress inflammation and normal immune response. Used in inflammatory states to decrease inflammation.Used to treat cerebral edema associated with a brain tumor, injury, and edema. *Nursing Considerations*: -Excreted by the liver - monitor liver profile - Avoid in active untreated infections - may cause CNS alterations - may cause peptic ulcers - may cause Cushingoid appearance (buffalo hump, moon face) - Weight gain - Osteoporosis - Decrease wound healing - May elevate blood sugars - May increase cholesterol and lipid values
Examples of delusions
*ideas of reference *persecution *grandeur *somatic delusions *jealousy *being controlled *thought broadcasting *thought insertion *thought withdrawal *religiosity *Control *Nihilistic
Enalapril
, an angiotensin converting enzyme inhibitor (ACE), is prescribed for nephrotic syndrome to decrease the intraglomerular pressure. The inhibition of the angiotensin converting enzyme (ACE) results in a reduction of proteinuria. Also an ACE inhibitor blocks aldosterone secretion. This prescription is appropriate.
The nurse is talking with the spouse of a client who has alcoholism and determines that the spouse is exhibiting co-dependent behavior. What comment by the spouse confirms this behavior? 1. "I frequently tell my spouse that drinking alcohol is ruining our relationship." 2. "I go and pick my spouse up from the bar when not home by midnight." 3. "I do not go out drinking with my spouse, and will not drink at home either." 4. "I have told my spouse that I am willing to attend a counseling session when my spouse wants to stop drinking."
. "I go and pick my spouse up from the bar when not home by midnight." 2. Correct: The spouse is attempting to please the alcoholic client. Codependent people are people pleasers, and they make excuses for others. The spouse is enabling the client to continue to drink. The spouse may feel keeping the client from driving while intoxicated will keep people safe. 1. Incorrect: This is a response by a person who is not codependent. This person is not afraid to show feelings and does not deny that there is a problem. 3. Incorrect: By not drinking with the client, the spouse shows that this behavior is not condoned.4. Incorrect: Again, the spouse does not deny a problem and wants to help the client quit rather than making excuses.
A nurse is communicating with a newly hired LPN regarding the plan of care for a client with delusions on an inpatient psychiatric unit. The client has a psychiatric advance directive (PAD) in the medical record, which was executed when the client was mentally competent. Which explanations made by the nurse about the client's PAD are correct? 1. "The PAD permits a client to express his/her wishes regarding future treatments, such as administration of medications and electroconvulsive treatment." 2. "The PAD should be followed even if an emergency situation exists." 3. "The PAD should be followed even if the client expresses that he does not wish to be involuntarily committed." 4. "The PAD should be followed even if the client's wishes conflict with accepted practice standards." 5. "The PAD is usually created by a client who experiences acute episodes of psychiatric illness and becomes unable to make treatment decisions."
. 1 & 5. Correct: Psychiatric advance directives permit clients to express their wishes regarding future treatments. Psychiatric advance directives are usually created by clients who experience acute episodes of psychiatric illness and become unable to make treatment decisions.2. Incorrect: Psychiatric advance directives do not have to be followed in an emergency situation.3. Incorrect: Psychiatric advance directives do not have to be followed if the client must be involuntarily committed to prevent harm to self or others.4. Incorrect: A client's PAD is not followed if it conflicts with accepted practice standards.
Which food selection would need to be removed from the tray by the nurse for a client recovering from thyroidectomy? 1. Roasted almonds 2. Mashed vegetables 3. Scrambled eggs 4. Ice cream
. 1 Roasted almonds Correct: Too hard and crunchy. Need soft diet because esophagus is right behind the thyroid and trachea. This would be difficult to swallow after surgery due to pain. This food selection would need to be removed.
A client with Bell's palsy is having difficulty eating. Which action by the nurse will be most helpful? 1. Perform active facial exercises several times a day. 2. Provide a liquid diet high in protein and calories that will be easily swallowed. 3. Provide oral hygiene after eating. 4. Have the client chew food on the unaffected side of the mouth.
. Have the client chew food on the unaffected side of the mouth. 4. Correct: Maintenance of good nutrition is most important. Having the client chew on the unaffected side will help the client avoid food trapping. This will decrease the risk of aspiration which prioritizes higher than the other options. 1. Incorrect: Performances of facial exercises is important in recovery from Bell's palsy and will help over a long period of time. This intervention is not the highest priority. 2. Incorrect: Liquids are too difficult for the client to manage, as lip closure and chewing are impaired. A purely liquid diet increases the risk for aspiration. 3. Incorrect: Providing oral hygiene is important to prevent dental caries; however, this is not more important than preventing aspiration.
Which interventions are most appropriate for the nurse to provide for the client diagnosed with late onset Alzheimer's disease? Select all that apply 1. Make sure the client's room is dark at bedtime to ensure sleep. 2. Offer fluids every 2 hours during the day and restrict fluids after 6 pm. 3. Teach client to dress self within 30 minutes. 4. Speak loudly and clearly while looking into the client's face. 5. Store frequently used items within easy reach of the client.
. Offer fluids every 2 hours during the day and restrict fluids after 6 pm. Store frequently used items within easy reach of the clien 2. & 5. Correct: Offering fluids every 2 hours during the day and restricting fluids after 6 pm will ensure adequate hydration but will also minimize nighttime wetness, incontinence, and having to get up frequently at night. Storing frequently used items within easy reach helps to ensure client safety.1. Incorrect: This is a safety issue. Keep a dim light such as a night light in the client's room.3. Incorrect: Allow plenty of time to accomplish tasks that are within the client's ability. It may take longer for the client to dress or the client may not be able to dress self at all. Clothing with easy removal or replacement, such as Velcro, facilitates independence.4. Incorrect: Client's with Alzheimer's disease are not hard of hearing. Speak softly and clearly while facing the client.
A client who is at high risk for developing a stroke has been advised to follow a Mediterranean type diet by the primary healthcare provider. Which food choices, if selected by the client, would indicate to the nurse that the client understands this diet. 1. Grilled eggplant 2. Purple grape juice 3. Bacon 4. Cashews 5. Skim milk 6. Salmon
., 2., 4., 5., & 6. Correct: It is reasonable to counsel clients to follow a Mediterranean-type diet over a low-fat diet. The Mediterranean type diet emphasizes vegetables, fruits, and whole grains and includes low fat dairy products, poultry, fish, legumes, and nuts. It limits intake of sweets and red meats. 3. Incorrect: Substitute fish and poultry for red meat. When eaten, make sure it's lean and keep portions small (about the size of a deck of cards). Also avoid sausage, bacon and other high-fat meats. The Mediterranean diet is based largely on plant based. In addition to fruits, whole grains, olive oil, cheese, yogurt and fish, the Mediterranean diet places a major emphasis on vegetables. Emphasis is placed on fruits and vegetables, whole grains, legumes and nuts. Butter should be replaced with healthy fats such as olive oil and canola oil. Herbs and spices instead of salt is used to flavor foods. Red meat is limited to no more than a few times a month and replaced with fish and poultry at least twice a week. Drinking red wine in moderation is acceptable or purple grape juice. Getting plenty of exercise is emphasized as well. Nuts are high in fat, but most of the fat is not saturated. Because nuts are high in calories, they should not be eaten in large amounts — generally no more than a handful a day. Avoid candied or honey-roasted and heavily salted nuts. Fatty fish such as mackerel, lake trout, herring, sardines, albacore tuna and salmon are rich sources of omega-3 fatty acids. Limit high fat dairy products such as whole or 2 percent milk, cheese and ice cream. Switch to skim milk, fat free yogurt and low-fat cheese. A glass of wine at dinner is acceptable if approved by the client's primary healthcare provider. If the client doesn't drink alcohol, purple grape juice may be an alternative. Eggplant, which is one of the few purple vegetables, is a good addition to the Mediterranean diet. This vegetable can be cut into thin slices and used in place of noodles when making lasagna or grill the eggplant slices and top them with fresh tomatoes and a drizzle of olive oil.
Pasero Opioid-Induced Sedation Scale
1 = awake and alert; no action necessary 2 = occasionally drowsy but easy to arouse; requires no action 3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose 4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone.
An LPN has been floated to a short-staffed pediatric floor. What client assignments would be most appropriate for this individual? 1. Obtain vitals for a 5 year old recovering from glomerulonephritis. 2. A newly diagnosed diabetic child being discharged with parents. 3. Perform sterile wound care on an 8-year-old with lower leg burns. 4. Administer antibiotics to newly admitted 3-year-old with epiglottitis. 5. Provide I.M. Demerol to an adolescent following an appendectomy.
1, 3 & 5. Correct: The LPN should be assigned clients who are stable and have predictable outcomes. Obtaining vital signs, even on a five-year old client, is well within the LPN scope of practice. Even if the client has glomerulonephritis, the LPN can report any elevated blood pressure findings to the RN. Other tasks within the appropriate skills level of an LPN include sterile wound care and administering I.M. pain medications to clients. 2. Incorrect: The parents of a newly diagnosed diabetic child are usually quite overwhelmed with all the aspects of care now needed. A great deal of discharge instruction needs presented to the parents and there will likely be a lot of questions to answer. Because of the nature of this particular situation, this client would be more appropriate for the RN. 4. Incorrect: Epiglottitis is an acute bacterial infection which results in obstructive airway problems. This is considered a medical emergency with an abrupt onset, severe respiratory distress, high fever, stridor and drooling with dysphagia. Because of the potential for airway obstruction, all medications must be administered I.V. during the acute stage of this illness. The LPN cannot give I.V. medications. What should you think about when presented with "select all that apply" questions? You need to consider each individual option as a true/false question, re-reading the scenario again before making a decision on each one. First of all, this licensed practical nurse has been floated to a pediatric unit, which is generally a specialized area of care. Secondly, children can deteriorate very quickly and need close observation. Finally, you will recall that even if a child is hospitalized, the staff must also consider developmental needs. However, does that mean only older, or adolescent, clients can be assigned to this LPN? Definitely not! Think carefully about not only the client, but the disease process and tasks that need performed. All three of these aspects factor into the choice of appropriate assignments for the LPN. Option 1: Good choice! You already know that the LPN is qualified to take vitals, even for a five year old child. Think about the clinical course for glomerulonephritis. This is an inflammatory process inside the glomeruli caused by Group A beta-hemolytic strep. Bed rest, antibiotics and reduced-protein diet are the main treatment options. Because blood pressure, facial edema and decreased urinary output need monitored, the LPN's scope of practice includes these tasks, making this a good client assignment. Option 2: Not this one. Although this client is being discharged home, there is a great deal of instruction involved for the parents. A newly diabetic child represents Type I diabetes, and the amount of care the parents will need to undertake is staggering at first. There is no indication if this child is pre-school or school-age, but involving the child in the entire learning process is crucial. Because of both the physical and psychologic aspects of diabetes, this client and family would best be assigned to an RN. Option 3: Excellent! LPN's are able to perform tasks, such as burn care, even if it a sterile technique. Did you consider that this eight-year-old child will be able to talk to the staff, indicating if the pain medication is working or responding to any questions asked. The age alone does not qualify this client as an appropriate assignment. The care that must be performed is well within the LPN's scope of practice. If needed, the RN can inspect the wounds after the old dressings are removed, but can permit the LPN to complete the care. Option 4: Were you tempted? Hope you decided this one was false! It has nothing to do with the fact this client is just three years old. Consider the facts about epiglottitis. This acute bacterial infection of the supraglottic structures seen in 2 to 8 year old children is considered a medical emergency because of its potentially obstructive airway problems. Clients with this diagnosis present with severe respiratory distress, stridor, high fever and drooling because the airway is so inflamed the client cannot swallow even saliva. The critical issue is that NOTHING is to be placed into the client's mouth, which may cause complete airway obstruction. A trach kit must be kept at the bedside at all times. All medications, including antibiotics and steroids, must be provided intravenously, which means this client cannot be assigned to the LPN. Option 5: Amazing! This client is definitely an appropriate assignment for an LPN. The adolescent can easily interact with the staff (providing the client is in the mood!), and administering I.M. pain medication such as Demerol is within the LPN scope of practice.
The homecare nurse is visiting a client to assess the response to new medications ordered for benign prostatic hyperplasia (BPH). What symptoms reported by the client would indicate to the nurse the medications are not working? Select all that apply 1. Bladder pain 2. Fever with chills 3. Urinary frequency 4. Terminal dribbling 5. Nighttime sweats
1, 3 and 4. CORRECT: Symptoms of benign prostatic hyperplasia are very similar to those of a urinary tract infection. As the prostate enlarges and presses against the bladder wall, it becomes more difficult for a client to start and maintain a stream of urine, or even to completely empty the bladder. Medications prescribed for this disorder are meant to shrink the prostate, allowing urine to flow easily when voiding. When the medications are ineffective, the client again experiences the original symptoms such as bladder pain, urinary frequency and a tendency to continue 'dribbling' urine after the bladder is emptied. The client may then need a different medication or a change in the dose currently prescribed. 2. INCORRECT: The symptoms of fever with chills are related to infection rather than benign prostatic hyperplasia. Although untreated BPH may lead to a urinary infection because of retained urine, these two symptoms do not relate directly to this prostate disorder. 5. INCORRECT: Nighttime sweats are not associated with benign prostatic hyperplasia. Nighttime sweats can be associated with tuberculosis.
The nurse is reinforcing diet teaching to the mother of a toddler diagnosed with cystic fibrosis. What food choices would be applicable for the nurse to include as appropriate for this toddler to consume? Select all that apply 1. potato chips 2. low-fat yogurt 3. salt-free bacon 4. hot dog on a bun 5. fresh avocadoes 6. macaroni and cheese
1, 4 and 6. CORRECT. Individuals with cystic fibrosis have many nutrient deficiencies along with insufficiencies of fat, protein and salt. The diet needs to include extra dairy, fat and protein, and salt in order to provide nourishment for growth and development. Prepared foods high in salt, such as potato chips and hot dogs, should be included in meals and snacks on a daily basis. Extra protein such as bacon, and whole dairy products, like milkshakes, butter and cheese, contribute to the required high calorie, salt-enhanced diet needed for proper growth and development in children with C.F. 2. INCORRECT. Yogurt would be a good source of nutrients for this child; however, low-fat yogurt removes most of the needed nutritional value. 3. INCORRECT. Individuals with C.F. need extra fat, protein and salt in the diet because of the inability to properly metabolize these nutrients. Low-salt bacon removes a great source of added sodium necessary to their diet. 5. INCORRECT. Avocado's have a lot of fat and carbohydrates. It won't help with the needed protein, salt, and dairy.
Which comments made by the nurse indicate an understanding of confidentiality as it relates to mental illness? 1. "Client approval is needed prior to talking with family members." 2. "My computer screen is left open for the next nurse to chart." 3. "Client situations can be discussed in the care planning meeting." 4. "Discussion about clients while in the elevator is prohibited." 5. "In the home setting, I can be more casual in discussing client information with others."
1. "Client approval is needed prior to talking with family members." 3. "Client situations can be discussed in the care planning meeting." 4. "Discussion about clients while in the elevator is prohibited." 1., 3., & 4. Correct. The nurse should be the client advocate and protect the client's confidential information. A client's personal data and identifiable health information should be shared only with persons approved by the client. 2. Incorrect: The nurse's computer screen should not be viewed by unauthorized persons. Also each nurse should log off the computer to ensure client confidentiality. 5. Incorrect. The confidentiality of the client information is to be maintained in the home setting. The nurse is the client advocate.
Which food selection would need to be removed from the diet tray of a client recovering from thyroidectomy? 1. Fresh apple 2. V8 juice 3. Mustard greens 4. Ice cream
1. Correct: Too hard and crunchy. Need soft diet because esophagus is right behind the thyroid and trachea. 2. Incorrect: Not everyone likes V8, it is high in sodium and potassium but it's soft and has calories and vitamins. 3. Incorrect: Soft and full of vitamins. 4. Incorrect: Yes, Ice Cream with neck surgery (Cold and Soft).
What statement by a new LPN would indicate an understanding of how to maintain skin integrity for a client on bedrest? Select all that apply 1. "Clients on bedrest should be placed on therapeutic mattresses." 2. "I will assess for the skin every 4 hours." 3. "I will assess the skin using the Braden scale." 4. "A pillow will be placed between the knees when client is side lying." 5. "The incontinent client will be kept clean and dry."
1. "Clients on bedrest should be placed on therapeutic mattresses." 3. "I will assess the skin using the Braden scale." 4. "A pillow will be placed between the knees when client is side lying." 5. "The incontinent client will be kept clean and dry." 1., 3., 4., & 5. Correct: Clients on bedrest should use a therapeutic bed or mattress. These prevent and treat pressure ulcers by molding to the body to maximize contact, redistributing weight, and reducing pressure. The Braden scale is the most preferred tool to monitor risk of developing pressure ulcers. It looks at sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A pillow between the knees can decrease pressure on knees if they were touching. Protect the client from moisture by keeping clean and dry. 2. Incorrect: When a client is on bedrest, the skin and subcutaneous tissue cannot perfuse adequately. Therefore, the skin should be monitored every 2 hours, not every 4 hours.
When providing instructions, the nurse asks the client to repeat the techniques for crutch walking. The nurse is aware that further action is needed when the client makes which statement? 1. "The elbows should be flexed at 10 degrees." 2. "I should not lean on the crutches with my armpit." 3. "When going upstairs, my non-surgical leg goes up first." 4. "Both crutches are held in one hand when sitting down".
1. "The elbows should be flexed at 10 degrees." 1. Correct: The nurse is looking for an incorrect statement from the client. This statement indicates the client will need further instruction prior to discharge. When using crutches, the client's elbows should be flexed at 30 degrees. 2. Incorrect: This is a correct statement by the client. The weight of the body is placed on the hands and handgrips rather than being supported by the armpits, which could cause axillary nerve damage. This is a correct statement by the client; however, the question asks for an incorrect statement by the client. 3. Incorrect: The client is aware that the non-surgical "good" leg should be placed on the steps first when going upstairs, while the surgical "bad" leg is placed on the stairs first when coming down steps. This is a correct statement, indicating that the client did understand teaching; however, this question is looking for an indication that the client needs further instructions. 4. Incorrect: When sitting down in a chair, the client would indeed place both crutches in one hand while safely reaching for the chair with the free hand. This is a correct statement and does not indicate the need for further teaching.
A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. A complete client evaluation has not identified a physical reason for the symptoms. The client tells the nurse, "The doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad some times that I can't function!" What is the nurse's most appropriate response? 1. "The pain you feel is real." 2. "The primary healthcare provider is right. Your pain is not real." 3. "Let me get you an appointment with the psychiatrist." 4. "Don't worry. Everything will be ok."
1. "The pain you feel is real." 1. Correct: Pain is real even if it is psychological pain. The client is expressing anxiety and stress through stomach pain. The nurse should use a therapeutic communication technique that is client centered and empowers the client. 2. Incorrect: This is an example of nontherapeutic communication. The response is confrontational and does not address how the client feels. The nurse should not tell clients that their pain is not real. 3. Incorrect: This nontherapeutic communication of changing the subject ignores the client's feelings. This action invalidates the client. The nurse should use therapeutic communication to explore the client's feelings. 4. Incorrect: This is a nontherapeutic communication technique, because the response shows false reassurance. The nurse can not know if everything will be ok for the client.
A client diagnosed with depression asks the nurse, "What is causing me to be depressed so often?" What is the best response by the nurse? 1. "There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain. " 2. "You experience depression because of your elevated levels of thyroid hormones." 3. "The primary healthcare provider will have to explain to you what is causing your depression." 4. "Tell me what you think causes you to be depressed."
1. "There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain. " 1. Correct: Decreased levels of norepinephrine, dopamine, and serotonin are neurotransmitter implications for depression. By giving this type of information to the client, it helps with their understanding of the depression and empowers them with knowledge. 2. Incorrect: Elevated levels of thyroid hormones are thought to contribute to panic disorder or manic-type behaviors. Decreased levels of thyroid hormones are affiliated with depression, but not increased levels, so this would be wrong. 3. Incorrect: The nurse can discuss this with the client. This would be ignoring the client's desire to have information and post-pone providing much-needed help to the client. 4. Incorrect: This statement may allow for dialogue, but does not answer the client's question. 1. The nurse must deliver care in a nonjudgmental manner. 2. Identify options that deny client feelings, concerns, and needs. Options that imply everything will be all right deny clients' feelings, change the subject raised by the client, encourage the client to be cheerful, or transfer nursing responsibility to other members of the healthcare team usually are distractors and can be eliminated from consideration.
The nurse in the clinic would recognize which client statement as most indicative of gallbladder disease? 1. "Yesterday, when I ate a hamburger and french fries, my belly really hurt." 2. "I have been gaining a lot of weight lately." 3. "My stools are darker. Sometimes they are even black." 4. "When I start hurting, it helps if I drink milk or have a small snack."
1. "Yesterday, when I ate a hamburger and french fries, my belly really hurt." 1. Correct: The gallbladder assists in digestion of fat. When foods high in fat are ingested, bile is released from the gallbladder to assist in digestion. If gallstones are formed in the gallbladder or are blocking the outlet to the gallbladder, the client may experience epigastric discomfort after a meal high in fat. 2. Incorrect: Weight gain is not associated with gallstones. 3. Incorrect: Black stools indicate blood in the stool and should be further investigated. Black stools are not associated with gallstones. 4. Incorrect: When drinking milk or having a small snack relieves the abdominal pain, a duodenal ulcer may be a possible diagnosis.
A nurse in a long-term care facility is reinforcing teaching to newly-unlicensed assistive personnel (UAP) about advance directives. Which statements by the nurse regarding a Health Care Power of Attorney are correct? 1. "The Health Care Power of Attorney identifies the person designated to make end-of-life care decisions on a client's behalf." 2. "The Health Care Power of Attorney identifies the health care providers that are permitted to care for the client." 3. "The Health Care Power of Attorney identifies the person designated to make financial decisions for the client if the client is incapacitated." 4. "The Health Care Power of Attorney identifies the person designated to make health care decisions for the client if the client is incapacitated." 5. "The Health Care Power of Attorney identifies the person designated to make funeral arrangements for the client if the client dies."
1. & 4. Correct: The purpose of the Health Care Power of Attorney is to identify the person designated by the client to make end-of-life decisions on the client's behalf. The purpose of the Health Care Power of Attorney is to identify the person designated to make health care decisions for the client if the client is incapacitated. 2. Incorrect: The Health Care Power of Attorney does not identify which health care providers may care for a client. 3. Incorrect: A Power of Attorney allows a designated person to act on the client's behalf with regard to financial matters whereas a Health Care Power of Attorney allows a designated person to act on the client's behalf with regard to medical decisions only. 5. Incorrect: The Health Care Power of Attorney does not identify the person designated to make funeral arrangements for the client if the client dies. This person would most likely be identified in the client's last will and testament.
What tips for administering medication to children should the nurse reinforce to parents? 1. Demonstrate proper measuring techniques for liquid medications. 2. Put crushed medications into the child's favorite food. 3. Place liquid medication in an 8-ounce bottle of formula. 4. Call medication "candy" to encourage children to take the medicine. 5. Do not place medications in a container other than the original container.
1. & 5. Correct: This is a safety issue and the parents need to be able to accurately measure the child's medication. Never put medications in dishes, cups, bottles, or other household containers that children or other family members may be unaware of. 2. Incorrect: Do not place crushed drugs into the child's favorite food or snack. The medication can change the taste of the food, and the child may refuse the food, therefore missing part or all of the dose. Additionally, the effectiveness of some medications may be harmed by the crushing of the drugs. 3. Incorrect: Do not place liquid drugs in a large bottle of formula. Unless the child drinks the entire amount, the correct dose will not be received. 4. Incorrect: Don't refer to drugs as candy. Children may try to take more candy, leading to overdose. When thinking about administering medication to children, keep in mind the importance of proper administration and ensuring that the child get all of the medication prescribed. Safety is also a key factor, so remember these things as you look at the options. Option 1. This is true. Don't mix and match cups to different products or the wrong amount may be given. We don't want them to just fill it up. Look carefully at the lines and letters on the cup to be sure that the correct amount has been poured. Be sure to reinforce that the cup needs to be level by putting it on a flat surface. Option 2. This is false. If you do this, then you might not get the child to eat that food again. The medication can change the taste of the food, and the child may refuse to eat the food, therefore missing part or all of the dose. Additionally, the effectiveness of some medications may be harmed by the crushing of the drugs. Option 3. Wrong. Do not place liquid drugs in a large bottle of formula. Unless the child drinks the entire amount, the correct dose will not be received. Option 4. Don't refer to drugs as candy. Children may try to take more candy, leading to overdose. Option 5. True. Never put medications in dishes, cups, bottles, or other household containers that children or other family members may be unaware of. This is a safety issue!
Which client assignments are most appropriate for the LPN to accept when working on the pediatric unit? 1. 10 year old paraplegic in for bowel training. 2. 2 year old with asthma newly admitted with dehydration. 3. 3 month old admitted with possible septicemia. 4. 7 year old in Buck's traction for a femur fracture. 5. 10 year old transferred from ICU yesterday with a head injury.
1. 10 year old paraplegic in for bowel training. 4. 7 year old in Buck's traction for a femur fracture. 1. & 4. Correct: These clients have conditions that the LPN/VN can care for with little assistance from the RN. Bowel training is a health promotion, self care activity that is within the scope of practice for the LPN/VN. Buck's traction is a type of skin traction that is also within the scope of practice for the LPN/VN. 2. Incorrect: This client will probably have IV fluids prescribed that the RN will need to administer. Assessment of lung status would be important since the client is a new admit with asthma. This is a potentially unstable client and would not be appropriate for the LPN/VN. 3. Incorrect: This client, admitted with septicemia, is potentially unstable and will probably require IV antibiotics and very close monitoring due to being very young with a major infection. 5. Incorrect: This client will need close observation and the higher skill level of an RN since there is a head injury and the client spent time in the ICU only one day before.
An LPN has been pulled from the adult medical surgical unit to the pediatric unit for the shift. What clients would be appropriate for an LPN to accept from the charge nurse on this unit? 1. A 12-year-old with diabetes mellitus. 2. A 6-year-old one day post tonsillectomy. 3. A 3-year-old admitted in sickle cell crisis. 4. A 9-year-old with Hirschsprung's disease. 5. A 2-year-old in a mist tent with epiglottitis.
1. A 12-year-old with diabetes mellitus. 4. A 9-year-old with Hirschsprung's disease. 1 and 4. CORRECT. The LPN scope of practice is task oriented. An LPN floated to a specialty floor, such as pediatrics, should be assigned the most stable, uncomplicated clients, and ideally those that may have a disease process which also occurs on a medical-surgical floor. The 12-year old with diabetes mellitus is a good choice. This client will require accu-checks and SubQ insulin, both of which are within the scope of practice for the LPN. A client with Hirschsprung's disease experiences bowel dysfunction, usually with constipation, pain or anorexia. This client could also be assigned to an LPN who would have experience with bowel issues. 2. INCORRECT. Even though this child is one day post-op, throat surgery would require frequent assessments of the airway and the client's ability to swallow. Additionally, pain medication is usually given I.V. since the child still has difficulty swallowing. LPN's may not give I.V. meds. 3. INCORRECT. Children in sickle cell crisis require on-going assessments of the vascular system as well as the need for supplemental oxygen and pain medication. In addition to the young age of the client, the disease process requires advanced assessments. This client is not appropriate for the LPN. 5. INCORRECT. A two-year-old with epiglottitis in a mist tent will need airway and respiratory assessments frequently, along with teaching the parents about this illness. This client is not appropriate for the LPN.
The orthopedic HCP instruct a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full-weight bearing on the rightv leg.Which advance crutch gait that most closely resembles normal walking should the nurse reinforce?
4 point gait
A new mother brings her infant to the clinic for a well-baby checkup. While at the clinic, the mother asks the nurse if there are any reasons why her infant should not have the measles, mumps, rubella (MMR) vaccine. The nurse's response is based on evidence that the MMR vaccine is contraindicated under which condition? 1. A known allergy to gelatin. 2. A family history of autism. 3. In infants with diarrhea. 4. A known allergy to sulfonamides.
1. A known allergy to gelatin. 1. Correct: The MMR vaccine is grown using chicken embryos and manufactured with the use of gelatin. Known allergies to gelatin would be a contraindication for administration.2. Incorrect: The Centers for Disease Control does not recognize a link between the administration of the MMR vaccine and the development of autism.3. Incorrect: Diarrhea is not a contraindication specifically for the MMR vaccine. Diarrhea may result in hypovoemia and electrolyte imbalance which would need to be addressed. 4. Incorrect: Sulfonamides are not used in the development of the MMR vaccine. Neomycin is used in the development of the MMR vaccine. Neomycin is the only antibiotic allergy that would contraindicate the administration of the MMR vaccine.
The nurse is providing care to a 5 year old client who has been experiencing moderate pain. Which intervention is appropriate for the nurse to use with this client? 1. Encourage the client to talk about the pain. 2. Provide distraction by asking the client to sing with the nurse. 3. Suggest that the client try to relax. 4. Tell the client that the pain can be self controlled
1. A strategy you can draw on to help answer priority questions is to refer to basic guiding theories that are part of the foundation of nursing. Maslow's Hierarchy of Needs, The Nursing Process, Kubler-Ross's Theory of Death and Dying, Teaching/Learning Theory, Therapeutic Communication. 2. If age, sex, nationality are identified in the stem, it is important to the question and will generally direct you to an answer. Remember Erickson's stages of psychosocial development and growth and development.
What signs/symptoms does the nurse expect to see in a client who has ulcerative colitis? 1. Abdominal cramping 2. Hematemesis 3. Diarrhea 4. Fever 5. Rebound tenderness 6. Rectal bleeding
1. Abdominal cramping 3. Diarrhea 4. Fever 5. Rebound tenderness 6. Rectal bleeding Rationale 1., 3., 4., 5., & 6. Correct: Ulcerative colitis is an ulcerative inflammatory bowel disease in the large intestines. Common s/s include abdominal cramping, diarrhea, fever, rebound tenderness, and rectal bleeding. 2. Incorrect: Hematemesis is seen with upper GI bleeding.
Nasogastric tube insertion
1. Adhere to Standard Precautions. 2. Explain procedure to patient. 3. Assemble equipment and examine tube for defects (rough edges or partially closed lumens). 4. Position patient, preferably in high-Fowler's, if not contraindicated. Drape patient with towel or disposable pads. 5. Instruct patient to blow nose to clear nostrils. Use a flashlight and occlude one nostril at a time to assess patency of nostrils before choosing site for insertion. Ascertain from patient any history of nasal surgery, injury or deviated septum. 6. Measure tube for placement from tip of nose to ear lobe to bottom of xiphoid process; mark tube with tape. Note location on tube; you may mark tube with tape or nontoxic marker. 7. Provide patient with glass of water or ice chips. Lubricate tip of tube with water-soluble lubricant and begin insertion. Rotating tube 180 degrees after it reaches the nasopharynx may help to prevent tube from entering patient's mouth. Instruct patient to take a swallow of water or suck on ice chips once tube passes nasopharynx. It is helpful to have the patient, unless contradicted, keep his/her chin tucked toward chest so that the tube passes into the stomach and not lungs. 8. Continue insertion in rhythm with swallowing until desired length of tube is passed. 9. Determine that tube is in stomach: a. Place stethoscope over stomach, inject 10 mL of air into tube and listen for air passage. b. Gently aspirate stomach content with irrigating syringe. Fluid from stomach or small bowel may be green, tan, brown, clear, yellow, bloody or bile-colored. Pulmonary fluid may be tan, off white, clear or pale yellow. Ph from stomach is 1.0 to 6.5, from small intestine 7.5 to 8.0, from the lungs over 6.0; however, none of these is fail-safe. If any doubt exists, placement should be checked with X-rays. It should be noted that chest X-ray is the only way to confirm correct placement. 10. Anchor tube with tape or securement device. Discomfort from weight of tube may be relieved by using a rubber band and safety pin to secure tube to patient's clothing. Remove safety pin from clothing before changing clothing. 11. Cap end of tube or proceed to Digestive - Nasogastric Tube Feeding. 12. Discard soiled supplies in appropriate containers.
Which tasks would be appropriate for the LPN/VN to accept from the RN? Select all that apply 1. Administer antibiotic via intravenous piggyback (IVPB). 2. Teach insulin self administration to a diabetic client. 3. Administer IV pain medication to a two day post op client. 4. Check for urinary retention. 5. Remove wound sutures.
1. Administer antibiotic via intravenous piggyback (IVPB). 4. for urinary retention. 5. Remove wound sutures. 1., 4., & 5. Correct. These tasks are within the PNs practice scope. The PN can administer antibiotics by IVPB, monitor for urinary retention and remove wound sutures. 2. Incorrect: The RN is responsible for teaching. The PN can reinforce teaching once taught by the RN. 3. Incorrect: The RN must give IV pain medications to clients. The PN can monitor the effectiveness of the medication after given by the RN and can report any problems if identified.
Which finding should a nurse expect when collecting data on a healthy 65 year old client? 1. Anomia 2. Presbyopia 3. BP 156/88 4. Apraxia
2
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? Exhibit CBC Guaiac stool: + for occult blood Hemaglobin: 10.0 g/dL Hematocrit: 40% RBCs: 4.5 Platelets: 90,000 1. Administer protamine sulfate. 2. Administer the next dose of enoxaparin. 3. Obtain vital signs. 4. Insert a nasogastric tube.
1. Administer protamine sulfate. 1. Correct: This client has a low hgb, hct, and platelet count and is actively bleeding. Protamine sulfate is the antidote for enoxaparin. 2. Incorrect: Administering another dose of enoxaparin would make the problem worse. The client is actively bleeding and has a low platelet count. 3. Incorrect: The client is actively bleeding. Obtaining vital signs is delaying treatment. The client needs protamine sulfate. 4. Incorrect: The client needs protamine sulfate to correct the problem. Enoxaparin is a low molecular weight heparin (LMWH). It works by blocking the formation of blood clots. Enoxaparin Sodium Injection is indicated for the prophylaxis of deep vein thrombosis (DVT), which may lead to pulmonary embolism (PE) and to treat Acute Deep Vein Thrombosis. Periodic complete blood counts, including platelet count, and stool occult blood tests are recommended during the course of treatment.
A client has a prescription for digoxin 0.125 mg PO every morning. Prior to administering digoxin, the nurse notes that the digoxin level drawn this morning was 0.9 ng/mL. Which action would be most important for the nurse to take? 1. Administer the digoxin. 2. Hold the digoxin. 3. Notify the primary healthcare provider. 4. Repeat the digoxin level.
1. Administer the digoxin. 1. Correct: This is a normal digoxin level. The nurse would administer the prescribed digoxin. The therapeutic serum levels of digoxin range from 0.5 to 2 ng/mL. 2. Incorrect: This is a normal digoxin level. The nurse would administer the prescribed digoxin .3. Incorrect: There is no need to notify the primary healthcare provider of a normal digoxin level. 4. Incorrect: There is no need to repeat a normal laboratory value.
Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Totaling I & O records on five clients at the end of the shift. 2. Assessing VS on a client who was admitted 30 minutes ago. 3. Administering nasogastric (NG) tube feeding. 4. Changing an abdominal surgical dressing on a client that is 3 days post op.
1. Correct: Totaling I & O is an appropriate task for a UAP to be assigned. This is within the scope of practice for the UAP. 2. Incorrect: New clients should be assessed by an RN; however, it is acceptable for the RN to get assistance with some of the information. The RN must verify all information. The client is a new admit, and is considered unstable; therefore, the RN should get the baseline vitals. 3. Incorrect: Administering a NG tube feeding is not within scope of practice for the UAP. 4. Incorrect: Changing a surgical dressing is not within the scope of practice for the UAP.
Which interventions are appropriate for the nurse to initiate for a client post liver biopsy? 1. Apply direct pressure to site immediately after needle is removed. 2. Monitor puncture site every 15 minutes for 1 hour. 3. Position client on left side. 4. Keep client NPO for 24 hours. 5. Advise client that pain may occur as the anesthetic wears off.
1. Apply direct pressure to site immediately after needle is removed. 2. Monitor puncture site every 15 minutes for 1 hour. 5. Advise client that pain may occur as the anesthetic wears off. 1., 2., & 5. Correct: Anyone who has a liver problem is at risk for bleeding. The clotting factor produced in the liver is prothrombin. Anytime a needle is inserted into the body and removed, bleeding can occur. Whenever there is risk for bleeding, the preventive measure is to apply pressure. The puncture site should be monitored frequently. The client may experience some discomfort at the biopsy site once the anesthetic wears off. 3. Incorrect: Lying on the left side does not put pressure on the puncture site. The liver is on the right side, as is the puncture site. 4. Incorrect: The client should be prescribed NPO for 2 hours. The client's usual diet as tolerated will be resumed after the 2 hours.
A newly admitted client with schizophrenia tells the nurse, "The doctor is trying to steal my organs for science." Which response by the nurse would be most therapeutic? 1. Are you feeling afraid now? 2. I am here with you. 3. Let's discuss something else. 4. You know that is not true.
1. Are you feeling afraid now? 1. Correct: The nurse should speak to the underlying feeling of the client's statement which is fear. 2. Incorrect: The nurse is offering self. This does not respond to the underlying message in the client's statement that indicates fear and false information. 3. Incorrect: The nurse is changing the subject. This is a non-therapeutic response by the nurse that will decrease communication between the nurse and the client. 4. Incorrect: The nurse is arguing with the client. This is a non-therapeutic response by the nurse that will decrease communication between the nurse and the client.
A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual? Select all that apply 1. Attend an activity with the client who is reluctant to go alone. 2. Allow the client to break an insignificant rule. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when the client is hungry.
1. Attend an activity with the client who is reluctant to go alone. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when the client is hungry. 1., 3., 4. & 5. Correct: Trust is demonstrated through nursing interventions that convey a sense of warmth and care to the client. These interventions are initiated simply, concretely, and directed toward activities that address the client's basic needs for physiological and psychological safety and security. Concrete thinking focuses thought processes on specifics, rather than generalities, and immediate issues, rather than eventual outcomes. Examples of nursing interventions that would promote trust in an individual who is thinking concretely include such things as: providing a blanket when the client is cold, providing food when the client is hungry, keeping promises, being honest, providing a written, structured schedule of activities, attending activities with the client who is reluctant to go alone, being consistent in adhering to unit guidelines, and taking the client's preferences, requests, and opinions into consideration when possible in decisions concerning care. 2. Incorrect: The client should be informed of all rules, simply and clearly, with reasons for certain policies and rules. Be consistent and provide written, structured, scheduled activities. Allowing a client to break a rule would not encourage them to think about the outcomes of their actions.
Which tasks are appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Bathe the client. 2. Provide spiritual support 3. Listen to the client reminisce. 4. Administer routine medications. 5. Weigh the client. 6. Take vital signs
1. Bathe the client 3. Listen to the client reminisce. 5. Weigh the client. 6. Take vital signs 1., 3., 5., & 6. Correct: The UAP can bathe, listen to the client reminisce, weigh, and take the vital signs. These are within the scope of practice of the UAP. These assignments are routine and revolve around activities of daily living. 2. Incorrect: The task of providing spiritual support could best be delegated to the pastor or chaplain. 4. Incorrect: The nurse can not assign routine medication administration to the UAP. This is not within the UAPs scope of practice. This is an LPN or RN responsibility.
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. 1., 2., 3., & 5. Correct: 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.
Which symptom would the client who overdosed on barbiturates most likely exhibit? 1. Bradypnea 2. Hyperthermia 3. Hyperreflexia 4. Tachycardia
1. Bradypnea 1. Correct: Barbiturates are central nervous system (CNS) depressants. They will slow the respiratory rate.2. Incorrect: Barbiturates would not cause hyperthermia. 3. Incorrect: Barbiturates are CNS depressants. They would diminish reflexes. 4. Incorrect: Barbiturates are CNS depressants. They would slow the heart rate.
Which task would be appropriate for the LPN to accept from the charge nurse? 1. Changing a colostomy bag. 2. Hanging a new bag of total parenteral nutrition (TPN). 3. Teaching insulin self administration to a diabetic client. 4. Administering IV pain medication to a two day post op client.
1. Changing a colostomy bag. 1. Correct: The only procedure listed that is within the LPN/VN's practice range is changing the colostomy bag. This is a task that can be delegated to the LPN/VN. 2. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. This is outside the scope of practice for the LPN/VN. Therefore, the RN must perform this task and cannot delegate this to the LPN/VN. 3. Incorrect: Teaching is outside the scope of practice for the LPN/VN. Teaching can be reinforced by the LPN/VN, but they cannot perform the initial teaching. Teaching insulin self-administration cannot be delegated to the LPN. 4. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/VN. This should not be delegated to the LPN/VN.
The nurse is reinforcing teaching to a client, who has reduced peripheral circulation, on how to care for the feet. What points should the nurse include? 1. Check shoes for rough spots in the lining. 2. File toenails straight across. 3. Cover feet and between toes with creams to moisten the skin. 4. Break in new shoes gradually. 5. Use pumice stones to treat calluses.
1. Check shoes for rough spots in the lining. 2. File toenails straight across. 4. Break in new shoes gradually. 1., 2., & 4. Correct: Rubbing from rough spots in the shoe can lead to corns or calluses. File the toenails rather than cutting to avoid skin injury. File nails straight across the ends of the toes. If the nails are too thick or misshapen to file, consult podiatrist. Break in new shoes gradually by increasing the wearing time 30-60 minutes each day. 3. Incorrect: Cover the feet, except between the toes, with creams or lotions to moisten the skin. Lotion will also soften calluses. Do not put lotion between the toes; moisture there can cause fungus growth. 5. Incorrect: Avoid self-treatment of corns or calluses. Pumice stones and some callus and corn applications are injurious to the skin. Do not cut calluses or corns. Consult a podiatrist or primary healthcare provider first.
A first time mother is to be discharged with infant. The LPN asks the client about the discharge teaching presented earlier in the shift. What statement by the client would indicate the need for further instruction? 1. "I will wake my baby every two hours to feed so she does not dehydrate." 2. "The baby's car seat must face backward in the back seat when we travel." 3. "I won't let people who are sick hold the baby till they are symptom free." 4. "The safest position for my baby to sleep is on her back with no pillows."
1. Correct: The LPN knows the client needs further teaching when an inaccurate statement is made. In this case, the client states it is necessary to wake an infant every two hours for feeding in order to prevent dehydration. This is not an accurate statement. Infants feeding appropriately do not dehydrate unless there is an ongoing problem with emesis or fever. Also, infants need to begin developing extended sleep patterns and purposely waking the newborn is not necessary. 2. Incorrect: This is an accurate statement. While the law can vary by state, all laws confirm that children are safer in car seats which are placed in the backseat and facing backward for at least the first year. This statement indicates the client understood the instructions. 3. Incorrect: This statement is also correct. People with known or visible signs of illness, such as coughing, sneezing or fever should not be permitted in close proximity to a new baby. Newborns have very poor immune systems and cannot fight off even basic illnesses. This statement indicates the mother has a clear understanding of infant care and does not need further instruction. 4. Incorrect: Research conducted as a result of sudden infant death syndrome(SIDS) and other safety concerns has shown the safest position in which to place a sleeping infant is supine. This statement indicates the client has a clear understanding of the instructions and will not need further teaching. Look carefully for clues in the question. The staff individual involved is a licensed practical nurse, and although the LPN cannot initiate teaching, verifying the client understands the information previously presented is well within the LPN scope of practice. What other clues do you see? The client is a first time mother, and because there is so much new information to learn, it is very important to be sure she understands the basics. Therefore, you realize that three of the options will be correct statements. You are looking for an inaccurate statement made by the client. Option 1: Awesome! You are looking for evidence the client did not understand the teaching. New mothers are not instructed to wake a sleeping infant for feeding unless there are some serious physical issues, such as prematurity. As long as an infant is eating regularly, there is very little chance for dehydration. This statement would alert the LPN that the client did not comprehend the discharge instructions. Option 2: Not this one. Remember you are looking for an incorrect statement; however, this statement is totally accurate! Children and infants are safest in car seats that are secured in the back seat, facing backwards, for at least the first year of life. Some states have laws requiring rear-facing car seats even after the first year. Obviously the client completely understood the instructions previously presented. Option 3: Definitely not. This statement by the client is completely true, indicating the client understood the teaching. Newborns have an under developed immune system and are unable to fight off even minor illnesses. Many pediatricians will tell new mothers to avoid crowds or public places for at least the first six weeks, allowing the infant's immune system to begin to strengthen. Obviously ill individuals should not be permitted to hold a newborn, or to even be in the vicinity of the baby. Option 4: Wrong again! The client has made a correct statement here, while you are looking for an inaccurate comment. Following years of research, prompted by a fear of SIDS, doctors have determined the safest sleeping position for infants is supine. Parents are told to never prop a bottle or place pillows and heavy blankets in the crib, to provide the safest possible sleeping environment.
Which client assignment should the LPN accept from the charge nurse? 1. Child needing pre-operative medication prior to reduction of a fracture. 2. Adult client reporting abdominal pain after being beaten up in a fight. 3. Adolescent with sickle cell disease requesting more medication via the patient controlled analgesia device. 4. Child admitted with cystic fibrosis 2 hours ago.
1. Child needing pre-operative medication prior to reduction of a fracture. 1. Correct: This is the most stable client that could be given to the LPN. Even though the client has a fracture, the focus is on giving pain medication prior to a surgical procedure. 2. Incorrect: This client could have internal bleeding and other complications not diagnosed. This is not the best client to give to the LPN. 3. Incorrect: This is a more complex client and is least likely to be assigned to a LPN because of the increased need for pain medications, like narcotics, and use of a technological device. Sickle cell pain episodes will vary in it's intensity and frequency. 4. Incorrect: This is a complex client and should not be given to the LPN. This client is a new admit at risk for respiratory distress and potential infections due to the chronic long term effects of cystic fibrosis. 1. "LPN" is the key to answering this question correctly. What type of client can the LPN accept? Stable and complex, stable clients.
A client diagnosed with schizophrenia comes up to the nurse and says, Tick, tock, duck clock. Clock, clock, tick, tock. How would the nurse document this impaired communication? 1. Clang association 2. Echopraxia 3. Perseveration 4. Magical thinking
1. Clang association 1. Correct: Clanging, or clang associations, involves choosing words based on their sounds rather than their meanings and usually involves alliteration or rhyming. 2. Incorrect: Echopraxia involves the client purposelessly imitating movements made by others .3. Incorrect: Perseveration involves the client persistently repeating the same word or idea in response to different questions. 4. Incorrect: Magical thinking involves the client believing that his or her thoughts or behaviors have control over specific situations or people. Ex: It's raining; the sky is sad.
Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection? 1. Cleans perineum from front to back after newborn soils diaper. 2. Makes certain the umbilical cord remains dry with each diaper change. 3. Places the top of the diaper just above the umbilicus. 4. Wraps sterile petroleum gauze around umbilical cord. 5. Submerges newborn in warm water up to the chest for first bath.
1. Cleans perineum from front to back after newborn soils diaper. 2. Makes certain the umbilical cord remains dry with each diaper change. 1., & 2. Correct: Cleaning from front to back will decrease the risk of infection by reducing the number of microorganisms at the urethral meatus. Keeping the umbilical cord clean and dry will decrease the risk of infection and will allow it to fall off. 3. Incorrect: The top of the diaper should be placed just below the umbilicus to prevent exposure to body waste and moisture. Placing the diaper above the umbilical cord will cause the diaper to rub the umbilicus, which will increase the risk of infection. 4. Incorrect: This would keep the umbilical cord moist and could lead to infection. Also a sterile dressing is not warranted. The umbilical cord needs to be kept dry so it will fall off. 5. Incorrect: The newborn should not be placed in water until after the umbilical cord falls off. Water submersion keeps the cord moist and at risk for infection. The umbilical cord should be kept dry so that it will fall off.
The charge nurse is assigning an unlicensed assistive personnel (UAP) to take vital signs on a group of adult clients. The charge nurse would instruct the UAP that a rectal temperature is contraindicated for which client? 1. Client with thrombocytopenia. 2. Client with a fractured femur. 3. Client with an inguinal hernia. 4. Client with irritable bowel syndrome.
1. Client with thrombocytopenia. 1. Correct: Thrombocytopenia is the deficiency of platelets in the blood. Due to the reduced platelet count, the clotting time of the client's blood will be reduced. Inserting a rectal thermometer increases the client's risk of rectal trauma. If there is rectal bleeding from the insertion of the rectal thermometer, the client may experience increased bleeding due to their decreased platelet count. 2. Incorrect: A client with a fractured femur can have their temperature assessed by a rectal temperature. There are no contraindications for a rectal temperature. 3. Incorrect: To evaluate a client's temperature by inserting a rectal thermometer is acceptable procedure for a client with an inguinal hernia. 4. Incorrect: There are no contraindications for clients with irritable bowel syndrome to have their temperature assessed by a rectal thermometer.
The nurse is caring for a client with a perineal burn. The skin is not intact. How will the nurse know if a perineal infection is occurring? 1. Color changes 2. Drainage 3. Odor 4. Fever 5. Bleeding 6. Increased pain
1. Color changes 2. Drainage 3. Odor 4. Fever 6. Increased pain 1., 2., 3., 4. & 6. Correct: Infection may cause color changes, drainage, odor, fever and increased pain. 5. Incorrect: Bleeding is a sign of hemorrhage, trauma, or other blood disorders, but is not caused by infection.
The LPN/VN is preparing to transfer a client from the delivery room to the postpartum unit. Which statement by the client would be the priority for the LPN/VN to notify the charge nurse? 1. "I just felt something gush." 2. "I feel like I am still having contractions." 3. "When I stand up, I feel dizzy for several moments" 4. "My hemorrhoids are hurting."
1. Correct. This could indicate postpartum hemorrhage (PPH) and requires immediate assessment by the nurse. PPH can be caused by the following: placenta previa, cervical lacerations, vaginal tear, or a ruptured or inverted uterus. 2. Incorrect. This is normal postpartum contractions of the uterus to help dispel clots and to return the uterus to normal size. The contractions may occur for several days after delivery. 3. Incorrect. Due to the fluid loss during the delivery, the client may be experiencing orthostatic hypotension. Teach safety measures. Although the LPN would need to inform the charge nurse of this, it is not the priority over the report that may indicate postpartum hemorrhage. 4. Incorrect. The client's hemorrhoids can be painful after delivery. However, this is not the priority to report. Remember, bleeding would be a priority over pain.
When caring for a client admitted with a diagnosis of pheochromocytoma, which finding would indicate the client has elevated levels epinephrine and norepinephrine? 1. Headache 2. Hypotension 3. Bradycardia 4. Polycythemia
1. Correct. This disease is characterized by a headache, hypertension, tachycardia, hypermetabolism and hyperglycemia due to the increased release of epinephrine and norepinephrine. 2. Incorrect. Hypertension, rather than hypotension, would be seen in this client. 3. Incorrect. The heart rate will increase rather than decrease. 4. Incorrect. Polycythemia is elevated red blood cell count, which is not seen with this disease. Pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension. The tumor is malignant in 10% of cases but may be cured completely by surgical removal. Signs and symptoms of pheochromocytomas often include: Signs and symptoms include: High blood pressure, hyperglycemia, rapid or forceful heartbeat, profound sweating, severe headache, tremors, paleness in the face and shortness of breath. Less common signs or symptoms may include anxiety or sense of doom, abdominal pain, constipation, weight loss. These signs and symptoms often occur in brief spells of 15 to 20 minutes. Spells can happen several times a day or less often.
The nurse is caring for a client who has a history of sleep apnea. The client is scheduled for a colon resection the following morning and asks if the sleep apnea machine should be brought to the hospital. What is the nurse's best response? 1. Yes, bring the sleep apnea machine. 2. No, do not bring the sleep apnea machine. 3. It is your choice. 4. Call your primary healthcare provider.
1. Correct: A client with sleep apnea is at risk for cardiac and respiratory complications postop due to decreasing oxygenation. So yes, the client needs to use the CPAP machine. Remember this client will also be receiving narcotics for pain and have a decreased activity level as well. All of these things can decrease oxygenation. 2. Incorrect: The client will need to have the machine after surgery. 3. Incorrect: The best response is for the nurse to recommend that the client bring the CPAP machine. 4. Incorrect: The nurse can answer this question.The primary healthcare provider does not need to be called. Sleep apnea is a concern for clients who are about to have surgery. These clients are at an increased risk for developing respiratory and cardiovascular complications in the postoperative period. Complications can include irregular heart rhythms, oxygen deficiency, high blood pressure, diabetes, stroke, heart attack, and even death. Positive airway pressure (PAP) is considered the gold standard treatment for sleep apnea. With continuous positive airway pressure (CPAP), the client will wear a mask over the nose and/or mouth while sleeping. An air blower will force air through the airway, which will prevent it from closing during sleep. The nurse should closely monitor the client's vital signs both during and after surgery.
The nurse is caring for a client taking a selective serotonin reuptake inhibitor (SSRI). The client tells the nurse "I am sweating more than ever!" What is the nurse's best response? 1. This is a common side effect of antidepressant medications. 2. Excessive sweating can have many causes. 3. You should report this side effect to your primary healthcare provider. 4. This symptom should go away within a few days.
1. Correct: A common side effect of SSRIs is increased sweating. This option gives the client an explanation. 2. Incorrect: This response shows a lack of understanding of the side effects of antidepressant medications. 3. Incorrect: This option does not acknowledge the client's problem and possible causes. 4. Incorrect: Increased sweating may continue throughout treatment with an antidepressant medication.
A client consumes a lacto-ovo vegetarian diet at home. During hospitalization, the primary healthcare provider prescribes an increased calorie diet. Which foods are appropriate for the nurse to serve as between meal snacks to boost caloric intake? 1. Cheese sandwich and milk 2. Boiled eggs but no dairy products 3. Fish sticks and cocktail sausages 4. Fresh vegetables but no milk or eggs
1. Correct: A lacto-ovo vegetarian diet is a vegetarian diet that does not include meat, but does contain eggs and dairy. The client can eat milk and dairy products along with grain products on this diet. 2. Incorrect: Dairy products and eggs are allowed on this diet. Milk, cheese and yogurt can be consumed on a lacto-ovo vegetarian diet. 3. Incorrect: The client does not consume meats. Meats, fish, and poultry should not be provided as a snack. 4. Incorrect: The client can consume milk and eggs as well as fresh fruits and vegetables. Milk and eggs can be consumed on a lacto-ovo vegetarian diet.
Following surgery, a client is placed on methylprednisolone. What additional drug therapy would the nurse expect to be prescribed for this client to prevent an adverse reaction related to methylprednisolone? 1. Pantoprazole 2. Phenytoin 3. Imipramine HCI 4. Aminocaproic acid
1. Correct: A potential side effect of methylprednisolone is a peptic ulcer. The primary healthcare provider will prescribe a proton pump inhibitor or H2 blocker to prevent this side effect. 2. Incorrect: Phenytoin is an anticonvulsant. Seizures are not a side effect of methylprednisolone. 3. Incorrect: Imipramine HCI is an antidepressant which is not routinely given with methylprednisolone (Although mood changes can occur with steroid administration, anti-depressants are not routinely given). 4. Incorrect: Aminocaproic acid is given when clients are bleeding. Bleeding is not a side effect of methylprednisolone.
A 9 month old with asthma symptomology has montelukast sodium oral granules prescribed. The nurse knows to administer the medication in what way? 1. Mix the granules with a spoonful of baby food such as applesauce. 2. Pour the granules directly on the back of the infant's tongue. 3. Dissolve the granules in an 8 ounce (240 mL) bottle of juice. 4. Administer the medication in the morning mixed in a bowl of rice cereal.
1. Correct: Applesauce is an appropriate baby food for a 9 month old infant. The medication is being mixed with a very small amount of baby food to facilitate all of the medication being consumed. 2. Incorrect: Although the medication can be administered directly into the mouth, a 9 month old is not likely to tolerate medication granules being placed in the back of the mouth and would likely spit the medication out or gag when the medication is placed in the back of the mouth, 3. Incorrect: The medication is being placed in too much juice. The infant might not drink this amount and would not receive all of the medication ordered. 4. Incorrect: If the child does not eat the entire amount of the cereal, the child would not receive the prescribed dose of the medication.
What is the nurse's best response to the pregnant client's question about appropriate exercise during pregnancy? 1. Discuss with healthcare provider your current exercise regimen and history. 2. You can continue any exercise that you have been doing before pregnancy. 3. If you haven't already started an exercise program, you should wait until after delivery. 4. Exercise is required during pregnancy for a minimum of 15 minutes each day.
1. Correct: Best advice for pregnant women. The healthcare provider can individualize according to the physical condition of the woman and the stage of pregnancy. 2. Incorrect: As pregnancy progresses, the exercise program may need modification because the change in the woman's center of gravity makes her more prone to falls. Therefore, an activity that is safe in the first trimester may not be safe in the third trimester. Those women who have been exercising strenuously before pregnancy should consult the healthcare provider but may be able to continue much of their usual routine. Recreational sports generally can be continued if no risk of falling or abdominal trauma exists. 3. Incorrect: Exercise during pregnancy is generally beneficial and can strengthen muscles, reduce backache, reduce stress and provide a feeling of well-being. The amount and type of exercise recommended depend on the physical condition of the woman and the stage of pregnancy. 4. Incorrect: Women who have no medical or obstetric complications should exercise in moderation each day for 30 minutes or more during pregnancy.
An 82 year old client tells the nurse at the clinic, "I have lived a good, successful life and married my best friend". Which of Erikson's developmental tasks does the nurse recognize that this client has probably accomplished? 1. Ego Integrity versus Despair 2. Generativity versus Stagnation 3. Intimacy versus Isolation 4. Industry versus Inferiority
1. Correct: Ego Integrity versus Despair is the major task of those 65 and over: The developmental task for this age involves the individual reviewing one's life and deriving meaning from both positive and negative events, while achieving a positive sense of self. If the individual considers accomplishments and views self as leading a successful life, a sense of integrity is developed. On the contrary, if life is viewed as unsuccessful without accomplishing life's goals, a sense of despair and hopelessness develops. 2. Incorrect: Generativity versus Stagnation is the major task for 40-64 year olds. To achieve the life goals established for oneself while also considering the welfare of future generations. The primary developmental task during this middle age period is one in which the individual contributes to society as well as helping to guide future generations. A sense of generativity (sense of productivity and accomplishment) often results from such things as raising a family and helping to better the society. In contrast, those individuals not willing to work to better society and those who are egocentric and self-centered often develop a sense of stagnation (dissatisfaction and the lack of productivity). 3. Incorrect: Intimacy versus Isolation is the objective for 20-39 year olds to form an intense, lasting relationship or a commitment to another person. If the individual cannot form the intimate relationships (possibly due to personal needs) a sense of isolation may develop which can lead to feelings of depression. 4. Incorrect: Industry versus Inferiority is the major task for 6-12 year olds in which they attempt to achieve a sense of self confidence by learning, competing, performing successfully, and receiving recognition from significant others, peers, and acquaintances. The child must develop the ability to deal with the demands of learning new social and academic skills, or a sense of inferiority, failure, or incompetence may result. 1. If age, sex, nationality are identified in the stem, it is important to the question and will generally direct you to an answer. Remember Erickson's stages of growth and development.
A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most important nursing measure for this client? 1. Observation and support of ventilation 2. Insertion of indwelling urinary catheter 3. Nasogastric suctioning 4. Frequent monitoring of level of consciousness
1. Correct: Guillain-Barre syndrome is an acquired inflammatory disease that results in demyelinization of the peripheral nerves. It is usually ascending in nature and can lead to respiratory paresis or paralysis. 2. Incorrect: Insertion of an indwelling urinary catheter may in fact be necessary but does not prioritize higher than support of ventilation. 3. Incorrect: Nasogastric suctioning is not a need identified with Guillain-Barre syndrome. 4. Incorrect: The client's cognitive function remains intact, and there is no data in the stem of the question that indicates otherwise; therefore, ventilation is the priority. Guillain-Barre does not affect the LOC.
Which comment by the client indicates understanding of possible complications of long term hypertension? 1. "I would like to have my serum creatinine checked at this visit." 2. "My blurred vision is part of getting older." 3. "I have leg pain caused by excessive exercise." 4. "Adding salt to my food is permissible."
1. Correct: Hypertension is one of the leading causes of end stage renal disease. The client understands that renal function is reflected by serum creatinine levels. This request demonstrates understanding of the disease and possible complications. 2. Incorrect: The appearance of the retina provides important information about the severity and duration of hypertension. Manifestations of severe retinal damage include blurred vision, retinal hemorrhage, and loss of vision. 3. Incorrect: Intermittent claudication is a complication of peripheral vascular disease (PVD). Hypertension speeds up the process of PVD. 4. Incorrect: Increasing the salt intake causes an increase in the sodium levels which can reduce the kidney's ability to remove excess fluid. This can result in a worsening of the hypertension. Lifestyle modifications to reduce hypertension include dietary sodium reduction, weight reduction, Dietary Approaches to Stop Hypertension (DASH) eating plan, moderation of alcohol consumption, regular physical activity, avoidance of tobacco use, and management of psychosocial risk factors.
A Hispanic client is considering treatment options for cancer. The client says that she needs to discuss the options with her sons before she makes her final decision. What should the nurse say to the client? 1. "I understand. Should I ask them to come to the hospital to discuss this with the primary healthcare provider?" 2. "It is really your decision about which option you choose." 3. "I will be happy to discuss this issue with you." 4. "The primary healthcare provider wants you to make the decision tonight."
1. Correct: In the culture, the client's family is important to her. Therefore, her sons and their opinions regarding decisions are also important. 2. Incorrect: Although clients have the right to make autonomous decisions, it is important to remember cultural variations regarding the decision making process. 3. Incorrect: The nurse can discuss the issue; however, the males in the family have much influence on decisions. 4. Incorrect: The client is being coerced into making a decision without time to consider the options.
Which nursing task would be appropriate for the LPN/VN to complete? 1. Obtain a wound culture from a client. 2. Administer regular insulin IV to a client in diabetic ketoacidosis. 3. Update plan of care for a client. 4. Initiate client teaching on ostomy care.
1. Correct: The LPN/VN has the knowledge and skill to obtain a wound culture. This is within the scope of practice for the LPN/VN. 2. Incorrect: The LPN/VN cannot administer IV medications to an unstable client. This client needs the RN for close monitoring. 3. Incorrect: The LPN/VN cannot develop or update a plan of care for a client. This is an RN task. The PN can contribute to the development and update, however. 4. Incorrect: Initiating teaching is the task of an RN. LPN/VN's can collect data, observe, monitor the client, and reinforce teaching
Which action, if done by a new LPN/VN, needs to be interrupted by the precepting LPN/VN? 1. Mixes diazepam and hydromorphone in one syringe. 2. Administers diazepam before meals. 3. Raises side rails after administering hydromorphone. 4. Instructs client to call for assistance getting out of bed after administration of diazepam.
1. Correct: In this question, you are looking for the answer that is unsafe and should not be done. Diazepam cannot be mixed with any other medication. The charge nurse should intervene. 2. Incorrect: This is an appropriate action. Food in the stomach delays absorption of diazepam, so it would need to be given before meals. 3. Incorrect: This would be an appropriate action. Hydromorphone is a narcotic and can decrease level of consciousness (LOC) and increase the risk of falls, so the nurse would be taking appropriate measures to ensure the client's safety. 4. Incorrect: This would be an appropriate action. Diazepam relaxes the muscles, decreases LOC, and can increase the risk of falls. 1. Client safety is always a priority. 2. Identify clues in the stem. Generally, the stem is short and contains only the information needed to make the question clear. A clue is the use of a word or phrase that leads you to the correct answer. The clue shows a relationship to word or phrase in the correct answer.
Which action by a new nurse demonstrates the need for intervention? 1. The two-handed method is used to recap a needle. 2. A needleless system is used to give intravenious piggyback (IVPB) medication through an intravenous (IV). 3. A blunt cannula is used to withdraw medication from a vial. 4. An engineered sharp injury protective device is used to recap a used needle.
1. Correct: Needles should be recapped using a one hand scoop method to prevent accidental sticks. Two-handed method increases the risk that the nurse's non-dominant hand will be punctured with the needle. Think about it. You do not want the hand holding the cap to get close to the needle. What if you miss the needle and stick your hand? The best solution is to not recap at all. Place the needle in the sharps container at once. But if the sharps container is not close by, then the one hand scoop method is appropriate. You are not exposing one hand to the needle. 2. Incorrect: This is a correct method to use. To prevent injury during injection administration or body fluid retrieval, use a one-handed scoop method, needleless system, blunt cannula for medication withdrawal from a vial, or an engineered sharp injury protective device whenever possible. 3. Incorrect: This is a correct method to use. To prevent injury during injection administration or body fluid retrieval, use a one-handed scoop method, needleless system, blunt cannula for medication withdrawal from a vial, or an engineered sharp injury protective device whenever possible. 4. Incorrect: This is a correct method to use. To prevent injury during injection administration or body fluid retrieval, use a one-handed scoop method, needleless system, blunt cannula for medication withdrawal from a vial, or an engineered sharp injury protective device whenever possible. 1. Identify key words in the stem that indicate negative polarity, such as not, except, never, contraindicated, unacceptable, avoid, unrelated, violate, least, further teaching needed. These words indicate negative polarity and the question being asked is looking for what is wrong. So in which option is the nurse doing something incorrectly? In option 1, the nurse is exposing herself or himself to potential injury. The nurse could miss the cap and stick the hand when using the two handed method. 2. Client and nurse safety is always a priority. If you didn't know the answer here, think about safety. Which option is least safe and could cause harm to the nurse in this situation? The two handed method for re-capping a needle. The other options are much safer for the nurse.
A client in the inpatient mental health unit has been determined not suicidal. The client is requesting to leave against medical advice (AMA). What should the nurse do first? 1. Inform the primary healthcare provider that the client is wishing to leave. 2. Make arrangements for a commitment hearing 3. Tell her that she must stay until her primary healthcare provider discharges her. 4. Call the primary healthcare provider and request a discharge order.
1. Correct: Protocols on the unit must be followed when someone is requesting to leave AMA. The first step involves calling the primary healthcare provider. 2. Incorrect: The client is not suicidal; however, the primary healthcare provider needs input into this decision. 3. Incorrect: If the client is not a threat or potential threat to self or others, the client may leave. But first the nurse must inform the primary healthcare provider. 4. Incorrect: The nurse should call the primary healthcare provider and discuss the situation. The primary healthcare provider should have input into this decision.
A client has been on the medical unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do? 1. Inform the primary healthcare provider that the client wishes to leave. 2. Make arrangements for a commitment hearing as soon as possible. 3. Tell the client the primary healthcare provider must discharge the client prior to leaving. 4. Call the primary healthcare provider and request a discharge order.
1. Correct: Protocols on the unit must be followed when someone is requesting to leave AMA. The first step is to call the primary healthcare provider about the client's desire to leave AMA. 2. Incorrect: The client is not suicidal; however, the primary healthcare provider needs input into their decision to leave AMA. It is not appropriate to prepare for a commitment hearing. 3. Incorrect: If the client is not a threat or potential threat to self or others, the client may leave. The nurse may discuss the decision to leave; however, this statement is not accurate. 4. Incorrect: The nurse should call the primary healthcare provider and discuss the situation. The primary healthcare provider should have input into this decision.
A young client experiencing a manic episode tells the night nurse, "If you do not go to bed with me, I am going to have you fired." Which statement by the nurse is appropriate? 1. "That is inappropriate behavior and you will need to go to your room." 2. "You've got to be kidding! You can't get me fired." 3. "I don't want to hear that again; don't ever say that again." 4. "I can see that you need attention, but this is not the way to get it."
1. Correct: Set limits on manipulative behaviors. Explain what is expected and what the consequences are if limits are violated. 2. Incorrect: Do not argue with the client. 3. Incorrect: This is confrontational and does not set consequences. 4. Incorrect: Remember to set limits and do not encourage this behavior.
Which diagnosis does the nurse expect in a client with a (+) Brudzinski's sign? 1. Meningitis 2. Peritonsillar abscess 3. Pharyngitis 4. Rhinosinusitis
1. Correct: Severe neck stiffness causes a client's hips and knees to flex when the neck is flexed. This is a (+) Brudzinski's sign which is suggestive of meningitis. 2. Incorrect: Brudzinski's sign is not suggestive of peritonsillar abscess. 3. Incorrect: Brudzinski's sign is not suggestive of pharyngitis.4. Incorrect: Brudzinski's sign is not suggestive of rhinosinusitis.
Which task by the nurse should be performed first? 1. Suctioning the tracheostomy of an anxious client 2. Changing a colostomy bag that is leaking 3. Collecting admission data on a client that has been on the floor for 45 minutes 4. Administering pain medication for a client that is 8 hours post op
1. Correct: Suctioning the tracheostomy should take priority. This client is anxious, which is a sign of hypoxia, and they need immediate action. 2. Incorrect: Not priority over airway 3. Incorrect: Important, but not first priority over airway. 4. Incorrect: Important, but not first priority over airway.
A client is admitted to the surgical unit with cholelithiasis and a history of psychosis and a known allergy to phenothiazines. Which prescription should the nurse discuss with the primary healthcare provider? allergies:Phenothiazines Penicillin Prescriptiom: Clear liquid diet Gallbladder ultrasound today IV of LR with KCL 20 mEq at 125 ml/hr Thioridazine 50 mg PO TID Ciprofloxacin 200 mg IVPB every 12 hours Haloperidol 5 mg by mouth twice daily Ondansetron 4 mg IM as needed for nausea or vomiting 1. Thioridazine 50 mg PO tid 2. Ciprofloxacin 200 mg IVPB every 12 hours 3. Haloperidol 5 mg PO bid 4. Ondansetron 4 mg IM prn nausea or vomiting
1. Correct: The client is allergic to phenothiazines. Thioridazine is a phenothiazine and should not be given to this client. 2. Incorrect: Ciprofloxacin is an antibiotic but is not a penicillin drug; therefore, it can be administered to this client. 3. Incorrect: Haloperidol is an antipsychotic medication. The classification is butyrophenone, not a phenothiazine. 4. Incorrect: Ondansetron is an antiemetic and is an appropriate drug for this client.
Which primary healthcare prescription should the nurse perform first? 1. Insert intermittent catheter in client who has not voided in 8 hours. 2. Administer a bolus feeding via a client's gastrostomy tube. 3. Reinsert nasogastric tube (NG) that was pulled out. 4. Remove wound sutures.
1. Correct: The client who has not voided after 8 hours needs to be catheterized. This is the priority since the bladder is likely full and could lead to backflow of urine to the kidneys. 2. Incorrect: Not the priority here. The feeding can be done after the catheter is inserted into the client who cannot void. 3. Incorrect: Again, not the priority. This can be done after the catheter is inserted. 4. Incorrect: Removing sutures is not a priority. This could be done last. A strategy you can draw on to help answer priority questions is to refer to basic guiding theories that are part of the foundation of nursing. Maslow's Hierarchy of Needs, The Nursing Process, Kubler-Ross's Theory of Death and Dying, Teaching/Learning Theory, Therapeutic Communication.
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. Correct: 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. 2. Incorrect: While this may be appropriate, it may also delay treatment of the problem, which is infection. Remember, you can only pick one answer to fix the problem and this action will only treat the symptoms. 3. Incorrect: The primary healthcare provider may want the site monitored, but this also delays treatment. Since you can only pick one option, this is not the best. 4. Incorrect: Comfort measures are always appropriate, but this is not the best action available.
While reviewing the prescriptions written by a primary healthcare provider, the nurse notes that ibuprofen 30 mg by mouth every 6 hours is prescribed for a child weighing 6 kg. The drug information book states that the appropriate dosage range is 20-30 mg/kg/24 hours. What action should the nurse take? 1. Administer the ibuprofen at 30 mg by mouth every 6 hours. 2. Contact the nursing supervisor regarding the prescription. 3. Ask the pharmacist to calculate the appropriate dose. 4. Notify the primary healthcare provider.
1. Correct: The maximum dose in 24 hours would be 30 x 6 = 180 mg. 30 mg every 6 hours is a safe dose. 2. Incorrect: The nursing supervisor does not need to be notified. This is a safe dose. 3. Incorrect: The nurse can calculate the appropriate dose based on the information provided. The pharmacist does not need to calculate the dose. The prescription is within the safe range. 4. Incorrect: The primary healthcare provider does not need to be notified since the prescription is written within the safe range.
A client who is Chinese comes to the clinic for a follow-up appointment following cardiac bypass surgery. The client's father accompanies the client into the examination room. What is the most appropriate action by the nurse? You answered this question Correctly 1. Ask the client's father if he has any questions regarding his son's condition. 2. Ask the client's father to leave the examination room due to confidentiality. 3. Perform needed assessments and care without interacting with the father. 4. Inform the father of the assessment findings and plan of care.
1. Correct: The nurse is responsible for providing culturally sensitive client care. In the Chinese culture, it is important to show respect to the elders of the family. This option respects the client's father by addressing him personally and providing a sense of involvement in the client's health. This option does not ignore the client's father nor does it violate the client's confidentiality. In addition, questions about certain conditions can be answered without direct reference to the client. 2. Incorrect: Asking the father to leave the exam room would be disrespecting not only the father, but also the client who allowed the father to be present. 3. Incorrect: By failing to acknowledge the presence of the father, this demonstrates a lack of respect for the elder of the family. The nurse should not ignore the presence of others in a client room. 4. Incorrect: By providing information of assessment findings and plan of care, this could violate the client's rights to confidentiality. The client would need to provide expressed permission for specific information to be shared in the presence of another individual. In the Chinese culture, the elder members of the family are considered to have the most authority and expect large amounts of respect. The elders are looked upon as having the final say over younger members of the family who are considered inferior. Failure to pay appropriate respect to the elders, especially failing to give reverence to those elders who have died, is sometimes viewed as bad luck to the family. The option that provides respect to the presence of the father without breaching confidentiality is where the nurse engages the father by asking if he has any questions regarding the client's condition. This not only provides respect, but it also allows an opportunity for the elder family member to have a sense of authority to be allowed to ask questions and be involved in his son's health care. Selecting the option where the father is asked to leave the room would be failing to provide culturally sensitive client care. This would be disrespecting the elder of the family and would be going against the wish of the client who allowed the father to be present. If the nurse ignores the presence of the father by never acknowledging the father or engaging him in conversation, this would also be disrespecting the client's father and could create tense family dynamics. The nurse should not just volunteer client information to family members as this would be a breach of confidentiality unless expressed permission has be granted to provide the information to a specific individual. Never assume that because someone is present in the room it is acceptable to discuss findings of client assessments, plans of care, or any other specific client information. The client must choose who is allowed to have access to private information.
A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first to assure that the client's request is respected? 1. Ensure a do-not-resuscitate prescription has been provided. 2. Report client wishes during the end-of-shift report. 3. Have the client sign an advanced directive. 4. Ask the client who holds the durable power of attorney for health care decisions.
1. Correct: The nurse should check the medical record for a DNR order. By law, a person who does not have a do-not-resuscitate (DNR) prescription, must be provided CPR in the event of a cardiac/respiratory arrest. This action will ensure the client's end-of-life wishes have been communicated and will honor the client's wishes. 2. Incorrect: It is appropriate to report the client's end-of-life wishes to other care givers, but not before ensuring a DNR order is in place. 3. Incorrect: If the client has advance directives, a copy should be placed in the medical record. However, a DNR prescription must also be in place to ensure the client is not resuscitated. 4. Incorrect: The client's request can be initiated by notifying the primary healthcare provider. It would be helpful for the client to have a durable power of attorney.
A Hispanic client is considering treatment options for cancer. The client is reports needing to discuss the options with the sons before making a final decision. What should the nurse say to the client? 1. You are wanting your sons to assist you in deciding about treatment options. 2. It is really your decision about which option you choose. 3. I will be happy to discuss this issue with you. 4. This shows that you are proud of your sons.
1. Correct: This is paraphrasing the client's statement and is a therapeutic response. Within this culture, the family plays a very important role when making decisions about healthcare. 2. Incorrect: Although clients have the right to make autonomous decisions, it is important to remember cultural variations regarding the decision making process. 3. Incorrect: The nurse can discuss the issue; however, the males in the family have much influence on decisions. 4. Incorrect: This is giving an opinion on the relationship of the mother and sons. While this may be true, it does not focus on the cultural aspect of the question and is not the best response.
A client who presents with severe epigastric pain, reports that three rolls of calcium carbonate were consumed in the past eight hours to treat the indigestion. Which blood gas report does the nurse associate with this situation? 1. pH - 7.49, pCO2 - 40, HCO3 - 30 2. pH - 7.32, pCO2 - 48, HCO3 - 20 3. pH - 7.38, pCO2 - 52, HCO3 - 32 4. pH - 7.29, pCO2 - 54, HCO3 - 26
1. Correct: These ABGs are indicative of metabolic alkalosis. The pH is high, the pCO2 is within normal limits and the bicarb is high (alkalosis). So, the excess Tums (calcium carbonate) could have caused metabolic alkalosis. 2. Incorrect: The client is not hypoventilating and would not be in metabolic acidosis because he ate 3 rolls of Tums, which is a base. These ABGs are indicative of acidosis. The pH is low (acidosis), the pCO2 is high (acidosis) and the bicarb is low (acidosis). 3. Incorrect: The client is not a long-term COPD client as these ABGs might suggest. These ABGs are indicative of fully compensated respiratory acidosis. The pH is normal. The pCO2 is high (as with chronic retention) and the bicarb is high to help compensate. 4. Incorrect: These ABGs are the result of an acute ventilation problem. They are indicative of respiratory acidosis. The pH is low, the pCO2 is high, and the bicarb is normal. No compensation has begun at this point.
A farm worker comes into the clinic reporting headache, dizziness, and muscle twitching after working in the fields. What condition does the nurse suspect? 1. Pesticide exposure 2. Heat stroke 3. Anthrax poisoning 4. Gastroenteritis
1. Correct: These are symptoms of pesticide exposure when combined with the details given of coming from the fields. Death can result from severe acute pesticide poisoning. 2. Incorrect: The data provided does not lead the nurse to suspect heat stroke. The stem does not tell the temperature the farmer is working in. Heat stroke signs and symptoms include increased sweating, tachypnea and temperature greater than 105.8°F (41.0°C). 3. Incorrect: The data provided does not lead the nurse to suspect anthrax poisoning. The worker has been outside in a field. This is not a risk factor for anthrax exposure. Inhalation anthrax develops when you breathe in anthrax spores. It's the most deadly way to contract the disease, and even with treatment it is often fatal. Initial signs and symptoms of inhalation anthrax include: Flu-like symptoms, such as sore throat, mild fever, fatigue and muscle aches, which may last a few hours or days. Mild chest discomfort, Shortness of breath, Nausea, Coughing up blood, Painful swallowing 4. Incorrect: The data provided does not lead the nurse to suspect gastroenteritis. These signs and symptoms do not go with gastroenteritis. Gastroenteritis signs and symptoms include diarrhea, nausea, vomiting, fever and abdominal cramping. 1. The nurse must be aware of risk factors that cause diseases. If the test taker does not know the correct answer, think about which body system the question is asking about may help rule out or rule in some of the options. Look at the clues in the stem: farm worker, headache, dizziness, and muscle twitching after working in the field. What do farmers work with? Crops that could have been sprayed with pesticides. Is heat stroke possible? Yes but the stem would have told you that the farmer was working on a hot day. Common hosts for anthrax include wild or domestic livestock, such as sheep, cattle, horses and goats. The stem doesn't say anything about the farmer working with animals. What about option 4, gastroenteritis? Eating food that's undercooked, stored too long at room temperature, or not reheated well can cause bacterial gastroenteritis, also known as "food poisoning." There are not hints in the stem suggesting gastrointeritis.
A psychiatric nurse, caring for several clients, recognizes that which client presents the greatest risk for violence toward others? 1. Twenty four year old man with paranoid delusions. 2. Sixty two year old woman with bi-polar disorder 3. Seventy year old man with major depression. 4. Twenty eight year old woman with borderline personality disorder
1. Correct: This client has a diagnosis that is consistent with a risk of violence, and his age falls within the age range for males who are most likely to present a risk of violence toward others. 2. Incorrect: This client may be irritable; however, it is not likely that she will present a great risk for violence. Her age does not fall within the range for women that are most likely to present a threat of violence. 3. Incorrect: This client is more likely to hurt himself. 4. Incorrect: This client is more likely to present a risk of violence toward self.
A client is admitted to the pediatric unit with a diagnosis to rule out tuberculosis (TB). What room assignment should the charge nurse make? 1. Private room and placed on airborne precautions. 2. Private room and place on protective isolation. 3. Room with a client diagnosed with a respiratory infection. 4. Room with a client who is 24 hours post appendectomy.
1. Correct: This client should be in a private room to prevent the spread by airborne contamination. In addition, the client should be placed on airborne precautions and standard precautions should be implemented. Remember, you are trying to protect staff and others without the disease from contracting TB. 2. Incorrect: Airborne isolation is needed to protect staff and others. There are no indications for protective isolation. The term 'protective isolation' describes a range of practices used to protect highly susceptible hospital clients from infection. 3. Incorrect: A respiratory infection client needs a private room. Also, it is best for the client with suspected TB to be in a private room. 4. Incorrect: 24 hours postoperative client does not need exposure to infection. Cross contamination is always a concern with a surgical client. 1. Identify opposites in options. When opposites appear, you need to give them serious consideration. One of them will be the correct answer, or they both can be eliminated from consideration. Look at options 3 & 4. Both say share a room with someone with another illness. Remember, like illnesses can go in the same room. So can someone with possible TB go in the room with someone with a respiratory infection or post op appendectomy? No. These are not like illnesses. That leaves options 1 and 2. Well, we know that a private room is needed. The question is, does the client need to be on protective isolation? No. What type of precaution is needed here? Airborne precautions. So that eliminates option 2. The correct option is #1.
The nurse is preparing to give a newly assigned client his routine home medications. As the nurse greets the client, she has several questions to ask the client. What should be the first question she asks? 1. What is your name? 2. Are you allergic to any medications? 3. How are you feeling today? 4. Do you have difficulty swallowing?
1. Correct: This is a new client, so the nurse needs to verify the client's name by asking even though there is an arm band in place. 2. Incorrect: This is an important question; however, the right client is the first right that the nurse needs to check. 3. Incorrect: This question is okay; however, the 5 rights of medication administration are essential now. 4. Incorrect: This is important to know; however, the right client is essential at this time.
The nurse is preparing to administer iron dextran IM. Which injection site would be best for administration? 1. Ventrogluteal 2. Vastus lateralis 3. Rectus Femoris 4. Deltoid
1. Correct: This site would be used for Z track IM injections. Iron preparations are administered by the Z track technique, preferably in a large, deep muscle such as the ventrogluteal muscle. 2. Incorrect: The vastus lateralis site could be used in adults with enough muscle mass, but the ventrogluteal is the preferred site. 3. Incorrect: The rectus femoris site can be used in adults when other sites are no longer accessible. It is not the preferred site. 4. Incorrect: The deltoid is a small muscle that is not well developed in many clients. It is not a recommended site for Z track medication administration.
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. 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.
Parents of school aged children are working toward a goal of healthy family TV viewing. Which parental statement indicates to the nurse an adequate understanding of appropriate use of TV in the family? 1. "I don't allow my kids to watch violent TV shows". 2. "Our children can watch anything that is on the kid network channel". 3. "I don't usually worry about the amount of time the kids watch TV on weekends". 4. "The kids can each choose one TV show per day without my input".
1. Correct: Violent TV shows are not recommended for school aged children. They may be disturbing and desensitize them to violence. 2. Incorrect: Even shows on kids' networks may demonstrate values that are not congruent with the healthy family. Input from the parents is needed here as well. 3. Incorrect: TV time should be limited each day to allow time for physical activity, social interaction, and development of hobbies and other skills. 4. Incorrect: The child needs the input of the parents. Parents and children may have an agreed upon list of shows that the child may watch.
A client who has schizophrenia tells the nurse, "I am Jesus and I am here to save the world". The client is warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What action should the nurse take? 1. Set limits and send the client to room. 2. Explain to the client that not all people are Christians. 3. Remove the Bible from the client and explain that the client is not Jesus. 4. Ask the client, "Share with the group how you know that you are Jesus."
1. Correct: Yes! You must set limits of where the client is allowed to preach. This is disrupting others, and the client needs to be redirected to the client's room for a cool down and then another activity shortly thereafter. 2. Incorrect: No, you should not tell the client that not all people are Christians, because the client will then go on a quest of salvation. 3. Incorrect: No, don't argue with the client. 4. Incorrect: This is ridiculing the client and also inflaming the situation.
A client who has schizophrenia tells the nurse, "I am Jesus and I am here to save the world". The client is warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What action should the nurse take? 1. Set limits and send the client to room. 2. Explain to the client that not all people are Christians. 3. Remove the Bible from the client and explain that the client is not Jesus. 4. Ask the client, "Share with the group how you know that you are Jesus."
1. Correct: Yes! You must set limits of where the client is allowed to preach. This is disrupting others, and the client needs to be redirected to the client's room for a cool down and then another activity shortly thereafter. 2. Incorrect: No, you should not tell the client that not all people are Christians, because the client will then go on a quest of salvation. 3. Incorrect: No, don't argue with the client. 4. Incorrect: This is ridiculing the client and also inflaming the situation.
The nurse is monitoring a client who is being treated with a non-steroidal antiinflammatory medication (NSAID) for an acute flareup of gout. Which finding should the nurse expect to observe? 1. Decrease in pain after beginning medications. 2. Report of severe abdominal pain following medication administration. 3. Decreased plasma uric acid levels. 4. Low-grade fever and rash.
1. Decrease in pain after beginning medications. 1. Correct. The client usually experiences improvement within 24 hours after beginning NSAIDs. 2. Incorrect. Most clients can tolerate NSAIDs fairly well. If severe pain in experienced, the primary healthcare provider should be notified immediately. 3. Incorrect. NSAIDs do not reduce plasma uric acid levels.4. Incorrect. This is not an adverse effect of NSAIDs. In fact, most NSAIDs are also antipyretics and would prevent fever.
The drug nadolol is prescribed to a client with stable angina. Which findings would the nurse expect to observe? 1. Decreased anxiety 2. Relief of chest pain 3. Bounding pulses 4. Lowered blood pressure 5. Bradycardia
1. Decreased anxiety 2. Relief of chest pain 4. Lowered blood pressure 1., 2., & 4. Correct: Nadolol is a beta-blocking agent. Beta-blockers block the beta 1 adrenergic receptor cells in the heart, thereby decreasing heart rate, contractility, and blood pressure. These effects decrease the workload on the heart. With decreased oxygen demand (workload on the heart), chest pain is relieved. Beta-blockers decrease cardiac contractility, thereby decreasing cardiac output. Beta blockers also relieve anxiety. 3. Incorrect: Bounding pulses would indicate fluid volume excess, thus making the problem worse. 5. Incorrect: Nadolol is a beta-blocking agent, which blocks the beta 1 adrenergic receptor cells in the heart, thereby decreasing heart rate; however, decreasing the heart rate to the point of bradycardia would be an adverse effect.
The drug nadolol is prescribed to a client with stable angina. Which findings would the nurse expect to observe? 1. Decreased anxiety 2. Relief of chest pain 3. Bounding pulses 4. Lowered blood pressure 5. Bradycardia
1. Decreased anxiety 2. Relief of chest pain 4. Lowered blood pressure 1., 2., & 4. Correct: Nadolol is a beta-blocking agent. Beta-blockers block the beta 1 adrenergic receptor cells in the heart, thereby decreasing heart rate, contractility, and blood pressure. These effects decrease the workload on the heart. With decreased oxygen demand (workload on the heart), chest pain is relieved. Beta-blockers decrease cardiac contractility, thereby decreasing cardiac output. Beta blockers also relieve anxiety.3. Incorrect: Bounding pulses would indicate fluid volume excess, thus making the problem worse.5. Incorrect: Nadolol is a beta-blocking agent, which blocks the beta 1 adrenergic receptor cells in the heart, thereby decreasing heart rate; however, decreasing the heart rate to the point of bradycardia would be an adverse effect.
The nurse is caring for a client diagnosed with paranoid personality disorder. Which interventions would be appropriate for the nurse to initiate? 1. Develop a trusting relationship. 2. Be honest when communicating with the client. 3. Encourage the client to participate in group therapy. 4. Encourage the client to clean the day room daily. 5. Give clear explanations of procedures beforehand.
1. Develop a trusting relationship. 2. Be honest when communicating with the client. 5. Give clear explanations of procedures beforehand. 1., 2. & 5. Correct: This disorder is characterized by distrust and suspicion towards others. The nurse should use open communication techniques to increase the client's trust in the nurse. Clear explanations of procedures will decrease the anxiety of the client. 3. Incorrect: The client with paranoid personality is reluctant to share personal information with other people. They suspect everyone of causing problems for them. Group therapy would not be appropriate for this client. 4. Incorrect: The client with paranoid personality feels that others are using or exploiting them. The client may perceive self as being exploited if asked to clean the dayroom daily.
The nurse is reinforcing discharge education to a client after a concussion. What should the nurse emphasize to report to the primary healthcare provider? 1. Difficulty waking up 2. Headache (3/10 on the pain scale) 3. Blurry vision 4. Achy feeling all over 5. Vomiting
1. Difficulty waking up 3. Blurry vision 5. Vomiting 1., 3. & 5. Correct: Increased intracranial pressure (ICP) is a result of increased pressure around the brain or blood in the brain. These are signs of increasing intracranial pressure (post-concussion syndrome). This is a medical emergency, and the primary healthcare provider should be notified immediately. 2. Incorrect: A headache of 3/10 on the pain scale does not warrant notifying the primary healthcare provider. The primary healthcare provider should be notified if the pain intensity increases. 4. Incorrect: This is not related. This is not a symptom of increased ICP.
Which observations should be made by the nurse in the home environment that may prevent threats to the safety of a toddler? 1. Do stairs have guard gates? 2. Are safety covers on electrical outlet plugs? 3. Is the swimming pool inaccessible to the toddler? 4. Are cleaning supplies located out of the toddler's reach? 5. Are stairs brightly lit
1. Do stairs have guard gates? 2. Are safety covers on electrical outlet plugs? 3. Is the swimming pool inaccessible to the toddler? 4. Are cleaning supplies located out of the toddler's reach? 1., 2., 3. & 4. Correct: Toddlers may fall if left unsupervised around stairs. Make sure that gates are in place and that they are used. Toddlers are at risk for exploring the outlets by putting metal objects into the outlets or putting their fingers in them. They should be covered unless in use. Toddlers can drown in small amounts of water and they may try to explore swimming pools if they are accessible. Pools should have fences or locking stairs and the child should never be left unsupervised around the pool. Toddlers are curious and may get into cabinets containing harmful substances. 5. Incorrect: This assessment would be important for the visually impaired or elderly, but not specifically for toddlers. The guard gates should be in place so that the toddler does not have access to the stairs. Before we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are home environment, safety, and toddler. Each option stands alone with the question. After reading each answer, you need to ask yourself is this answer is true or false. Remember client safety is always a priority. This question is asking about toddler safety in the home. There are all kinds of safety hazards in and around the home for the toddler. So let's look at the options. Option 1. This is true. There should be hardware-mounted safety gates at the top and bottom of every stairway. Otherwise, the toddler might fall and sustain a bad injury. Option 2 is also true. All unused outlets should be covered with safety plugs so the toddler cannot stick anything into the outlet. Doing so could electrocute the child. Option 3 is true. There should be climb-proof fencing at least 5 feet (1.5 meters) high on all sides of the pool. Does the fence have a self-closing gate with a childproof lock? It should. Option 4 is true. Low cabinets within easy reach of the toddler, such as under the sink should be free of cleaning supplies, bug sprays, dishwasher detergent, and dishwashing liquids. These supplies should be out of the reach of children. Option 5 is false. The toddler should not have access to the stairs at all. A well-lit stairway is good for people who are older and have difficulty seeing in dim light, however.
A nurse is reinforcing information given to a client suffering from gout about foods that contribute to exacerbation of gout. Which foods should the nurse teach the client to avoid? 1. Boiled shrimp 2. Baked pork chop 3. Broiled tilapia 4. Tuna salad 5. Low fat yogurt
1., 2. & 4. Correct: A diet for gout helps to control the production and elimination of uric acid, which may help prevent gout attacks or reduce their severity. Limit animal protein and avoid or limit high-purine foods, including organ meats, such as liver, and herring, anchovies and mackerel. Red meat (beef, pork and lamb), fatty fish and seafood (tuna, shrimp, lobster and scallops) are also associated with increased risk of gout. 3. Incorrect: Tilapia is one type of fish that would be appropriate to eat if one has gout. 5. Incorrect: Choose low-fat or fat-free dairy products. Some studies have shown that drinking skim or low-fat milk or milk products, such as yogurt, helps reduce the risk of gout.
The nurse is caring for a client following a cholecystectomy. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms? 1. Drink between meals. 2. Reduce intake of carbohydrates. 3. Eat small, frequent meals daily. 4. Sit semi-recumbent for meals. 5. Remain upright for one hour after eating. 6. Lie down on left side after eating.
1. Drink between meals. 2. Reduce intake of carbohydrates. 3. Eat small, frequent meals daily. 4. Sit semi-recumbent for meals. 6. Lie down on left side after eating. Rationale 1., 2, 3, 4., & 6. Correct: Clients are instructed to eliminate all fluids during meals. In some cases, clients may also need to eliminate fluids for one hour before and immediately after meals in order to control symptoms and slow the progress of food through the digestive tract. The symptoms described indicate the client is experiencing dumping syndrome, an adverse response following gastric or bariatric surgery. Clients may also experience tachycardia, nausea or cramping with the intake of food due to surgical restructuring of the gastrointestinal tract. Because this will be a lifetime issue, the nurse must teach the client to adjust eating habits and patterns. Reduction of carbohydrates will help decrease the problem since carbohydrates speed through the digestive track too quickly. Eating smaller, more frequent meals in a semi-recumbent position will further slow food through the digestive tract and eliminate most of the uncomfortable symptoms. After eating, the client should lie down on the left side to keep food in the stomach longer. 5. Incorrect: Sitting up after a meal is counterproductive, since this will increase the speed of food through the digestive tract. Therefore, clients are encouraged to lie down on the left side following meals to slow the processing of food.
A client has a history of deep vein thrombosis (DVT) and pulmonary embolism (PE). What should be included in the teaching by the nurse as preventive measures for the development of a DVT and PE?
1. Drink plenty of fluids on a daily basis. 3. Perform isometric and stretching exercises in the lower extremities. 4. Need for weight management. 5. Walk around 4-6 times per day. Rationale 1., 3., 4., & 5. Correct: In order to get this question correct, you must first consider some of the risk factors for developing a DVT and PE. Some causes include: dehydration, venous stasis from prolonged immobility or surgery, obesity, birth control pills, clotting disorders, and heart arrhythmias like A-Fib. Therefore preventive measures would include such things as hydration by increasing fluid intake, prevention of stasis by isometric and stretching exercises of the feet, knees, and hips every 2 to 4 hours, prevention of obesity, and walking around at least 4 to 6 times per day.
A client who has been trying to lose weight reports to the nurse that it is just easier to stop by the fast food restaurant on the way home from work than to go home and prepare a meal. Which suggestions should the nurse provide to help the client stay on track? 1. Eat yogurt and a piece of fruit upon returning home. 2. Order low fat options at the restaurants. 3. Pack a healthy snack to eat on the way home from work. 4. Fast foods do not contain healthy options. 5. Alter route home from work in the evenings.
1. Eat yogurt and a piece of fruit upon returning home. 2. Order low fat options at the restaurants. 3. Pack a healthy snack to eat on the way home from work. 1., 2. & 3. Correct: The client is describing lack of convenience, a barrier to making better choices. The client can consume yogurt and fruit on the way home and still be making a good choice for dinner. Accessibility of healthier items will help the client stay on track. Availability of healthy foods will help the client stay on the food plan.4. Incorrect: There are healthier choices currently at most fast food restaurants. Clients should be encouraged to choose from those.5. Incorrect: While this may help the client stay on track, it may make a healthy choice inaccessible. The client is more likely to make healthy choices when they are accessible, available, and affordable. 1. Identify opposites in options. When opposites appear, you need to give them serious consideration. One of them will be the correct answer, or they both can be eliminated from consideration. 2. With Select All That Apply questions, look at each option as a true/false statement. Match what is being asked in the stem with the options. If the stem is asking for a true response, then the true options should be selected.
A LPN/VN plans to reinforce education that was provided to a group of new parents about how to prevent burn injuries in children. What points should be included? 1. Eliminate use of placemats. 2. Establish "no" zones for space heaters. 3. Cover unused electrical outlets. 4. Warm baby bottle in microwave for 30 seconds. 5. Set the hot water heater thermostat to 140°F (60°C).
1. Eliminate use of placemats. 2. Establish "no" zones for space heaters. 3. Cover unused electrical outlets. 1., 2., & 3. Correct: Placemats and tablecloths can be pulled down by children. If something hot is sitting on it, the child can be scalded. The parents should be taught to block access to stove, fireplace, space heaters, and water heaters. They need to be inaccessible to small children. Covering unused electrical outlets will prevent a child from sticking things, such as a fork, in it which could result in an electrical burn.4. Incorrect: The parents should not use microwave at all for warming the bottle. Food and liquids can heat unevenly and burn the child.5. Incorrect: Hot water heater thermostats should be set to below 120°F (48.9°C). Bath water should be around 100°F (38°C) to prevent burn injuries with children. The water should be tested before allowing the child to step into the bath also.
The client is worried and distracted, and explains to the nurse that because of the direct admission from the primary healthcare provider's office, there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client? 1. I will speak to the charge nurse about your needs so a case manager can be notified to help you with your concerns. 2. I know how you feel. I will be sure to tell your night nurse in shift report that you will probably need something to help you sleep tonight. 3. An unexpected hospital admission can be very stressful. Is there anyone who I can call for you? 4. I can call your primary healthcare provider for you and ask if you could go home today, then schedule another date for your hospital admission.
1. I will speak to the charge nurse about your needs so a case manager can be notified to help you with your concerns. 1. Correct: The charge nurse will notify the case manager. The case manager should be involved in coordinating the client's care from the date of admission in order to help the client navigate unexpected situations like a last-minute hospital admission. The ability to make telephone calls to notify family and friends will help to decrease the client's sudden sense of isolation from normal daily life, loss of control, and anxiety. 2. Incorrect: Although sleeping medication may be warranted for this client, the nurse neglects to offer a viable solution to the client's problem. The nursing interventions should focus on assisting the client to explore their feelings. 3. Incorrect: Although this is a helpful response, this answer does not include notifying the case manager. The nurse should forward this request to the case manager who can identify client needs. 4. Incorrect: Calling the primary healthcare provider is inappropriate, as the client requires hospitalization now. The primary healthcare provider will determine if the client should be hospitalized.
Which client assignments would be appropriate for the LPN/VN to accept from the charge nurse? 1. In Bucks traction requiring frequent pain medication. 2. Twenty four hours post appendectomy. 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM. 4. Admitted 6 hours ago in adrenal insufficiency. 5. Client newly diagnosed with Type 2 diabetes.
1. In Bucks traction requiring frequent pain medication. 2. Twenty four hours post appendectomy. 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM. 1., 2., & 3. Correct: These clients are stable and require predictable care that can be done appropriately by the LPN/VN. 4. Incorrect: This client has adrenal insufficiency. Primary adrenal insufficiency occurs when at least 90 percent of the adrenal cortex has been destroyed, generally from autoimmune disorders. Secondary adrenal insufficiency can be caused by such things as abrupt stoppage of corticosteroid medications and surgical removal of pituitary tumors. As a result, often both glucocorticoid (cortisol) and mineralocorticoid (aldosterone) hormones may be lacking. This puts the client at risk for fluid volume deficit (FVD) and shock. This requires the higher level assessment skills of the RN. 5. Incorrect: A newly diagnosed diabetic client may be unstable and would require assessment, care plan development, and teaching, which cannot be performed by the LPN/VN.
Which nursing statement about a client reflects correct documentation in the hospital medical record? 1. Skin warm and dry to touch. 2. Small wound noted on right arm. 3. Client slept well. 4. Client appears upset at spouse.
1. Skin warm and dry to touch. 1. Correct: Documentation should include data that the nurse obtains using only observations that are heard, seen, smelled, or felt. 2. Incorrect: The nurse should record findings or observations precisely and accurately. Documentation of an arm wound should include its exact size and location. 3. Incorrect: Stating that the client slept well doesn't provide precise information to be useful. 4. Incorrect: Documenting observed behaviors or conversations is appropriate; however, drawing conclusions about feelings is not.
The nurse is caring for a client in an outpatient clinic who is being treated with warfarin for prevention of a stroke due to atrial fibrillation. The international normalized ratio (INR) was noted to be 4.6. What action should the nurse take? 1. Inform the primary healthcare provider immediately. 2. Instruct the client to continue medication as ordered. 3. Inform the client to watch for signs of bleeding. 4. Inform the client to return to the clinic per routine monitoring schedule. 5. Take no action as this value is within target range.
1. Inform the primary healthcare provider immediately 3. Inform the client to watch for signs of bleeding. 1. & 3. Correct: The primary healthcare provider should be notified. The value of 4 is above the usual target range of 2-3. The client has a potential for decreased clotting and bleeding. The client should be told to watch for signs of bleeding. 2. Incorrect: The medication dosage is likely to be reduced.4. Incorrect: The client should not leave the clinic until the primary healthcare provider has been notified. Further action is indicated and may include changing the usual warfarin dosage.5. Incorrect: The normal range for a INR is 2-3. When a client is prescribed warfarin, the INR should increase to a therapeutic target range. The value of 4.6 is greater than the usual target range.
Which home safety measures are appropriate for the nurse to remind an older client about prior to discharge post total hip replacement? 1. Install a grab bar in the tub. 2. Turnsnight light on at bedtime. 3. Use assistive devices only when leaving home. 4. Go barefoot while in the home. 5. Ensure chairs in the home are low.
1. Install a grab bar in the tub. 2. Turnsnight light on at bedtime. 1. & 2. Correct: Placing a grab bar in a slippery tub can assist the older adult in getting into and out of the tub. Turning on night lights at night ensures that the older adult can navigate safely, thus reducing the risk of falls. 3. Incorrect: If the adult has an assistive device, it should be used inside and outside of the home. 4. Incorrect: The client should wear proper fitting shoes that have nonskid protection all the time. 5. Incorrect: Chairs should not be too low. The hip should be higher than the knees when sitting.
Which activities can the nurse safely assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Administer a nebulizer treatment to a client diagnosed with pneumonia. 2. Obtain vital signs on a postoperative client who required naloxone 5 minutes ago. 3. Report a urinary output (UOP) less than 50 mL/hr on a post-op client. 4. Assist a client with obtaining a clean catch urine sample. 5. Remove an indwelling urinary catheter from a client.
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The palliative care nurse is reinforcing instructions with the family of a client who is experiencing nausea and vomiting on methods of controlling these symptoms. What methods should the nurse include? 1. Offer electrolyte replacement drinks or broths. 2. Avoid cooking close to the client. 3. Provide light, bland food. 4. Drink liquids less often. 5. Drink tea infused with ginseng.
1. Offer electrolyte replacement drinks or broths. 2. Avoid cooking close to the client. 3. Provide light, bland food. 1., 2., & 3. Correct: These are all methods that can help control nausea/vomiting symptoms. Sports drinks and broths can help with hydration. Juices and soft drinks should be avoided. Smells from foods cooking can lead to nausea and vomiting. Bland foods in small portions may be tolerated vs. fried or heavy foods. 4. Incorrect: The client should drink small amounts of liquid more often. If tolerated, fluids will help prevent dehydration. Avoid milk products and sugary drinks as they will increase nausea and loss of fluids. 5. Incorrect: Ginseng is a herb that improves mental and physical abilities. This question is asking for nausea and vomiting prevention/control.
The client has been working on weight loss for 8 months and has been successful in losing 35 lbs (15.9 kg). The client is now entering the maintenance phase of the health promotion plan. Which strategies are important for the nurse to reinforce as the client enters this phase? 1. On going support from weight-loss program personnel. 2. Periodic weigh-ins with the nurse. 3. Decrease programmatic exercise plan. 4. Relapse prevention plan. 5. Continued peer support.
1. On going support from weight-loss program personnel. 2. Periodic weigh-ins with the nurse. 4. Relapse prevention plan. 5. Continued peer support. 1., 2., 4. & 5. Correct: The person must have ongoing support to prevent a relapse. The weigh-ins increase accountability for prolonged behavioral change. Anytime that a new behavior is instituted, there is a chance that the person will return to old habits. Having a plan in place may help the person to stay on track. Ongoing peer support can be very helpful as the client continues in the maintenance phase. 3. Incorrect: A programmatic exercise plan is still needed. If this is taken away or reduced too much, the client may return to old habits. Increasing physical activity is essential to maintain weight loss.
Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should the nurse see first? 1. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke." 2. Multigravida at term who is dilated to six centimers and at minus one station with moderate contractions every five to ten minutes. 3. Primipara at 38 weeks gestation who is dilated to five centimeters and at zero station with strong contractions every four minutes. 4. Multigravida at 36 weeks gestation with pregestational diabetes in for a biophysical profile for fetal well being.
1. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke." 1. Correct: Minus two station is high with the presenting part not engaged. This client is at high risk for prolapsed cord, which would require relieving pressure on the cord and emergency cesarean delivery. 2. Incorrect: Contractions are not close enough for this client to be an emergent situation. Also, since this is a multigravida client and not fully dilated yet, she is not a high risk client. 3. Incorrect: This client is in the active phase of labor, but there is much work to be done before she is fully dilated and engaged for delivery. 4. Incorrect: This client is not in labor and is a non-emergent client, particularly compared to client #1.
Which assignment would be most appropriate for the LPN/VN to accept from the charge nurse in the Labor, Delivery, Recovery and Postpartum Unit (LDRP)? Select all that apply 1. Primipara needing assistance with breastfeeding. 2. Multipara reporting a headache and epigastric discomfort. 3. Primipara who is two days post op cesarean section. 4. Primipara who is preeclamptic in active labor. 5. Multipara post op cesarean section with a PCA pump.
1. Primipara needing assistance with breastfeeding. 3. Primipara who is two days post op cesarean section. 1. & 3. Correct: These are stable clients whose care is within the scope of practice of an LPN/VN. 2. Incorrect: This client is high risk because she is exhibiting symptoms of postpartum onset preeclampsia. 4. Incorrect: This client is considered to be at high risk since she is in labor and exhibiting symptoms of preeclampsia. This is an unstable client whose care is not within the scope of the LPN. 5. Incorrect: This client has an IV narcotic infusing which cannot be assigned to an LPN. IV narcotics are within the scope of the RN only.
In order to prevent injury or discomfort and maximize overall performance, what essential elements of ergonomic principles should the nurse utilize when caring for clients? 1. Promote maximal stability by utilizing a wide base of support. 2. Maintain a low center of gravity. 3. Use both the arms and the legs when performing strenuous activity. 4. Save effort by lifting rather than rolling, turning, or pivoting. 5. Utilize muscles of the back rather than muscles of the shoulders. 6. Obtain assistance from other nurses as needed.
1. Promote maximal stability by utilizing a wide base of support. 2. Maintain a low center of gravity. 3. Use both the arms and the legs when performing strenuous activity. 6. Obtain assistance from other nurses as needed. 1., 2., 3., & 6. Correct: When in a standing position, the center of gravity is at the center of the pelvis. The wider the base of support and the lower the center of gravity the nurse maintains, the greater the stability for the movement. Using both the arms and the legs provides a sense of balance for the activity. It is always smart to seek more assistance when needed to avoid injury to self. 4. Incorrect: Rolling, turning, and pivoting are less likely to cause injury than attempting to lift. Lifting puts more strain on the back than these other methods. 5. Incorrect: The larger muscles of the thighs, buttocks, and shoulders should be utilized for activity because the smaller muscles such as those in the back and arms are more susceptible to injury.
A client is admitted with a diagnosis of myasthenia gravis. What nursing interventions will assist in managing the client's swallowing and chewing impairment? 1. Provide foods that are soft and tender. 2. Allow client to rest between bites. 3. Encourage client to drink thickened liquids. 4. Position upright with head tilted slightly backwards. 5. Dissolve the client's medications in water.
1. Provide foods that are soft and tender. 2. Allow client to rest between bites. 3. Encourage client to drink thickened liquids. 1., 2., & 3. Correct: Myasthenia gravis is a disorder wherein the postsynaptic neuromuscular junction receptor sites are decreased. This decrease in receptor sites causes decreased muscular depolarization. The clinical manifestations of this disease are progressive muscle weakness and fatigue. Eventually clients may experience difficulty breathing due to weakness and fatigue of the respiratory muscles. Muscle fatigue impairs chewing and swallowing. These actions decrease the risk of aspiration, decrease the work of muscles, and allow for improved swallowing. 4. Incorrect: The head should be positioned slightly forward (chin tuck, head turn). 5. Incorrect: The client's medications should not be dissolved in water due to the client's difficulty swallowing. Liquids should be thickened.
A client appears anxious and fearful of the equipment in the room. The nurse observes this and takes the time to explain each piece of equipment and its role in providing care to the client. How does this action demonstrate client advocacy? 1. Providing information to the client. 2. Promoting client compliance. 3. Providing emotional support. 4. Ensuring the client's wishes for treatment are followed. 5. Fostering a sense of security.
1. Providing information to the client. 3. Providing emotional support. 5. Fostering a sense of security. 1., 3. & 5. Correct: Client advocacy has been described in many different ways and involves many things such as assistance in gaining needed healthcare, assuring quality of care, protection of client's rights, and simply serving as a mediator between the client and the healthcare system as a whole. Client advocacy involves regular communication in which the nurse explains what is being done or likely to happen, reasons for tests or procedures, and simplifying medical terminology into words that can be easily understood. Emotional support is also an aspect of client advocacy that the nurse should employ. The nurse acts as a client advocate by providing information to the client to alleviate fear of the unfamiliar equipment and by fostering a sense of security. 2. Incorrect: This question addressing client advocacy is not related to client compliance. Client compliance may improve if the nurse served as an appropriate client advocate. However, promotion of compliance is not a basic part of advocacy. 4. Incorrect: This question addressing client advocacy is not related to client's healthcare treatment wishes. This would be related to the client's advance directive
Which nurse is providing cost effective care to a client? 1. Providing palliative care to a terminally ill client. 2. Following the discharge plan throughout hospitalization. 3. Reinforce education on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood immunizations. 5. Performing a postop wound dressing change using clean gloves.
1. Providing palliative care to a terminally ill client. 2. Following the discharge plan throughout hospitalization. 3. Reinforce education on cigarette smoking cessation. 1., 2., & 3. Correct. Palliative care is considered cost effective when caring for the terminally ill client. There was a 60% drop reported in the healthcare costs since palliative care was introduced. In comparison to conventional care, palliative care is considered as cost effective in reducing unnecessary utilization of resources. Palliative care has focused on the efficient and the effective care that is centered on the clients. The nurse who begins discharge planning on admit is providing cost effective care. The client may not be able to learn all that is needed if waiting until the day of discharge. Also, supplies and equipment may be needed. If waiting until the day of discharge to determine client needs, then discharge can be delayed. This is costly. Reinforcing education to quit cigarette smoking, colonoscopies, giving beta-blockers to clients after heart attacks are well-established interventions that are effective and also are cost-effective. 4. Incorrect. This is a preventive intervention that is cost-saving, however, the PN cannot initiate teaching, but can reinforce it. 5. Incorrect. A postop surgical wound dressing change is a sterile procedure: Sterile gloves are necessary and failure to use them could lead to infection, which would then increase the cost of care to a client.
Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? 1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. 2. Twelve year old admitted 5 days ago receiving total parenteral nutrition (TPN). 3. Two year old taking only clear liquids since admission 24 hours ago. 4. Nine month old admitted 2 days ago for diarrhea and now on ½ strength formula.
1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. 1. Correct: This child has been receiving only clear liquids for more than 3 days and would be a nutritional risk. Proper nutrients are required for healing after surgery, and only liquids would not be adequate. 2. Incorrect: The child receiving total parenteral nutrition (TPN) has already had a nutritional evaluation and is receiving supplementation for nutritional needs. After reviewing the nutritional evaluation, the TPN will be formulated accordingly. 3. Incorrect: The two year old taking only clear liquids is acceptable until the child is on liquids for more than 3 days. At that point, the child would be at nutritional risk. After 3 days, the nutritional status of the child should be evaluated due to the food restrictions of a clear liquid diet. 4. Incorrect: The nine month old is being put back on formula at ½ strength. Once this is tolerated, then the strength will be advanced; therefore, this client is not at risk.
Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? 1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. 2. Twelve year old admitted 5 days ago receiving total parenteral nutrition (TPN). 3. Two year old taking only clear liquids since admission 24 hours ago. 4. Nine month old admitted 2 days ago for diarrhea and now on ½ strength formula.
1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. 1. Correct: This child has been receiving only clear liquids for more than 3 days and would be a nutritional risk. Proper nutrients are required for healing after surgery, and only liquids would not be adequate. 2. Incorrect: The child receiving total parenteral nutrition (TPN) has already had a nutritional evaluation and is receiving supplementation for nutritional needs. After reviewing the nutritional evaluation, the TPN will be formulated accordingly. 3. Incorrect: The two year old taking only clear liquids is acceptable until the child is on liquids for more than 3 days. At that point, the child would be at nutritional risk. After 3 days, the nutritional status of the child should be evaluated due to the food restrictions of a clear liquid diet. 4. Incorrect: The nine month old is being put back on formula at ½ strength. Once this is tolerated, then the strength will be advanced; therefore, this client is not at risk.
Which health promotion strategies are best for the nurse to reinforce for a single parent of young children who is trying to increase personal physical activity level but expresses a lack of time? Select all that apply 1. Suggest walking up and down steps at home several times each morning and evening. 2. Suggest parking further away from the grocery store and work. 3. Walk with the children in the evening instead of watching TV with them. 4. Suggest waking one hour earlier in the morning to go to the gym. 5. Suggest walking for 30 minutes with a buddy each afternoon before leaving work
1. Suggest walking up and down steps at home several times each morning and evening. 2. Suggest parking further away from the grocery store and work. 3. Walk with the children in the evening instead of watching TV with them. 1., 2. & 3. Correct: These strategies will allow the parent to stay home without adding further time demands to the day. Parking farther away is one plan to get more steps into the day without increasing time demands drastically. Walking with the children allows the parent to spend quality time with the children as well as offers them a good example.
What factors should a licensed practical nurse (LPN) consider when deciding to accept a delegated task or responsibility from a registered nurse (RN)? 1. The stability of the client's condition. 2. The workload of the RN on the unit. 3. The number of years that the LPN has worked on the unit. 4. One's knowledge related to the delegated task or responsibility. 5. One's own competence to perform the delegated task or responsibility.
1. The stability of the client's condition. 4. One's knowledge related to the delegated task or responsibility. 5. One's own competence to perform the delegated task or responsibility. 1., 4. & 5. Correct: When deciding to accept a delegated task or responsibility, the stability of the client's condition should be considered. Since client assessment is performed by the RN, unstable or critically ill clients should remain the RN's responsibility. The LPN should also consider his or her own knowledge related to the assigned task or responsibility. Do not accept the assignment if you do not know how to handle the situation or perform the task. Ask for additional information or instruction before accepting the assignment. The LPN should evaluate his or her own competence to perform the delegated task or responsibility. Client safety is always the priority. Be familiar with the Nurse Practice Act in your state.2. Incorrect: In the "real world," the workload of the RN on the unit often influences whether or not tasks or responsibilities are delegated. However, the LPN should not feel pressured to accept an assignment which he or she is not capable of performing.3. Incorrect: The number of years that the LPN has worked on the unit is not relevant. Years of service are not indicators of competence.
The client reports having trouble sleeping at night. "My mind is constantly working, and I can't fall asleep until 2:00 or 3:00 a.m." Which behaviors found in the data collection are likely to contribute to sleep difficulty? 1. Performs office work before going to bed. 2. Watches night-time drama shows on TV. 3. Drinks caffeine after dinner each evening. 4. Reads for pleasure before going to bed. 5. Exercises 45 minutes at 5 pm each evening.
1., 2. & 3. Correct: Working on job-related tasks before bedtime may increase anxiety and contribute to difficulty sleeping. Suspenseful night-time drama TV shows may be too stimulating prior to going to bed. Caffeine following dinner may interfere with sleep. 4. Incorrect: Quiet reading is likely to ease the transition from wakefulness to sleep and may be an important intervention to promote sleep. 5. Incorrect: Exercising early in the evening may be an effective intervention. If exercise is performed prior to going to bed, it may interfere with falling asleep.
Which components of the communication cycle should the nurse include as necessary for effective verbal communication? 1. There is a sender for every message. 2. A clear message is formulated. 3. There is a receiver for every message. 4. The sender and receiver share the same life experiences. 5. There can be incongruence between the verbal and nonverbal message.
1. There is a sender for every message. 2. A clear message is formulated. 3. There is a receiver for every message. 1., 2. & 3. Correct: The communication cycle includes the sender, a clear and concise message, the receiver, plus verbal or nonverbal feedback to acknowledge understanding of the message. The sender is the person who delivers the message, and the receiver is the person who receives the message. 4. Incorrect: The sender and receiver may not share the same life experiences; however, therapeutic communication can still be achieved. The more the sender and receiver have in common and the closer the relationship, the more likely they will accurately perceive one another's meaning and respond accordingly. However, this is not required for effective verbal communication. 5. Incorrect: There should be congruence between verbal and nonverbal communication. Incongruency can lead to misunderstanding and miscommunication. 1. Nurses need to use interviewing techniques to effectively communicate in a nonthreatening way with clients. The nurse must remain nonthreatening and realize clear messages need to be delivered. 2. With Select All That Apply questions, look at each option as a true/false statement. Match what is being asked in the stem with the options. If the stem is asking for a true response, then the true options should be selected. Ok, review your fundamentals of nursing and the communication cycle. Also read the question stem carefully - see the word "effective"? This one word will be important in getting this question correct. Option 1: Yes. The communication cycle has 4 components. The first is the sender. Option 2: Yes. The second component of the communication cycle is the message. Option 3: Yes. The communication cycle cannot be completed without the receiver. Option 4: No. They do not both share the same life experiences. The sender and the receiver are 2 different people. Option 5: No. Read the question stem and this option carefully. The stem asks for components of the communication cycle necessary for effective verbal communication. Effective is the key word in the stem and you know that incongruency in the communication will not lead to effective verbal communication.
A nurse from the pediatric unit is transferred to the adult medical-surgical unit. Which client assignment should the nurse accept from the charge nurse? 1. Undergoing surgery for tonsillectomy and adenoidectomy. 2. Diagnosed with leukemia, hospitalized for induction of chemotherapy. 3. Prescribed IV heparin for left leg thrombosis. 4. Admitted with a cerebrovascular accident.
1. Undergoing surgery for tonsillectomy and adenoidectomy. 1. Correct: This is the most stable client to give to the nurse who was transferred from the pediatric unit. A pediatric nurse cares for postop T&As daily in this specialty area and can transfer this knowledge to the adult client. 2. Incorrect: This is not a good client for a pediatric nurse because knowledge of lab values, chemotherapy precautions, protective isolation and chemotherapy drugs is required for the RN in order to care for this client. 3. Incorrect: This is not the best client for a pediatric nurse because thrombosis problems are not commonly seen on the pediatric unit. Monitoring clotting factors and being aware of signs and symptoms of pulmonary emboli are essential for safe care of this client. 4. Incorrect: This client is very unstable and requires skilled observation and assessment using the Glasgow Scale. This client will require the skills of the RN
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.
What's the most important information for the nurse to reinforce in the teaching plan of a client with aplastic anemia? 1. Use a soft toothbrush or swab for mouth care. 2. Plan a high intake of raw fruits and vegetables. 3. Include a generous amount of red meats in the diet. 4. Return to the normal routines of living as quickly as possible.
1. Use a soft toothbrush or swab for mouth care. 1. Correct: With aplastic anemia, the client experiences pancytopenia (decrease in all the blood components). Platelets will be low and this places the client at risk for bleeding. Measures to reduce the risk of bleeding is the priority answer because the bleeding risk is the most life threatening to the client.2. Incorrect: The client will have a decrease in the WBC and resulting decreased immune system. The client should AVOID raw fruits and vegetables as they can harbor bacteria or fungi.3. Incorrect: Red meats are important as the client will be anemic, but this is not as life threatening as the prevention of bleeding.4. Incorrect: Returning to the normal routines of living as quickly as possible is an incorrect answer. The client will need to avoid fresh fruits and vegetables, use proper hand washing techniques, and carry out bleeding precautions.
Metronidazole (Flagyl) is
1. Used to treat anaerobic infections 2. DO NOT USED ALCOHOL (antabuse effect will be nauseous)
Which interventions decrease risk of infection or damage to delicate tissue when the nurse is changing a wound dressing? Select all that apply 1. Warm cleansing solutions to body temperature. 2. Clean the wound when there is drainage present. 3. Use cotton balls to clean the suture site. 4. Use sterile gauze squares to dry the wound before applying the dressing. 5. Use sterile forceps when cleaning the wound.
1. Warm cleansing solutions to body temperature. 2. Clean the wound when there is drainage present. 5. Use sterile forceps when cleaning the wound. 1., 2. & 5. Correct: Using cleansing solutions at body temperature enhances the healing process by not lowering the temperature of the wound. Drainage should be removed so that it does not become the focus for infection. Sterile forceps should be used so that contaminated hands/gloves do not increase the risk of infection at the wound site. 3. Incorrect: Cotton balls may leave small cotton filaments behind that may serve as a site for infection. 4. Incorrect: Moisture is important for the healing process.
Which behavior by the nurse indicates proper use of standard precautions? 1. Wearing clean gloves while performing a heel stick on an infant. 2. Wearing the same gloves for assessment of clients in the same room. 3. Wearing sterile gloves when changing the urine bag and nasogastric canister of an infected client. 4. Donning a gown when responding to a request by the family to check the IV pump on a client with rotovirus.
1. Wearing clean gloves while performing a heel stick on an infant
What laboratory results would the nurse anticipate finding in a client receiving chemotherapy who is experiencing pancytopenia? 1. White blood cell count of 3,800 (3.8 x 109/L) 2. White blood cell count of 15,000 (15.0 x 109/L) 3. Platelet count of 90,000/µL (90 x 109/L) 4. Platelet count of 450,000/µL (450 x 109/L) 5. Red blood cell count of 3.0 million/mcL (3.0 x 1012/L) 6. Red blood cell count of 7.3 million/mcL (7.3 x 1012/L)
1. White blood cell count of 3,800 (3.8 x 109/L) 3. Platelet count of 90,000/µL (90 x 109/L) 5. Red blood cell count of 3.0 million/mcL (3.0 x 1012/L) 1., 3., 5. Correct: Pancytopenia is a condition in which there is a concurrent leukopenia (a reduction in white blood cells), thrombocytopenia (a reduction in platelets), and anemia (reduction in red blood cells). The normal white blood cell count is 5,000-10,000 (5.0 to 10.0 x 109/L), so a level of 3,800 (3.8 x 109/L) represents leukopenia. The normal platelet count is 150,000-400,000/µL (150 - 450 x 109/L), so a level of 90,000/µL represents thrombocytopenia. The normal red blood cell count for a Female is 4.2 - 5.4 million/mcL ( 4.2 - 5.4 x 1012/L), and the normal red blood count for a Male is 4.7 - 6.1 million/mcL (4.7 - 6.1 X 1012/L). Therefore, a red blood cell count of 3.0 million/mcL (3.0 x 1012/L) is indicative of anemia, regardless of the sex of the client. 2. Incorrect. The normal white blood cell count is 5,000-10,000 (5.0 to 10.0 x 109/L). A WBC count of 15,000 (15.0 x 109/L) is considered leukocytosis (elevated WBC level). 4. Incorrect: The normal platelet count is 150,000-400,000/µL (150 - 450 x 109/L). Therefore, a platelet count of 450,000/µL (450 x 109/L) would be an elevated platelet level (thrombocytosis). 6. Incorrect: The normal red blood cell count for a Female is 4.2 - 5.4 million/mcL (4.2 - 5.4 x 1012/L), and the normal red blood count for a Male is 4.7 - 6.1 million/mcL (4.7 - 6.1 X 1012/L). Therefore, a level of 7.3 million/mcL (7.3 x 1012/L) is elevated (polycythemia).
What is the best method for the nurse to verify correct nasogastric (NG) tube placement after insertion? 1. X-ray of the upper GI 2. Gastric aspiration and pH testing 3. Auscultation of air instilled into the stomach 4. Visualization of the tube markings
1. X-ray of the upper GI 1. Correct: The gold standard for nasogastric feeding tube placement is radiographic confirmation with X-ray. This is the most reliable method! 2. Incorrect: Both respiratory and gastrointestinal aspirates may be similar in color and may be misinterpreted. 3. Incorrect: This method cannot differentiate tube placement in the stomach or lung. The practitioner may still hear a rush of air. 4. Incorrect: Visualization of tube markings does not provide a reliable verification that the tube is in the stomach. This has never been a reliable way of verifying placement.
A client is going home on a potassium sparing diuretic, spironolactone. What should the nurse tell the client about this medication? 1. You may be at risk for high potassium levels. 2. Check with primary healthcare provider before taking over the counter potassium. 3. Consume potassium rich foods in moderation. 4. You may be at risk for hypokalemia . 5. You should increase your intake of potassium rich foods.
1. You may be at risk for high potassium levels. 2. Check with primary healthcare provider before taking over the counter potassium. 3. Consume potassium rich foods in moderation. 1., 2., & 3. Correct: With potassium sparing diuretics, hyperkalemia may occur if the kidney function is compromised, or takes potassium supplements. The client should check with the primary healthcare provider before taking over the counter potassium supplements due to risk of hyperkalemia. Too much potassium rich foods could raise serum potassium levels. 4. Incorrect: Loop diuretics are likely to cause hypokalemia. 5. Incorrect: Potassium sparing diuretics decrease the amount of potassium excreted with the urine; therefore, there is a risk for hyperkalemia.
instruct how to collect clean catch urine specimen for culture sensitivity
1. wash hands 2. open container and do no topen inner lid 3. Clean vulva from front to back with single antiseptic wipe,Initiate urine stream to flush away any remaing any microorganisms from the urethral meatus before passing the contaubner into the stream for specimen collection 4. remove the specimen colellection from urine stream before urine flows ends 5. replace cap becareful not to touch the inner lid 6. wash hands
An adult client has just returned to the nursing care unit following a gastroscopy. Which updates to the client's plan of care should be initiated by the nurse? 1. Vital sign checks every 15 min x 4 2. Supine position for 6 hours 3. NPO until return of gag reflex 4. Irrigate NG tube every 2 hours 5. Raise four siderails
1., & 3. Correct: Vital signs, post procedure, are important to monitor for any post-procedure complications such as bleeding or any signs of respiratory compromise. VS are checked frequently for the first hour post procedure. Any client who has a scope inserted down the throat and has received numbing medication in the back of the throat to depress the gag reflex should be kept NPO until the gag reflex returns. 2. Incorrect: Supine position for 6 hours is contraindicated. The head of bed (HOB) should be elevated. In the event the client vomits in the supine position, there is an increased chance of aspiration.4. Incorrect: A client who is going for a gastroscopy procedure cannot have a nasal gastric (NG) tube. An NG tube would interfere with the procedure. 5. Incorrect: Raising all side rails is a form of restraint. Have the bed in low, locked position. Raise two side rails, and have call light within reach.
A primipara at 36 weeks gestation is seen in the OB/GYN clinic. Which sign/symptom should the nurse immediately report to the primary healthcare provider? 1. Puffy hands and face 2. Reports indigestion 3. Pedal edema 4. Backache 5. Severe headaches rated 9/10
1., & 5. Correct: Facial and upper extremity edema can be a sign of pre-eclampsia, which can endanger both the mother and fetus. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in a woman whose blood pressure had been normal. Even a slight rise in blood pressure may be a sign of preeclampsia. Left untreated, preeclampsia can lead to serious, even fatal, complications. Signs and symptoms of preeclampsia include hypertension and may include proteinuria, severe headaches. changes in vision, upper abdominal pain, nausea or vomiting, decreased urine output, thrombocytopenia, impaired liver function, shortness of breath, sudden weight gain, and edema (particularly in face and hands). 2. Incorrect: Indigestion should be assessed for severity, but it is a common symptom in the 3rd trimester of pregnancy. 3. Incorrect: Pedal edema should be assessed but is common in the 3rd trimester of pregnancy. 4. Incorrect: Backache is common in the 3rd trimester. It is caused by the center of gravity shifting.
What risk factors should the nurse identify when screening individuals for type 2 diabetes mellitus? 1. Fat distribution greater in abdomen than in hips. 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. 5. Polycystic ovary syndrome.
1., & 5. Correct: If the body stores fat primarily in the abdomen, the risk of developing type 2 diabetes is greater than if the body stores fat elsewhere, such as the hips and thighs. Women with polycystic ovary syndrome have increased risk of developing type 2 diabetes. 2. Incorrect: Being overweight is a primary risk factor for type 2 diabetes. The more fatty tissue, the more resistant cells become to insulin. 3. Incorrect: A type 1 diabetic will remain a type 1 diabetic. 4. Incorrect: Blacks, Hispanics, American Indians, and Asian Americans are more likely to develop type 2 diabetes than Caucasians.
A nurse who has never had varicella has been exposed to a client diagnosed with herpes zoster. What actions should the nurse take? 1. Notify the infection control nurse. 2. Continue to care for client as varicella and herpes zoster are not related. 3. Go to the lab to have a Tzanck smear performed. 4. Obtain herpes zoster vaccine for protection from this exposure. 5. Receive the varicella-zoster immune globulin within 96 hours of exposure.
1., & 5. Correct: Notify the person responsible for infection control to get post-exposure treatment initiated within a timely manner. For persons who are susceptible, the varicella-zoster immune globulin should be given within 96 hours of exposure. The infection of herpes zoster is contagious until the crusts have dried and fallen off the skin. 2. Incorrect: Varicella is chickenpox and herpes zoster is shingles. Both are closely related. Exposure to herpes zoster by someone who has not had varicella places the person at risk for developing herpes zoster. 3. Incorrect: A Tzanck test consists of examining tissue from the lower surface of a lesion in a vesicular condition to determine cell type. The Tzanck test is not associated with immunity from the varicella-zoster virus. 4. Incorrect: The vaccine will not prevent the nurse from developing shingles from this exposure. The nurse needs immune globulin for immediate protection.
A client is admitted to the hospital due to a left-sided cerebrovascular accident. Which interventions should the nurse initiate? 1. Apply splint nightly to affected extremities. 2. Approach client from the right side. 3. Provide full range of motion once a shift. 4. Elevate left extremities on a pillow. 5. Place pillow in the right axilla. 6. Wrap affected hand into a fist.
1., & 5. Correct: With a left-sided stroke, the right side of the body is affected. Applying a splint at night to the affected extremity will prevent flexion of that extremity. Prolonged flexion leads to contractures. Prevent adduction of the affected shoulder with a pillow placed in the axilla. 2. Incorrect: Vision is controlled by the left side of the brain. Vision on the right side of both eyes may have decreased (hemianopia) due to this left-sided stroke, so approach the client from the left side. 3. Provide full range of motion four or five times a day to maintain joint mobility. 4. Incorrect: Remember, left-sided cerebrovascular accident = right sided paralysis. The right extremities, which are affected by the left-sided stroke should be elevate on a pillow to prevent dependent edema. 6. Incorrect: The fingers should be positioned so that they are minimally flexed. This will prevent a contracture of the hand. Flexing the fingers into a fist will cause them to contract. A cerebrovascular accident, an ischemic stroke or "brain attack," is a sudden loss of brain function resulting from a disruption of the blood supply to a part of the brain. Some problems that happen after stroke are more common with stroke on one side of the brain than the other. In most people, the left side of the brain controls the ability to speak and understand language. The right side of the brain controls the ability to pay attention, recognize things you see, hear or touch, and be aware of your own body. Let's look at what the left side of the brain most commonly controls. Agnosia may occur. This is the inability to name everyday objects. Aphasia occurs which affects the ability to speak, read, write, listen, deal with numbers, understand speech or written words and think of words when talking or writing. This person may also have any number of the following problems: Paralysis or sensory disturbances on the right side of the body; Vision on the right side of both eyes may have decreased (hemianopia); Problems with object recognition (agnosia); Problems with daily activities, routines which formerly went well (apraxia); Memory for verbal things; Decreased analytical skills; Problems with chronology; Reduced timing and speed skills. The client may demonstrate some insecure, anxious and withdrawn behavior. The major goals for the client may include improved mobility, avoidance of shoulder pain, achievement of selfcare, relief of sensory and perceptual deprivation, prevention of aspiration, continence of bowel and bladder, improved thought processes, achieving a form of communication, maintaining skin integrity, restored family functioning, improved sexual function, and absence of complications. So, let's look at each of these options to determine which interventions will help to achieve one of the major goals. Option 1 is true. Will applying a splint to the affected extremities while the client sleeps help the client? Yes. The goal is to improve mobility and decrease the risk for contractures. A splint will keep the joints from flexing for long periods of time. Flexing can lead to contractures. Option 2 is false. The right visual field may be affected with a left-sided stroke, so approach the client from the left side. This will help relieve perceptual deprivation. Option 3 is false. What is wrong with providing full range of motion once a shift? The problem is that once a shift is not often enough. Full range of motion should be provided four or five times a day to maintain joint mobility, regain motor control, prevent contractures in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. If tightness occurs in any area, perform range of motion exercises more frequently. Option 4 is false. Does paralysis occur on the left side with left-sided stroke? No. Left-sided stroke causes right sided paralysis, so elevate the affected right extremities. Option 5 is true. Position the client to prevent contractures, relieve pressure, attain good body alignment, and prevent compressive neuropathies. We want to prevent adduction. How? Prevent adduction of the affected shoulder by placing a pillow in the axilla. Option 6 is false. FLEXION! We don't want flexion. The fingers should be positioned so that they are minimally flexed. This is the natural position of the fingers when the hand is at rest.
Which data collected from a client admitted with peripheral vascular disease (PVD) should the nurse identify as contributing to this diagnosis? 1. Family history of hyperlipidemia 2. Postmenopausal 3. BMI of 24 4. Swims three times a week 5. Leg pain when walking
1., 2 & 5. Correct: A family history of hyperlipidemia, hypertension, or PVD increases the risk of a client developing PVD. Men over age 50 and postmenopausal women are at increased risk. A decline in the natural hormone estrogen may be a factor in the increased risk of heart disease among post-menopausal women. Estrogen is believed to have a positive effect on the inner layer of arterial walls, helping to keep blood vessels flexible.The risk of developing PVD also increases if the client has hyperlipidemia, cerebrovascular disease, heart disease, diabetes, hypertension, and/or renal failure. Leg pain with activity, such as walking, is a sign of PVD. 3. Incorrect: Overweight clients are at increased risk for PVD. A BMI of 24 means the client is of normal weight for height. Body mass index (BMI) is a measure of body fat based on height and weight that applies to adult men and women. Underweight = <18.5; Normal weight = 18.5-24.9; Overweight = 25-29.9; Obesity = BMI of 30 or greater. 4. Incorrect: Swimming three times per week is good exercise for the client. Sedentary life style increases the risk for development of PVD. Peripheral vascular disease (PVD) is a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm. This can happen in arteries or veins. PVD typically causes pain and fatigue, often in the legs, and especially during exercise. The pain usually improves with rest. It can also affect the vessels that supply blood and oxygen to the vital organs. The primary causes of PVD are: smoking; high blood pressure; diabetes; high cholesterol; over age 50; postmenopausal. Additional causes of PVD include extreme injuries, muscles or ligaments with abnormal structures, blood vessel inflammation, and infection. So knowing this information, which options are true? Options 1, 2, and 5.
What information should be reinforced for parents regarding the promotion of adequate bowel elimination in their toddler? 1. Include adequate fiber in the diet through whole grains and fruits. 2. Increase intake of water daily. 3. Provide toileting opportunities that are free from distractions. 4. Encourage the toddler to go to the bathroom at least three times daily. 5. Take away attention from the toddler unable to potty.
1., 2. & 3. Correct: Fiber is important for achieving adequate bowel elimination. Fruits and whole grains may help. Water intake is important, coupled with adequate fiber. Distractions at toileting times may result in poor elimination results. 4. Incorrect: The toddler should be taken to the bathroom after meals and at bedtime to encourage adequate elimination. Routine is very important. Peristalsis increases after meals. 5. Incorrect. Embarrassment or punitive measures will not yield positive results. Rather, the toddler should be praised for using the potty. 1. If age, sex, nationality are identified in the stem, it is important to the question and will generally direct you to an answer. Remember Erickson's stages of psychosocial development and growth and development. 2. With Select All That Apply questions, look at each option as a true/false statement. Match what is being asked in the stem with the options. If the stem is asking for a true response, then the true options should be selected. Options 1 and 2 are true. Increasing fiber and fluid in the diet will promote adequate bowel elimination by increasing peristalsis. Option 3 is true. Toddlers who are distracted may not wait for complete bowel elimination before getting up from the toilet. Option 4 is false. The best time to have a bowel movement is after a meal when peristalsis increases and prior to bedtime. Therefore, the child is not simply encouraged to go to the bathroom, but should be taken at these times to promote elimination. Option 5 is false. A client's emotional status must be maintained. You do not want to punish the child if unable to have a bowel movement.
The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client? 1. Document the client's statement in the client's own words. 2. Provide information on advance directives to the client. 3. Provide personnel for assistance with completing an advance directive. 4. Encourage client to complete advance directive as soon as possible. 5. Determine if the client's daughter agrees with the client's decision.
1., 2. & 3. Correct: The nurse should document the client's statement in the client's own words. The nurse should provide the client with information on advance directives and assurance that there are hospital personnel to assist with completing the advance directive. 4. Incorrect: The nurse should explain to the client that the law requires all clients be asked about the existence of an advance directive at the time of hospital admission. Preparing an advance directive ensures that the client's wishes will be followed in the event that the client is unable to make healthcare decisions. The decision about an advance directive is the client's decision to make and not the nurse's decision. 5. Incorrect: Providing information is the appropriate nursing action, not questioning the daughter.
A nurse is administering medications to a client and notes that a newly prescribed medication is on the client's list of allergies. When advocating for this client, which actions should the nurse take to ensure the client's safety? 1. Check the client's allergies against the list of client allergies documented in the medical record. 2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Discontinue the medication on the client's medication administration record (MAR). 4. Give the medication as ordered by the primary healthcare provider and administer diphenhydramine to the client. 5. Hold the medication and administer diphenhydramine to the client.
1., 2. & 3. Correct: To ensure client safety, the nurse should always check the client's allergies against the allergy list in the medical record before administering any medication. To prevent harm to the client, the nurse should advocate for the client by notifying the primary healthcare provider immediately and informing of client allergy. The nurse should discontinue the medication on the client's medication administration record (MAR) so that other staff members will not administer the medication. 4. Incorrect: Never administer a medication to which the client is allergic. 5. Incorrect: It is not necessary for the nurse to administer diphenhydramine because no medication to which the client is sensitive has been administered.
A nurse is administering medications to a client and notes that a newly prescribed medication is on the client's list of allergies. When advocating for this client, which actions should the nurse take to ensure the client's safety? 1. Check the client's allergies against the list of client allergies documented in the medical record. 2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Discontinue the medication on the client's medication administration record (MAR). 4. Give the medication as ordered by the primary healthcare provider and administer diphenhydramine to the client. 5. Hold the medication and administer diphenhydramine to the client.
1., 2. & 3. Correct: To ensure client safety, the nurse should always check the client's allergies against the allergy list in the medical record before administering any medication. To prevent harm to the client, the nurse should advocate for the client by notifying the primary healthcare provider immediately that the client is allergic to the medication. The nurse should discontinue the medication on the client's medication administration record (MAR) so that other staff members will not administer the medication. 4. Incorrect: Never administer a medication to which the client is allergic. 5. Incorrect: It is not necessary for the nurse to administer diphenhydramine because no medication to which the client is sensitive has been administered.
Ensuring the confidentiality of client health information and documentation is the responsibility of whom? Select all that apply 1. The primary healthcare provider and all consulting primary healthcare providers. 2. The health care personnel involved in direct care of the client. 3. The client's family members and friends. 4. All members of the multidisciplinary team and employees of a health care facility. 5. The client's spiritual leader.
1., 2. & 4. Correct: Ensuring the confidentiality of client health information is the responsibility of every employee of a health care organization including its primary healthcare provider. 3. Incorrect: The health care facility cannot ensure the client's family and friends will keep client health information confidential. 5. Incorrect: The health care facility cannot ensure the client's spiritual leader will keep client's health information confidential.
Which safety interventions would be appropriate for the nurse to reinforce to parents of school aged children? Select all that apply 1. Encourage bicycle helmet use when riding bikes. 2. Teach children to swim at an early age. 3. Teach children to not be afraid of playing with neighborhood dogs. 4. Keep firearms in the home locked and unloaded. 5. Teach "stop, drop, and roll" in case clothing catches on fire.
1., 2. 4., & 5. Correct: Wearing a helmet when bike riding may prevent head injury in case of a bike accident. Children should learn to swim at early ages. Children may drown in home or neighborhood pools. Children are curious about firearms, which should be safely locked away and unloaded. Fire safety is important. Being able to extinguish a fire quickly can save a life. 3. Incorrect: Children do need to be cautious around any pet that is not their own. Teach child to not tease or surprise dogs. Also teach them not to invade a dog's territory or try to pet a dog when eating food.
The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (VTE). What actions should the nurse initiate? 1. Measure the calf and thigh daily. 2. Apply sequential compression device to legs. 3. Position paralyzed leg with each distal joint higher than the proximal joint. 4. Place a trochanter roll at the hip. 5. Perform passive range of motion exercises once daily. 6. Monitor for pain by checking Homan's sign.
1., 2., & 3. Correct: Monitoring for VTEs is accomplished by measuring the calf and thigh daily, observing swelling, noting unusual warmth of the leg, and asking the client about pain in the calf. Prevention of VTEs include the use of sequential compression devices for bedridden clients. This device helps promote venous return. Positioning the paralyzed leg with each distal joint higher than the proximal joint will prevent dependent edema. 4. Incorrect: A trochanter roll does not prevent VTEs. They are used for the prevention of external hip rotation. 5. Incorrect: Passive range of motion exercises should be done several times a day to promote venous return and muscle tone. Once a day is not adequate. 6. Incorrect: Routinely checking the Homan's sign can actually cause a clot to dislodge. The nurse should not perform this procedure. After a stroke, the client is at risk for venous thromboembolism (VTE), especially in the weak or paralyzed lower extremity. VTE is related to immobility, loss of venous tone, and decreased muscle pumping activity in the leg. The nurse is responsible for preventing VTEs and checking for the presence of them. This includes measuring the calf and thigh daily, observing swelling of the lower extremities, noting unusual warmth of the leg, and asking the client about calf pain. The most effective prevention is to keep the client moving. Active range of motion exercises should be taught if the client can voluntarily move the affected extremities. If not, then passive range of motion exercises should be done several times a day to promote venous return and muscle tone. The affected extremity should be positioned to decrease dependent edema. Elastic compression gradient stockings or support hose as well as sequential compression devices may also help to increase venous return.
What information should a nurse include when reinforcing education to a client regarding buccal administration of a medication? 1. This route allows the medication to get into the blood stream faster than the oral route. 2. Stinging may occur after placing the medication in the cheek. 3. If swallowed, the medication may be inactivated by gastric secretions. 4. The buccal dose of medication will need to be increased from the oral dose. 5. Remove the tablet from buccal area after 15 seconds.
1., 2., & 3. Correct: These are correct statements about buccal administration of medication. Buccal administration involves the medication being placed between the gums and cheek, where it dissolves and becomes absorbed into the bloodstream. The cheek area has many capillaries that allow the medication to be absorbed quickly without having to pass through the digestive system. The degree of stinging experienced depends on the medication being administered. Some effects of certain medications can be lessened by digestive processes. 4. Incorrect: When given by the buccal route, the medication does not go through the digestive system. This means that the medication is not metabolized through the liver, and thus a lower dose can be used. 5. Incorrect: Placement should be maintained until the tablet is dissolved in order to get the dosage and effects desired.
The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which client would be appropriate for the LPN/VN to accept? 1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM 4. Admitted 6 hours ago in adrenal insufficiency 5. In diabetic ketoacidosis receiving IV insulin
1., 2., & 3. Correct: These are stable clients that the LPN/VN can provide care. The LPN can provide medications for pain management. Since the postop client is not requiring frequent assessments and is considered stable at this point, the RN can assign the LPN to care for this client. The client having surgery in the AM is stable and will require predictable preop care the evening prior to surgery, so the LPN can care for this client as well. 4. Incorrect: This client has adrenal insufficiency. It occurs when at least 90 percent of the adrenal cortex has been destroyed. As a result, often both glucocorticoid (cortisol) and mineralocorticoid (aldosterone) hormones are lacking. This puts the client at risk for fluid volume deficit and shock. This would require higher level knowledge and skills of the RN and should not be assigned to the LPN. 5. Incorrect: The client in diabetic ketoacidosis is not considered a stable client. The administration of IV insulin is outside the scope of practice for the LPN. Caring for this client would require higher level assessment skills, knowledge, and nursing care that is within the RNs scope of practice. This client should not be assigned to the LPN. In order to answer this question correctly, you need to know what an LPN can do. LPNs can be assigned to stable clients. Now don't get complex clients confused. A client can have a complex problem or problems and still be stable. Predictable is the key word here. Do you see any clients in these options that you know right away are unstable and unpredictable? Did you say Option 5, the client with DKA needing IV insulin is unstable and unpredictable? Yes. Good job! What do you think about option 4 - Client with adrenal insufficiency? Well, do you remember what adrenal insufficiency is? Insufficient of what? Glucocorticoids, mineralocorticoids, and sex hormones, right? Right! So this client is low in mineralocorticoids - aldosterone. If you do not have enough aldosterone, you will lose sodium and water, which will lead to FVD, shock! Unstable client. Don't assign this client to the LPN. What about options 1, 2, and 3? Are these stable and predictable clients? Yes they are and the LPN can be assigned to care for these clients. Now you may be saying that the client scheduled for surgery in the AM will need teaching. The RN can still do the teaching, but the LPN can provide the rest of the care since this is a stable client.
What behaviors would the nurse expect to observe in a client admitted to the psychiatric unit with a diagnosis of major depression? 1. Withdrawn behavior 2. Sitting in room, lights out, drapes closed 3. Unkempt appearance 4. Overeating 5. Severe insomnia
1., 2., 3., & 5. Correct: The client with severe depression has extremely low self-esteem and low energy levels and may just sit for hours. Depressed clients prefer to be alone and avoid social interactions. The room environment mimics the mood of the client (dark and gloomy). The client may not have the energy to bathe, change clothes, or even comb hair. The severely depressed person may have severe insomnia. However, sleeping too much is also a symptom of mild depression. 4. Incorrect: The client who is severely depressed, as in the depressive disorder, usually has no appetite and loses weight. A mildly depressed client is more likely to overeat as a coping mechanism.
What signs/symptoms would the nurse expect to find in a client diagnosed with acute pyelonephritis? Select all that apply 1. Chills 2. Fishy smelling urine 3. Polyuria 4. Dysuria 5. Headache
1., 2., & 4. Correct: Chills, fever, fishy smelling urine, painful and frequent urination are common signs/symptoms of acute pyelonephritis. 3. Incorrect: Polyuria is a symptom of chronic pyelonephritis. 5. Incorrect: Chronic pyelonephritis leads to the buildup of toxins in the body. This can cause the client to have a headache. Acute pyelonephritis is a sudden, severe kidney infection which causes the kidneys to swell and may permanently damage them. Pyelonephritis can be life-threatening. When repeated or persistent attacks occur, the condition is called chronic pyelonephritis. Acute pyelonephritis usually starts in the lower urinary tract as a urinary tract infection (UTI). Bacteria enter the body through the urethra and begin to multiply and spread up to the bladder. From there, the bacteria travel through the ureters to the kidneys. E. coli is most often the cause. However, any serious infection in the bloodstream can also spread to the kidneys and cause acute pyelonephritis. Symptoms usually appear within two days of infection. Common symptoms include chills with a fever greater than 102°F (38.9°C), flank pain, pain in the abdomen, side, or groin, dysuria, cloudy urine, hematuria, urgency, and fishy smelling urine. People with chronic pyelonephritis may experience only mild symptoms or may even lack noticeable symptoms altogether. Some patients have fever, flank or abdominal pain, malaise, or anorexia. Option 1 is true. Fever is the body's natural defense against infection. The body is making the environment in the body uninhabitable for germs. Chills occur when the body temperature is higher than normal. This makes the air and environment feel colder than it usually does. Chills occur because muscles rapidly contract and relax to produce body heat. It happens in response to both cold air temperatures and an increase in a person's internal body temperature. Option 2 is true. Normal urine is nearly odorless and clear. Passing urine which smells like fish may occur due to urological causes such as urinary tract infections and pyelonephritis commonly caused by E. coli. Option 3 is false. Polyuria is the passage of abnormally large volumes of urine, which equates to about 2.5-3 liters of urine per day or urine output more than 40 mL/kg/day. Chronic infections can lead to scarring and impaired kidney function, which can result in polyuria. Option 4 is true. Dysuria is the sensation of pain, burning, or discomfort on urination. Dysuria typically accompanies a urinary tract infection (UTI), and pyelonephritis. Option 5 is false. Chronic pyelonephritis leads to increased scarring of the kidneys which decreases the kidneys ability to remove waste products and toxins. As toxins build up in the body, a headache can occur.
What discharge instructions should the nurse reinforce to the client post abdominal hysterectomy? 1. Ambulate at least 3-4 times per day. 2. Notify the primary healthcare provider of a yellow discharge from the surgical wound. 3. Swimming is allowed if staples were used to close the skin. 4. Press a pillow over incision when coughing to ease discomfort. 5. Apply moist heat to surgical site the first couple of days for pain relief.
1., 2., & 4. Correct: The client should get up and move to prevent complications such as deep vein thrombosis (DVT), pneumonia, constipation, etc. The healthcare provider should be notified if the surgical wound is bleeding, red and warm to touch, or has a thick, yellow, or green drainage. Pressing a pillow over incision when coughing or sneezing will ease discomfort and protect the incision. 3. Incorrect: Do not go swimming or soak in a bathtub or hot tub until the primary healthcare provider says it is ok. You worry about infection. 5. Incorrect: In the first couple of days, an ice pack may help relieve some pain at the site of surgery. Remember, NCLEX wants you to think safety first when it comes to the use of heat.
After a client returns from surgery, which actions should the nurse initiate to reduce the risk of pneumonia? 1. Allow 2 hours of rest between deep breathing and coughing exercises. 2. Assist with splinting the incision when client coughs. 3. Have the client drink a glass of water before coughing. 4. Perform percussion and vibration every 2 hours. 5. Promote incentive spirometer use several times per hour while awake.
1., 2., & 5. Correct: They need to cough and deep breath at least every 2 hours. Deep breathing and coughing will expand the lungs and help expectorate secretions. Splinting helps with the ability to control pain and produce an effective cough. Incentive spirometry encourages deep inspiratory efforts, which are more effective in re-expanding alveoli than forceful expiratory efforts. 3. Incorrect: It takes longer than a few minutes to liquefy secretions and, if the stomach is full, vomiting may occur which would put the client at risk for aspiration.4. Incorrect: After the surgery, we do not want to percuss and vibrate the incision. Besides being extremely painful, this could potentially disrupt the suture line.
A client who has diabetes calls the nurse at the clinic reporting shakiness, nervousness, and palpitations. Which questions would yield information that would assist the nurse to gather data to share with the primary healthcare provider? 1. What have you eaten today and at what times? 2. Are you using insulin as a treatment of diabetes, and if so, what kind? 3. Do you feel hungry? 4. Do you have access to a glucose monitor to check your current glucose level? 5. Does your skin feel hot and dry?
1., 2., 3. & 4. Correct. This question will give the nurse information about how much time has elapsed since the last meal and will indicate the amount of protein and carbohydrates consumed at the last meal. Even a minor delay in meal times may result in hypoglycemia. Insulin type will give the nurse information about duration of action and peak time. Hunger is a symptom of hypoglycemia.If the client has a glucose monitor, an accurate reading would give the nurse valuable information about how much food the client should consume now.5. Incorrect. Hot and dry skin is not an indicator of hypoglycemia and would not help the nurse determine if the client is experiencing a hypoglycemic episode. Cool, clammy skin is a symptom of hypoglycemia. 1. Nurses need to use interviewing techniques to effectively communicate in a nonthreatening way with clients. 2. The test taker would need basic knowledge about hypoglycemia and insulin to answer this question easily, but some clues may be found in the stem. 3. With Select All That Apply questions, look at each option as a true/false statement. Match what is being asked in the stem with the options. If the stem is asking for a true response, then the true options should be selected. This question wants the nurse to verify that the client on the phone is having a hypoglycemic episode. So what questions could the nurse ask to verify this diagnosis? Option 1. Is it important to know if the client has eaten and what time? Yes. If the client has not eaten, would that lead to hypoglycemia? Yes. So this is true. Option 2. True. We know that insulin does what to glucose? Decreases it. Option 3. True. Hunger is a symptom of hypoglycemia. Option 4. Is it important to know if the client can check to see what their glucose level is? Yes, true. Option 5. Does the skin get hot and dry with hypoglycemia? No. It gets cool and clammy doesn't it? Yes, so this statement is false.
Which nursing interventions are appropriate for an adult client with constipation? 1. Allow adequate time for defecation. 2. Provide privacy for bowel elimination. 3. Suggest increasing fluid intake. 4. Encourage client to increase fiber in the diet. 5. Encourage the client to delay the urge to defecate until after a meal.
1., 2., 3. & 4. Correct: Clients should have ample time for defecation. Rushing the client may lead to a client ignoring the urge. Since clients may be hesitant to have a bowel movement in the presence of others, privacy should be provided. (The nurse may need to stay with weak or disabled clients.) Increasing fluid intake will lead to softer stools. This makes defecation easier. Fiber deficiencies may contribute to constipation. Fiber in the diet adds bulk to the stools which help them pass more readily through the intestines. 5. Incorrect: Ignoring the urge to defecate may increase the risk of constipation. Trying to defecate after a meal when peristalsis is increased may be helpful; however, if the urge occurs at other times, the client should go to the bathroom at that time to prevent constipation.
The nurse, caring for a client who has chronic renal failure, suspects that the client is experiencing anxiety. Which statements by the client would validate the nurse's suspicion? 1. "I do not think I can continue working." 2. "My husband has taken over the house cleaning and cooking." 3. "I fear I am dying." 4. "I have an "uneasy" feeling most of the time." 5. "Most of the time I feel very 'down and blue'."
1., 2., 3. & 4. Correct: The inability to maintain employment is of concern to most clients who have been used to working. With a chronic illness, the client is unlikely to be able to return to work. Anxiety related to role strain is common. The client may not be able to perform the duties that she once did, thus causing others to have to assume their roles. Death is a possible outcome if transplant does not occur. Fear may be a later diagnosis as the client's condition deteriorates. Clients with anxiety often report feeling uneasy or on edge. 5. Incorrect: These comments are more indicative of a depressed mood than anxiety. Depression may also occur in the client who has chronic renal failure. The nurse in this question wants to determine if the client is having anxiety. First you need to understand what anxiety looks like. The symptoms depend on what type of anxiety disorder a client has, however general symptoms include: feelings of panic, fear, and uneasiness; problems sleeping; cold or sweaty hands or feet; shortness of breath; heart palpitations; not being able to be still and calm; dry mouth; numbness or tingling in the feet or hands; nausea; muscle tension; dizziness So, what statements by the client would validate that the client is experiencing anxiety? Look at option 1: "I do not think I can continue working." True. The inability to maintain employment is of concern to most clients who have been used to working. With a chronic illness, the client is unlikely to be able to return to work. What about option 2: "My husband has taken over the house cleaning and cooking." True. Anxiety related to role strain is common. The client may not be able to perform the duties that she once did, thus causing others to have to assume their roles. Option 3: "I fear I am dying." True. Fear. Death is a possible outcome if transplant does not occur. Fear may be a later diagnosis as the client's condition deteriorates. Option 4: "I have an "uneasy" feeling most of the time." True. Clients with anxiety often report feeling uneasy or on edge. That leaves option 5: "Most of the time I feel very 'down and blue'." This one is false. These comments are more indicative of a depressed mood than anxiety. Depression may also occur in the client who has chronic renal failure.
Which statements, if made by the client, would indicate to the nurse that reinforcement of teaching has been successful regarding prevention of hip prosthesis dislocation? 1. I should not cross my affected leg over my other leg. 2. I should not bend at the waist more than 90 degrees. 3. While lying in bed, I should not turn my affected leg inward. 4. It is necessary to keep my knees together at all times. 5. When I sleep, I should keep a pillow between my legs.
1., 2., 3. & 5. Correct: One of the most common problems after hip surgery is dislocation. Until the hip prosthesis stabilizes, it is necessary to follow these instructions for proper positioning to avoid dislocation. Flexion and movement of the leg on the affected side past midline should be avoided. These precautions are needed to keep the new head of the femur in the acetabulum and prevent dislocation until healing and tissues are strong enough to hold the joint in place. 4. Incorrect: The knees should be kept apart at all times. This is called abduction and is needed to keep the new head of the femur (prosthetic device) in the acetabulum and therefore prevent hip dislocation until healing occurs and tissues are strong enough to hold the joint in place.
Which activities would demonstrate a nurse manager's responsibility to employees? 1. Resolving conflicts between employees, clients, client family members, or other members of the organization. 2. Evaluating employees, offering constructive criticism, and developing staff. 3. Representing employees at organizational committee and management meetings. 4. Acting as clinical expert in the area of health care. 5. Enhancing employee performance with appropriate learning opportunities.
1., 2., 3. & 5.Correct: Managers are responsible for conflict resolution, employee evaluation, and staff development. Managers also represent employees at committee and management meetings and enhance employees performance with education. 4. Incorrect: A manager is not required to demonstrate expertise in the clinical area of supervision.
What should the nurse reinforce to the parents of a newborn about a Guthrie test? 1. The purpose of this test is to determine the presence of phenylalanine in the blood. 2. A positive test indicates a metabolic disorder. 3. To conduct this test, a sample of blood is taken from the baby's heel. 4. An increase in protein intake can interfere with the test. 5. This test will be done when the baby is 6 weeks old.
1., 2., 3. Correct: These are true statements. The Guthrie test is a screening blood test for phenylketonuria (PKU). A positive test indicates decreased metabolism of phenylalanine, leading to phenylketonuria. The normal level of phenylalanine in newborns is 0.5 to 1 mg/dl. The Guthrie test detects levels greater than 4 mg/dl. Only fresh heel blood, not cord blood, can be used for the test. The main objective for diagnosing and treating this disorder is to prevent cognitive impairment. 4. Incorrect: A lack of protein intake can interfere with the test. The screening test is most reliable when the blood sample is obtained after the baby has ingested a source of protein. 5. Incorrect: Screening protocol involves testing the infant as close to discharge as possible but no later than 7 days after birth. If the infant is less than 24 hours old when the specimen is collected, a repeat test should be done before the infant is 2 weeks of age.
A home care nurse is visiting a client who delivered her first baby one week ago. What behavior by the client would indicate to the nurse that maternal-infant bonding is occurring? 1. Holds baby face to face 2. Talks about the baby's features 3. Touches baby frequently 4. Talks to baby 5. Allows baby to cry vigorously for 15 minutes
1., 2., 3., & 4. Correct: Positive behaviors that would indicate that maternal-infant bonding is occurring include making eye contact; assuming the in face position when holding the infant; pointing out common features; smiling and gazing at the infant; touching infant, progressing from touching with fingertips to holding; speaking in soft, high-pitched tones; and speaking positively about the infant. 5. Incorrect: Crying vigorously for 15 minutes is an indication that the baby has a need that the mom is ignoring. This is not a common behavior promoting maternal-infant bonding. Options 1, 2, 3, and 4 are all true. A positive maternal-infant bond has formed when baby and mom become intimately involved with each other through behaviors and stimuli that are complementary and provoke further interactions. These options illustrate such behaviors. Option 5 is false. This is not a behavior that is seen when there is a positive maternal-infant bond.
A nurse is reinforcing teaching to a group of preteens with acne about how to care for the skin. What points should the nurse include? 1. Wash face with soap and warm water. 2. Avoid using oily creams. 3. Do not use cosmetics that block sebaceous gland ducts. 4. Do not squeeze lesions. 5. Clean face vigorously with a terrycloth.
1., 2., 3., & 4. Correct: Washing the face frequently (at least twice a day) with mild soap or detergent and warm water will remove oil, dirt, and bacteria which increase inflammatory reactions and resulting acne. Oily creams and oil based cosmetics can block the ducts of the sebaceous gland ducts and the hair follicles, making the acne worse. These should be avoided. Squeezing or picking at lesions will increase potential for infection and scarring. 5. Incorrect: Clean face gently, as trauma during acne breakouts may worsen the acne and cause scarring. When washing face, use hands, as terrycloth or other
A client states, "I have not had a drink for 24 hours and I am beginning to feel anxious". What additional signs/symptoms would indicate to the nurse that the client is in the early phase of alcohol withdrawal? 1. Agitation 2. Insomnia 3. Course tremors 4. Visual hallucinations 5. Confabulation 6. Tachycardia
1., 2., 3., & 6. Correct: The earliest signs of alcohol withdrawal are anxiety, agitation, insomnia, and tremors. Tachycardia of 120-140 /min persists throughout withdrawal. 4. Incorrect: The onset of hallucinations indicates alcohol withdrawal delirium, a potentially fatal complication of alcohol withdrawal that occurs when the withdrawal process has not been medically managed. It begins the 2nd or third day after the client's last drink and lasts 48-72 hours. 5. Incorrect: Confabulation is a symptom of alcohol amnestic disorder or Korsakoff syndrome. Thiamine deficiency is thought to cause this syndrome. Alcohol withdrawal symptoms can occur as early as two hours after a person's last drink. Typically, symptoms will peak within the first 24 to 48 hours. This is when the client may experience the most uncomfortable withdrawal symptoms such as insomnia, tachycardia, hypertension, sweating, tremors, and fever. Six to 12 hours post-ingestion of alcohol, the client may experience agitation, anxiety, headaches, shaking, nausea and vomiting. Twelve to 24 hours post-ingestion, the client might exhibit disorientation, hand tremors, and seizures. Forty-eight hours post-ingestion, tactile, auditory and visual hallucinations with high fever can occur.
A nurse in the nursing home has several issues regarding staff maintaining proper infection control while caring for clients. What actions should the nurse take regarding this issue? Select all that apply 1. Place colorful posters regarding infection control in conspicuous places on unit. 2. Monitor staff providing client care for the use of appropriate infection control. 3. Give staff written information on proper infection control. 4. Have all staff read agency policy and procedures regarding infection control. 5. Dock pay of staff who do not maintain proper infection control. 6. Inform staff of in-service sessions on infection control for every shift.
1., 2., 3., 4., & 6. Correct. Each of these actions can be taken by the LPN/VN. The staff needs further information, reminders, and follow-up observation. 5. Incorrect. This is not the best solution. Most people want to do what is right. Education should be tried first, then documentation of infractions.
A nurse is contributing to an educational program for adults considering smoking cessation. What information should the nurse include? 1. Nicotine is the drug in tobacco products that produces dependence. 2. Withdrawal symptoms may include irritability, difficulty concentrating, and increased appetite. 3. Stopping smoking reduces the risk of coronary heart disease. 4. All smokers need to have a prescription for bupropion SR in order to quit. 5. Refer to smoking quit-lines that offer free support, advice, and counseling from experienced coaches.
1., 2., 3., 5. Correct: These are correct statements. Nicotine is the drug in tobacco products that produces dependence. Other withdrawal symptoms include anxiety and cravings for a cigarette. There are many health benefits to smoking cessation, including reducing the risk of coronary heart disease, stroke, peripheral vascular disease, and COPD as well as reducing the risk for infertility in women. Clients should be referred to educational programs and support groups. 4. Incorrect: The majority of cigarette smokers quit without using this prescription; however, treatments can help the smoker quit, so they should discuss possible medications with their primary healthcare provider. Other medications such as the nicotine patch or varenicline (Chantix), may also be used to assist with smoking cessation. 1. Identify specific determiners in options. These convey a thought or concept that has no exceptions. Words such as just, always, never, all, every, none, and only are absolute and place limits on the statement that generally is considered correct. Statements including these words generally make the statement false as the statement is general and broad and does not allow for exceptions. 2. With Select All That Apply questions, look at each option as a true/false statement. Match what is being asked in the stem with the options. If the stem is asking for a true response, then the true options should be selected. Option 1 is true. Nicotine is the drug in tobacco that causes dependence. Option 2 is true. The symptoms listed in this option are often seen during withdrawal. Note the words "may include". These words make this statement less absolute. Option 3 is true. The risk of coronary heart disease does decrease after a person stops smoking. Option 4 is false. See the word "ALL"? That is too absolute. Not "all" smokers need bupropion in order to stop smoking. Option 5 is true. Referring to community resources is something the NCLEX likes to see the nurse do for clients!
The nurse is talking with parents of school-aged children about promoting healthy eating in their children. What information should the nurse provide? 1. Skipping breakfast will decrease energy level and could lower school grades. 2. Freeze fruit before placing in lunch box to keep it tasting fresh. 3. Limit snacks to when the child is hungry, rather than bored. 4. Enforce rule that child must eat food even if they do not like it. 5. The parent should eat a variety of foods as an example to children. 6. Prepare homemade healthy version of favorite take out meals.
1., 2., 3., 5., & 6. Correct: Don't let the child skip breakfast. The child will have less energy to play well later in the day. Skipping breakfast can also lower grades in school as concentration decreases. Freeze fruits before putting them in the lunch box. This will keep the lunch items cool and the fruit fresh tasty. Canned pineapple, bananas, and grapes freeze well. Children need to learn to eat only when they are hungry. Children often eat out of boredom. Discourage nonstop grazing by planning activities to occupy the child. Lead by example. Children eventually adopt the eating patterns of their parents. If they see the parents eat vegetables, they will eventually try them. Prepare homemade healthy versions of take out favorites. 4. Incorrect: Forcing children to eat foods they do not like will only deepen their dislike for them. Give them the healthy foods they do enjoy and eventually they will explore more options.
A nurse, serving on the quality assurance (QA) committee, is asked to collect data regarding the implementation of fall precautions on at 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Ask staff what fall precautions are taken for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.
1., 2., 4 & 5. Correct: The QA manager is responsible for evaluating performance improvement plans to ensure that staff are providing appropriate care. The nurse can do chart reviews to see if staff are documenting fall precaution for a client. Direct observation of unit staff will let the nurse know if staff are performing proper precautions while caring for clients. The first step is to identify what clients are at risk for falls and then see if the staff have identified these clients to be at risk as well. Monitoring should be at unpredictable intervals, so staff do not comply when it is time for an evaluation. 3. Incorrect: Asking the staff what they do to provide fall precautions for at risk clients does not ensure that they follow through. It will tell you if they know what should be done.
A nurse is giving a report to another nurse during a shift change. Which information provided during a change-of-shift report is essential to ensure continuity of client care? 1. Priorities for client care. 2. Medications and allergies. 3. Normal lab results. 4. Client needs and responses to prior treatments. 5. Current course of illness.
1., 2., 4. & 5. Correct: The essential components of an effective change-of-shift report that will ensure the continuity of client care should include information about priorities for client care. Information about the client's medications and allergies must be communicated in order to provide safe, competent client care. To ensure continuity of care, information about the client's needs and responses to prior treatments should be shared. Information about events related to the current course of illness are essential for ongoing client care. 3. Incorrect: The change of shift report does not need to include lab results of the client that are normal. Only abnormal lab results need to be reported.
A nurse is planning to participating in educating students about oral health. Which points should the nurse reinforce? Select all that apply 1. Do not drink soft drinks between meals. 2. Eat raw vegetables to help keep teeth clean. 3. Brush teeth twice a day with toothpaste that does not have fluoride. 4. Use a pea size amount of toothpaste. 5. Floss teeth daily.
1., 2., 4., & 5. Correct: Avoid sweet foods and drinks between meals. Take them in moderation at meals. Eat coarse, fibrous foods, cleansing foods, such as fresh fruits and raw vegetables. If unable to brush after a meal, vigorously rinse mouth with water. Teeth should be flossed daily. 3. Incorrect: Brush the teeth thoroughly with toothpaste that has fluoride. Bacteria feed on sugar and produce acid waste, which erodes the tooth to create a cavity—so one of the best ways to keep to keep teeth healthy is to limit intake of sugary foods and drinks. Soda, Gatorade, sticky candy, and other sweets increase risk. Limit sugary snacks and drinks to mealtimes and brushing soon after eating. Crunchy fresh fruits and veggies like apples, carrots, and celery are better options because they help scrub plaque from teeth as you eat. Once a child gets the first tooth, brush gently with a soft-bristled toothbrush twice daily for 2 minutes or as needed, with the goal of removing plaque from each tooth. Flossing is also necessary to reach the spaces between teeth and should be done as soon as two teeth touching each other. Because the toothpaste has fluoride, only a small amount, the size of a pea, is needed. The toothpaste should be spit out of the mouth rather than swallowed. With Select All That Apply questions, look at each option as a true/false statement. Match what is being asked in the stem with the options. If the stem is asking for a true response, then the true options should be selected.
Which immunizations obtained by the age of two would indicate to the nurse that the child is up-to-date on immunizations if taken as recommended on the immunization schedule? 1. Diptheria-tetanus-pertussis (DTaP). 2. Inactivated polio (IPV). 3. Herpes zoster. 4. Hepatitis B 5. Haemophilus influenza type B (Hib).
1., 2., 4., & 5. Correct: By the age of two, the recommended doses of DTaP, IPV, MMR, Hib, varicella, pneumococcal, hepatitis B and rotovirus vaccines should have been received. The nurse should clarify this with the parent. 3. Incorrect: This vaccine is recommended for people 60 years or older whether or not the person has ever had chicken pox and is at risk for developing shingles. Although the vaccine can be given to adults between the ages of 50-59, routine administration is not recommended.
While examining a client's health history, which data indicates to the nurse that the client is at increased risk for developing cancer? 1. Family history 2. Alcohol consumption 3. Spicy diet 4. Human papillomavirus 5. Tobacco use
1., 2., 4., & 5. Correct: Family history of cancer increases the risk for having the same type of cancer. Alcohol and tobacco use increase the risk of cancer. When used together, they have a synergistic effect. Human papillomavirus (HPV) increases the risk of cervical, head, and neck cancers. 3. Incorrect: Although there are some dietary factors associated with cancer development, a spicy diet does not necessarily increase the risk of cancer.
Which documentation entries by the LPN would be appropriate to place in a client's electronic record? 1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. 2. Appears to be having abdominal discomfort. 3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. 4. Pre op Diazepam 10.0 mg given po. 5. Transferred to surgical suite per stretcher with side rails up, in stable condition.
1., 3, & 5. Correct: These are written correctly with complete, concise and objective information for each statement pertaining to the client. 2. Incorrect: "Appears" is a subjective word. Remember to use objective words. Pain should be assessed in an objective manner, such as by using a pain scale that is appropriate for the client's age and communication abilities. If the client were unable to respond to a pain scale assessment, the nurse would need to describe objectively the behavior of concern; for instance, the nurse could document "client moaning, guarding abdominal area with both hands, and knees pulled towards chest". 4. Incorrect: Do not use trailing zeros after a decimal point to prevent incorrect dosage. Likewise, always lead a decimal point with a zero (0.5)
What does a Durable Power of Attorney for Health Care as a legal document provide? 1. Direction about treatment choices in certain circumstances such as an advance directive. 2. A surrogate decision-maker for the client's financial matters in the event that the client becomes incapacitated. 3. A surrogate decision-maker in the event the client becomes incapacitated or unable to make informed health care decisions. 4. A permanent part of the client's medical record. 5. A surrogate decision-maker for the client's burial wishes.
1., 3. & 4. Correct: A Health Care Durable Power of Attorney is one example of an advance directive. Advance directives are documents signed by a competent person giving direction to health care providers about treatment choices in certain circumstances. A Durable Power of Attorney for Health Care is a legal document that identifies a surrogate decision-maker in the event the client becomes incapacitated or unable to make informed health care decisions. The document becomes a permanent part of the client's medical record. 2. Incorrect: A legal document that identifies a client's surrogate for financial matters is incorrect because a Durable Power of Attorney for Health Care identifies a surrogate decision-maker for health care decisions only; this document does not designate a surrogate for financial matters. 5. Incorrect: The Durable Power of Attorney for Health Care identifies a surrogate decision maker for health care decisions only. This document does not designate surrogate for burial wishes.
A client has been admitted to a psychiatric unit for severe depression after attempting suicide. Which interventions should the nurse include in this client's plan of care? 1. Provide constant visual observation. 2. Assign client to a private room close to the nurse's station. 3. Supervise closely during meals. 4. Provide simple, concrete instructions for getting dressed each morning. 5. Allow client to sleep as long as desired for the first three days.
1., 3. & 4. Correct: Close observation should be done. Since this client has already attempted suicide, one on one contact or constant visual observation should be done. Create a safe environment for the client. Remove all potentially harmful objects from the client's access. Supervision during meals and med administration is necessary. Perform room searches as necessary. Show clients how to perform activities with which he or she is having difficulty. When a client is depressed, he may require simple, concrete demonstrations of activities that would be performed without difficulty under normal conditions. 2. Incorrect: The client should not be placed in a private room. Placing near the nurses' station is appropriate, however. 5. Incorrect: Rest is important, and while it is not unusual for depressed clients to have a sleep deficit, excessive sleeping is a form of withdrawal, and sleeping at atypical times can further disrupt the client's circadian rhythm, interfering with sleep in the long run.
Which data collected from a client would indicate dementia? 1. Slow progressive deterioration of cognitive functioning 2. Decreased level of consciousness 3. Personality changes 4. Difficulty paying attention 5. Suicidal thoughts and sadness
1., 3. & 4. Correct: Dementia is characterized by a slow onset of symptoms over months to years. Dementia progresses to noticeable changes in personality. Dementia progresses to noticeable changes in attention span. 2. Incorrect: Dementia is progressive deterioration of cognitive functioning with no change in consciousness. 5. Incorrect: Sadness and suicidal thoughts are signs of depression. You must know about dementia and the signs/symptoms seen in a client with dementia. This is a straight forward question and determines your knowledge of dementia. Option 1: Yes. There is a slow onset and progression occurs over time. Dementia causes memory loss and loss of other mental abilities. This affects cognitive functioning! Option 2: No. There is no change in consciousness. Consciousness is the state of being awake and aware of one's surroundings. Option 3: Good choice. The client with dementia has personality changes and may become more irritable, less motivated, easily upset, and less talkative. Option 4: Yes. Attention span and concentration will decrease. The client will have difficulty staying focused. Option 5: No. This client may have frequent mood swings and increased anxiety. Also, in latter stages, the client may become paranoid. But suicidal thoughts and sadness are not part of dementia.
A client who is obese and paraplegic needs to be repositioned in the bed. What actions should the nurse take? 1. Obtain assistance from a coworker. 2. Place the bed in the lowest position with the client close. 3. Adjust the bed to a workable position and move close to the client. 4. Use a draw sheet with the assistance of a coworker and pivot the hips while pulling the draw sheet upward. 5. Use the client's arms and pull to head of bed to aid positioning.
1., 3. & 4. Correct: The nurse should solicit a coworker for help, adjust the bed to a workable position, move close to the client, use a draw sheet with the assistance of a coworker, and pivot the hips while pulling the draw sheet upward. These steps will prevent injury to the nurse and client. 2. Incorrect: The bed needs to be adjusted to the nurse's working height, not in the lowest position. 5. Incorrect: The client's arms should not be pulled on or used to position a client.
The nurse is caring for a client hospitalized with dissociative amnesia. Which nursing interventions are appropriate for this client? 1. Obtain client likes and dislikes from family members. 2. Expose the client with data regarding the forgotten past. 3. Expose client to stimuli that was a happy memory of the past. 4. Hypnotize the client to help restoration of memory. 5. Ensure client safety.
1., 3. & 5. Correct: Considering likes and dislikes may help the client to remember. Using information to expose the client to stimuli that were happy memories may help the client remember. The client's disorder may lead to inattention to safety. Think safety first! 2. Incorrect: Do not expose the client to data regarding the forgotten past. Clients who are exposed to painful information from which the amnesia is providing protection may decompensate even further into a psychotic state. Dissociative amnesia is marked by an inability to recall important personal information, often traumatic or stressful in nature. 4. Incorrect: Hypnosis therapy requires advanced training in noninvasive modalities. 1. The nurse must deliver care in a nonjudgmental manner. 2. Identify client-centered options. The focus of the nurse should be the client. Items that test your ability to be client-centered tend to explore client feelings, identify client preferences, empower the client, provide the client choices, or in some way put emphasis on the client. The client is the priority. Nursing interventions should affect the client in a positive way. Also, they need to be within the nurse's scope of practice. First, think safety. Then, think of nursing interventions that will help relieve symptoms. Option 1: Do it. Obtaining information including client likes and dislikes will help the nurse plan client care. Also, this may help the client begin to remember and process the painful memories. Then the client can develop new coping skills. Option 2: No. The amnesia is protecting the client from memories that are traumatic. The memories can resurface after being triggered. Nursing interventions must focus on helping the client express and process painful memories in appropriate ways. This is not the way. Option 3: Yes! You want the client to remember happy times. This is therapeutic! Option 4: Oh no! The stem asks for a nursing intervention. Do not choose this option. Hypnosis may be a treatment for dissociative amnesia but is not a nursing intervention. Read the stem carefully. Option 5: Excellent. A priority is client safety. This disorder may be so distressing and cause behavior problems and confusion. An appropriate nursing intervention is client safety.
The women's health unit is short one staff member and will receive a LPN/VN from the medical-surgical unit. Which clients should the LPN/VN accept from the charge nurse? 1. Total abdominal hysterectomy (TAH). 2. Client post C-section to be discharged home. 3. Breast Reduction. 4. Vaginal delivery of fetal demise. 5. 28 week gestation of bed rest. 6. Bladder suspension with anterior and posterior repair.
1., 3. and 6. Correct: When a nurse is pulled to another unit, always assign them like a brand new nurse. A client with a TAH, breast reduction, or bladder suspension require basic post-operative care. These are within the scope of knowledge of a brand new LPN/VN with medical-surgical knowledge. 2. Incorrect: This client is going to require specific discharge teachings related to care, medication, and care of the newborn. Specialized training is necessary here. 4. Incorrect: The nurse caring for this client needs to have skills related to postpartum care as well as psychological care of this type of loss. A pulled nurse from the medical-surgical floor will not be prepared to assist this client with all her needs. 5. Incorrect: This client is on bedrest for a reason and is hospitalized for a reason. Skilled assessment to identify change in status or denote impending complications is essential. This is not appropriate for the pulled medical-surgical nurse. 1. The key to this question is the fact that, although the nurse is an experienced medical-surgical nurse, the nurse is not experienced in gynecological nursing. The client who is stable and could receive care on a medical-surgical floor should be assigned to the nurse. 2. With Select All That Apply questions, look at each option as a true/false statement. Match what is being asked in the stem with the options. If the stem is asking for a true response, then the true options should be selected. With Select All That Apply questions there will be two or more correct options. The key to this question is the fact that, although the nurse is an experienced medical-surgical nurse, the nurse is not experienced in gynecological nursing. The client who could receive a treatment on a medical-surgical floor should be assigned to the nurse. So, let's look at the client options we have been provided. Option 1 is a client who had a total abdominal hysterectomy. Can the medical surgical nurse take care of a surgical client? Yes. Look at option 2. A client who had a C-section to be discharged. This client is going to require specific discharge teachings related to her care, medication and care of the newborn. Specialized training is necessary here. So do not assign the medical-surgical nurse to this client. What about option 3. The client post breast reduction. Is any specialized knowledge needed to take care of this post op client beyond what a medical-surgical nurse would know? No. So this nurse could care for this client. Option 4 is a client who lost her baby after vaginal delivery. The nurse caring for this client needs to have skills related to postpartum care as well as psychological care of this type of loss. A pulled nurse from the medical-surgical floor will not be prepared to assist this client with all her needs. Option 5 is a client who is at 28 weeks gestation who is on bedrest. What do you think? No. This client is on bedrest for a reason and is hospitalized for a reason. Skilled assessment to identify change in status or denote impending complications is essential. This is not appropriate for the pulled medical-surgical nurse. What about option 6? Client who had a bladder suspension. Is specialized knowledge needed that only an OB/GYN nurse should know how to care for? No. Bladder suspension requires basic post-operative care.
When caring for a client on bedrest, which interventions should the nurse implement to decrease the risk of deep vein thrombosis? 1. Apply compression hose. 2. Place pillow under knees while supine. 3. Assist client to perform active foot and leg exercises. 4. Place client on intermittent pneumatic compression device. 5. Assess extremities for negative Homan's sign.
1., 3., & 4. Correct. The client will need compression or compression hose and/or intermittent pneumatic compression device. The client should perform leg and foot exercises to decrease stagnation of blood. Compression hose, foot and leg exercises, as well as pneumatic compression devices increase venous return and prevents stasis of blood. Other interventions to decrease deep vein thrombosis (DVT) include early ambulation, passive and active range of motion, isometric exercises, and anticoagulant drugs such as heparin. 2. Incorrect: Do not compromise blood flow by placing pillows under the knees, crossing legs, or sitting for long periods of time. When pillows are left under the knees for an extended time, venous return could be compromised. A pillow under the knees is not a recommended intervention for DVT prevention. 5. Incorrect: Do not assess Homan's sign, as it may dislodge a clot. Homan's sign is not a preventative intervention. Assessing a Homan's sign is considered to be controversial, and this test may contribute to the release or dislodgement of a clot.
An unconscious client is admitted to the ICU with a closed head injury suffered in a fall. Despite aggressive efforts, the client expired within 24 hours. The nurse must complete postmortem care while awaiting the coroner. The nurse knows what action is not appropriate in this situation? 1. Remove indwelling catheter 2. Disconnect the ET tube from ventilator 3. Remove hospital ID band 4. Cap all intravenous lines 5. Wash body head to toe
1., 3., & 5.CORRECT. The client expired of injuries within 24 hours of being admitted to the hospital, which requires investigation by a coroner. It must be determined if death resulted from fall injuries, or whether any action, or lack thereof, by medical personnel contributed to the client's demise. When completing postmortem care on a "coroner's case", the nurse must leave all invasive lines and tubes in place for investigative purposes. Therefore, it would not be appropriate for the nurse to remove the foley catheter, although the urine can be emptied from the bag. It is also incorrect to remove any hospital identification bands. Washing the body should never be done since evidence could be disturbed or even removed. 2. INCORRECT. This action is acceptable since the client would not be transported while still attached to a ventilator. However, the endotracheal tube itself must remain taped in place when the client is transported to the coroner's facility. 4. INCORRECT. It is not necessary to leave the IV bags attached to intravenous catheters. The tubing and bags may be removed as long as the intravenous catheter itself remains intact on the client. Any variation of this standard procedure would be determined by the facility or coroner in advance. You may have heard the term "coroner's case", perhaps even on television, but were unaware of the specific postmortem care for such a client. A hospital is not the only type of facility where you may find a "coroner's case", although the time criteria is generally the same regardless of the location. If a client dies within 24 hours of admission or discharge to a hospital or other care facility, a coroner is generally contacted. Obviously exceptions exist, such as the case of a hospice client or even an individual refusing further treatment. When facts are unclear, mechanism of injury is questioned or exact cause death is not known, the coroner must conduct a thorough investigation with autopsy to determine those answers. Remember that any emergency treatment provided by ambulance or hospital personnel must also be ruled out as a possible contributing factor in the client's death. In order to prepare this client for transport, the nurse must be careful not to disturb potential evidence, including anything relating to medical treatment. Note this scenario has a negative stem. You are looking for actions by the nurse that are wrong! Option 1: Great. You are looking for anything that might be an incorrect action by healthcare personnel; therefore, removing an indwelling tube or line could compromise the results of an investigation. Invasive medical equipment, such as a foley catheter, should not be removed by anyone other than the coroner. Remember that the use of medical equipment must be ruled out as contributing to the client's demise. Option 2: Not this one. It is obviously necessary to remove the ventilator since a client would not need to be transported while attached to a vent. However, it is crucial to leave the endotracheal tube taped securely in place for investigative purposes. Option 3: Yep! This action by the nurse is definitely wrong! A client's identification band must remain in place until the client is physically removed from the facility. Should there be any sudden problems, or cancellation of the discharge, the client must still be identifiable. In this situation, the coroner uses the ID band, plus subsequent toe tag, to verify identification. Option 4: Try again. There is nothing improper about capping off invasive IV lines, including central lines, since it is unnecessary to send the actual bags of fluid with the client. In special circumstances, the coroner may request tubings be left attached, but generally, lines are simply capped off for transport. Option 5: Excellent. You have found one of the worst actions anyone could do prior to transporting a client to the coroner. It is inappropriate to wash the client's body. You are not preparing a client for the family, but rather for an intense medical investigation. Cleansing may remove small particles of evidence necessary in determining cause of death.
The nurse is working with a client who is experiencing urinary incontinence. What alterations in diet could improve urinary function? 1. Encourage the client to drink cranberry juice to acidify the urine. 2. Encourage the client to drink caffeine containing beverages in the evening. 3. Ask the client to limit or eliminate artificial sweeteners in the diet. 4. Ask the client to limit intake of caffeine to no more than 2 cups of coffee per day. 5. Suggest that the client limit or eliminate alcoholic drinks in the diet.
1., 3., 4. & 5. Correct. Increasing acidity of urine may help to reduce the risk of repeated urinary tract infections. Artificial sweeteners may irritate the bladder, thus increasing incontinent episodes. Caffeine containing beverages may serve as a bladder irritant, thus contributing to incontinence. Alcohol containing drinks may also increase the likelihood of urinary incontinence. 2. Incorrect. Fluid intake in the late evening should be decreased so that the client is less likely to have nighttime episodes of incontinence.
The nurse is assisting a new mother with breastfeeding her newborn baby. The mother verbalizes concern that the baby is not getting adequate milk. Which observations by the nurse indicate adequate fluid intake? 1. Birth weight regained in 14 days 2. Fontanels soft and depressed 3. Pulse rate of 135/min 4. Six to eight wet diapers a day 5. Baby appears satisfied after feedings
1., 3., 4. & 5. Correct: Are all indicators of adequate fluid intake in a newborn. Gaining weight, a heart rate between 70 to 190 beats per minute (BMP), six to eight wet diapers a day and periods of contentment after feedings alternate with periods of wakefulness indicate adequate breast feeding. 2. Incorrect: Fontanels should be soft, firm and flat. A depressed or sunken fontanel may indicate dehydration. Dehydration is one of the major causes of sunken fontanels.
The clinic nurse answers a call from a client who is voicing intent to commit suicide. The client tells the nurse, "I am sitting here with a bottle of pain killers in my hand." What response by the nurse is appropriate? 1. "I want to help you to resolve the problem." 2. "You should drive yourself to the emergency room." 3. "You did the right thing by calling." 4. "I want you to stay on the phone with me." 5. "Someone is calling 911 for an ambulance."
1., 3., 4. & 5. Correct: The nurse wants to establish a positive relationship with the client as quickly as possible. The nurse wants to recognize positive qualities. Keeping the client on the phone may prevent the client from taking the pain killers. The clinic nurse keeps the person on the line as long as possible as this is most important. Losing contact is a threat to the client's safety. This client is planning action with access to the plan. Emergency personnel should be called. 2. Incorrect: The client has a plan and the means available for suicide. The client does not need to drive to the emergency room. The nurse keeps the client on the phone as the 911 call is being activated. 1. With Select All That Apply questions, look at each option as a true/false statement. Match what is being asked in the stem with the options. If the stem is asking for a true response, then the true options should be selected. 2. Client safety is always a priority. In this select all that apply question, you should read each option as a true or false statement. Remember to take all suicide plans by the client seriously. Keep the client safe! Option 1: Great choice! The nurse offers to help. By calling the clinic, the client is reaching out for help to prevent carrying out the suicide plan. Option 2: No way! This client is in great emotional pain and does not need to drive to the emergency department. This is unsafe! Option 3: Yes. The nurse is supporting the client in their call for help. This statement is supportive of the client. Option 4: For sure! Keeping the client on the phone will keep the client from carrying out the suicide plan. This allows time for emergency help to arrive. This is a very important nurse response. Option 5: A must! Both the 911 call and emergency personnel are needed. This client has definite suicide plans and the means (bottle of pain medication) to carry out the suicide plan.
The nurse should reinforce which instructions given to the unlicensed assistive personnel (UAP) about care needed to reduce the risk of infection when a client has an indwelling catheter? 1. Check catheter for kinks in the tubing when the client is in the bed or chair. 2. Disconnect the catheter from the bag when measuring output. 3. Wash hands before providing personal care to the client. 4. Ensure that catheter remains secured to the thigh. 5. Make sure that the drainage bag is always below the level of the bladder.
1., 3., 4. & 5. Correct: Tubing that becomes obstructed cannot allow adequate urine flow. The urine flow occurs by gravity. Adequate handwashing before providing care is one defense against infection. Tension on the tubing may cause irritation and subsequent infection. The bag should be below the level of the bladder so that urine flows appropriately. 2. Incorrect: A closed drainage system should be maintained to prevent entry of microorganisms. Disconnecting the catheter from the bag would be incorrect and potentially cause harm to the client.
A nurse is caring for a client diagnosed with Alzheimer's disease. What actions should the nurse initiate? 1. Monitor client's ability to perform activities of daily living. 2. Perform activities of daily living for the client. 3. Place a clock and calendar in client's room. 4. Encourage family to visit client often. 5. Have nursing staff spend time talking and listening to client.
1., 3., 4., & 5. Correct: All of these should be included in this client's care. Monitor the client's ability to perform activities of daily living and allow client to perform alone if capable. Facilitate orientation by placing items such as a clock, newspaper, and calendar. Encourage family to visit to maintain socialization. Plan for staff to spend some time talking and listening to the client. 2. Incorrect: The staff should facilitate client's independence in all activities for as long as they are able. Encouraging self-care and allowing the client to be involved in activity of daily living (ADL) is a basic right and core principle of client-centered care.
A client diagnosed with cancer has been losing weight. How should the nurse reinforce teaching for the client regarding methods for improving nutritional status to maintain weight? 1. Add butter to foods. 2. Drink a cup of cubed beef broth. 3. Add powdered creamer to milkshake. 4. Use biscuits to make sandwiches. 5. Eat fish sauteed in olive oil. 6. Put honey on top of hot cereal.
1., 3., 4., & 6. Correct: Butter added to foods adds calories. This client needs more calories and more protein. Spread peanut butter or other nut butters, which contain protein and healthy fats, on toast, bread, apple or banana slices, crackers or celery. Use croissants or biscuits to make sandwiches which provides more calories. Add powdered creamer or dry milk powder to hot cocoa, milkshakes, hot cereal, gravy, sauces, meatloaf, cream soups, or puddings to add more calories. Top hot cereal with brown sugar, honey, dried fruit, cream or nut butter. 2. Incorrect: One cube of beef broth is 11 calories. Supplementing the diet with beef broth would not add significant calories. 5. Incorrect: Although cooked in olive oil, fish is low in calories. This would not be helpful in maintaining weight.
The nurse, caring for a client diagnosed with Alzheimer's disease (AD), notices the client becoming agitated. What nursing intervention would be appropriate for the nurse to initiate? 1. Provide a snack for the client. 2. Tell the client to stop the unwanted behavior. 3. Take client for a walk. 4. Ask the client to sweep the floor. 5. Inform the client that restraints will be used if behavior continues. 6. Turn on the client's favorite music.
1., 3., 4., & 6. Correct: Nursing interventions that address difficult behavior include redirection, distraction, and reassurance as provided by these correct interventions. 2. Incorrect: These behaviors are often unpredictable and not intentional. Do not challenge the client. Use redirection, distraction, and reassurance. 5. Incorrect: When dealing with a difficult client, do not threaten to restrain the client or call the primary healthcare provider. Behavioral problems occur in about 90% of clients diagnosed with Alzheimer's. These include repetitiveness, delusions, hallucinations, agitation, aggression, altered sleeping patterns, wandering, and resisting care. These behaviors are often unpredictable and may challenge caregivers. Caregivers need to be aware that these behaviors are not intentional. Nursing strategies that address difficult behavior include redirection, distraction, and reassurance. Option 1: Good choice. This nursing action will serve as a distraction and redirection. This changes the client's focus and helps decrease agitation. The AD client also may be malnourished and underweight and benefit from a healthy snack. Option 2: No. The client with AD may not be able to control their behavior. This is a behavioral change that comes with the disease. Option 3: Yes! Taking the client for a walk involves exercise and change of environment. This serves as redirection and distraction. Option 4: Another good choice. Redirection and distraction are helpful in controlling agitation. Sweeping the floor gives the AD client a purposeful activity. Option 5: Oh no - wrong! Stay away from restraints! This is a very last resort. Also, this is threatening the client and would most likely increase agitation. Reassurance involves communicating to the client that he or she will be protected from harm, danger, and embarrassment. Reassurance is an appropriate nursing strategy for AD. Option 6: Yes! Use of songs, poems, music, massage, and favorite objects can soothe the client.
What side effects would the nurse expect to find in a client who has received too much levothyroxine? 1. Angina 2. Bradycardia 3. Hypotension 4. Heat intolerance 5. Tremors
1., 4., & 5. Correct: These are side effects of too much levothyroxine. Levothyroxine is the replacement hormone for clients with hypothyroidism, so if too much is given, they would exhibit symptoms just like someone with hyperthyroidism. These clients also tend to have coronary artery disease (CAD), which is why angina is a significant side effect. 2. Incorrect: Tachycardia, rather than bradycardia, will be seen with too much levothyroxine. 3. Incorrect: Hypertension, rather than hypotension, will be seen with too much levothyroxine.
What signs/symptoms does the nurse expect indomethacin to manage? 1. Pain 2. Inflammation 3. Fever 4. Cough 5. Urticaria
1.,2., & 3. Correct: Indomethacin is a non-steroidal anti-inflammatory agent used to treat pain, inflammation, and fever. 4. Incorrect: Indomethacin does not have any cough suppressant actions. 5. Incorrect: Urticaria is a side-effect associated with indomethacin use. So what is indomethacin? It is a non-steroidal anti-inflammatory agent. So what symptoms does it manage? Did you say: Option 1? Yes. Indomethacin is used to treat pain by reducing hormones that cause pain in the body. Option 2? Yes, true. Indomethacin is used to treat inflammation by reducing hormones that cause inflammation in the body. What do you think about option 3? True. Indomethacin prevents prostaglandin synthesis (prostaglandin elevates body temperature and makes nerve endings more sensitive to pain transmission). Option 4. No, this is false. Indomethacin does not have any cough suppressant actions. Option 5. False. Urticaria is a side-effect associated with indomethacin use, so we would not give it to manage urticaria.
Which interventions are appropriate for the nurse to identify for a client admitted to the psychiatric unit for management of anorexia nervosa? 1. Weigh daily at the same time each day. 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.,4. & 5. Correct: Weigh daily, immediately upon rising and following morning void, using same scale and clothes if possible. The established time for meals is usually 30 minutes. This takes the focus off of food and eating and provides the client with attention and reinforcement. Observation for 1 hour following meals is important to monitor if the client is attempting to discard food stashed from tray or to engage in self-induced vomiting, which could be detrimental to the anorexic client. 2. Incorrect: The client will work with their primary healthcare provider to create a controlled exercise program. This is usually done once healthy eating habits and some weight gain is achieved. See the word "only" in this option and think incorrect. 3. Incorrect: Do not argue or bargain with the client who is resistant to treatment. Be matter of fact about which behaviors are unacceptable and how privileges will be restricted for noncompliance. The person who is denying a problem and who also has a weak ego will use manipulation to achieve control. 1. The test taker would need basic knowledge about anorexia nervosa to answer this question easily, but some clues may be found in the stem. Think nursing interventions. And how to manage anorexia nervosa. Option 1: A must! Weight loss programs recommend weighing weekly. But wait! This client with anorexia nervosa is seriously underweight. Weight gain is a life saving measure. The nurse needs to get a daily weight on this client in the psychiatric unit. And remember, if hospitalized, the anorexia nervosa is severe and causing acute symptoms in the client. Option 2: No. This inpatient client may be on restricted activity! A very individualized exercise plan prescribed by the primary healthcare provider is needed as the client improves. Option 3: No way. Bargaining is a nontherapeutic technique. The client will learn acceptable and unacceptable behaviors and how to obtain privileges. Option 4: Yes! Much can be observed by the nurse during meal time. The nurse can intervene appropriately during this time with positive reinforcement. Option 5: Oh yes! The anorexic client may engage in self-induced vomiting, although restricting intake is classic with anorexia nervosa. The client may try to hide food during meal time and may use the hour after meals to induce vomiting or discard the food due to client's fear of weight gain.
The nurse has received a change-of-shift report about a client who had a left radical mastectomy 6 hours ago. The nurse has been advised that since surgery the client has consumed 3 cups of ice chips, has not been out of bed, and has had a urinary output of 200 mL. Which of the following actions would be appropriate for the nurse to take in the next 2 hours?
1.check the client's urinary output 1. check the client's urinary output 2.show the client a 30-minute videotape about wound care 2. show the client a 30-minute videotape about wound care 3.assist the client to ambulate in the hallway for 20 minutes 3. assist the client to ambulate in the hallway for 20 minutes 4.perform passive range-of-motion (ROM) exercises with the client's left arm 4. perform passive range-of-motion (ROM) exercises with the client's left arm
adult male hemoglobin range
13-17
Normal platelet count
150,000-400,000
The nurse has reinforced teaching with a client who is scheduled for a bronchoscopy. Which of the following statements by the client would require follow-up? 1."I should remove my dentures prior to the procedure." 2."I can eat and drink immediately after the procedure." 3."I will be given a local anesthetic during the procedure." 4."I will need to sign a consent form prior to the procedure."
2
Which interventions should the nurse include for a client experiencing pain with sickle cell crisis? 1. Apply cold compresses to affected joints. 2. Massage affected areas gently. 3. Support and elevate swollen joints. 4. Monitor pain level by looking for BP, respiratory, and heart rate elevation. 5. Administer acetylsalicylic acid 325 mg every 4 hours in order to thin the blood.
2. & 3. Correct: Apply massage gently to affected areas which helps reduce muscle tension. Elevation of joints helps to decrease swelling, thus decreasing pain. 1. Incorrect: Apply warm, moist compresses to affected joints or other painful areas. Avoid use of ice or cold compresses. 4. Incorrect: Although pain can cause vital signs to elevate, it does not always occur. The nurse should assess pain with an objective scale such as having the client rate the pain on a scale of 1-10, remembering that pain is what the client says it is. 5. Incorrect: Acetylsalicylic acid should be avoided because it alters blood pH and can make cells sickle more easily.
A home health nurse visits a patient with Alzheimer's, the caregiver is frustrated and says that client has been persistently restless and agitated. Which nursing action is the priority at this time? 1.Assess for sources of excessive noise 2. Ask about recent bowel movements 3.Provide information about respite care 4.Review behavior management technique with care giver
2. Ask about recent bowel movements Check Maslow hierarchy of needs Behavioral changes (agitation, aggression, resistance to care)are often the result of inability to identify stressors(eg; constipation.)inability to feed oneself
The nurse is helping a client to bed when the client begins having a generalized seizure. Which action should the nurse take? 1. Place a tongue blade in the client's mouth. 2. Assist the client to the floor in a side-lying position. 3. Restrain the client. 4. Notify the primary healthcare provider.
2. Assist the client to the floor in a side-lying position. 2. Correct: By assisting the client to the floor, the nurse prevents harm to the client. The side-lying position prevents aspiration should the client vomit. It helps to keep the airway clear and this is the first priority. 1. Incorrect: When a client is experiencing a seizure, nothing should be placed in the client's mouth. Efforts to hold the tongue down can injure teeth. 3. Incorrect: The client should not be restrained. However, linens or a pillow should be placed around the client to prevent injury. 4. Incorrect: The primary healthcare provider may be notified after the client is safe. The airway is priority as the initial action. Do something to help the client.
The nurse monitors the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non-pharmacologic interventions may help the client's backache? 1. Reinforcing teaching about pain and pain control. 2. Assisting the client into a side lying position. 3. Providing a back massage. 4. Providing heat therapy. 5. Using distraction techniques.
2. Assisting the client into a side lying position. 3. Providing a back massage. 4. Providing heat therapy. 5. Using distraction techniques. 2., 3., 4. & 5. Correct: Assisting the client to a side lying position, providing a back massage, providing heat therapy, and using distraction techniques are all proven interventions that can raise the client's pain threshold. In other words, raise the level at which a client first perceives a stimulus as pain. All of these provide comfort, are non-invasive, and show the client that the nurse cares. 1. Incorrect: Reinforcing teaching regarding pain control does not help the client's pain and would not be appropriate while the client is experiencing pain.
An elderly client with vomiting and diarrhea for three days, is receiving IV fluids at 200 mL/hr via pump. What is the priority nursing action? 1. Intake and output every shift. 2. Auscultate lungs every 2-4 hours. 3. Vital signs every shift. 4. Monitor IV site every 2-4 hours.
2. Auscultate lungs every 2-4 hours. 2. Correct: The IV is infusing at 200 mL/hr which is a rapid infusion rate for an elderly client. The lungs should be auscultated every 2-4 hours to monitor for potential fluid volume excess (FVE). 1. Incorrect: Input and Output (I&O) are important, but are a less priority than lung auscultation in the elderly client to monitor for FVE.3. Incorrect: Vital signs should probably be more frequent than every shift on the elderly client with dehydration. In addition, the client's IV rate is 200 mL/hr which may result in FVE.4. Incorrect: The site should be monitored but will not be the priority over lung auscultation in the elderly client to monitor for FVE.
The client has been prescribed a topical anticholinergic medication for the treatment of glaucoma. Which report by the client indicates a common side effect? 1. Constriction of the iris sphincter 2. Blurred vision 3. Pain 4. Confusion
2. Blurred vision 2. Correct: Blurred vision is a common side effect of the medication due to the dilatation of the iris sphincter.1. Incorrect: Dilatation is the desired effect from the medication.3. Incorrect: Pain indicates an adverse effect and possible angle-closure glaucoma.4. Incorrect: Confusion would indicate an adverse and systemic response to the medication.
When the surgical transport team arrives to take a client to the operating room, the client is sitting in a chair in the room. What is the best way for the nurse to get the client onto the transport litter? 1. Using a foot stool, assist client to step up and crawl onto litter. 2. Have client return to bed and utilize slide board to transfer to litter. 3. With feet placed apart, grasp client around waist and lift onto litter. 4. Put Hoyer pad under client, using Lift to move client from chair to litter.
2. CORRECT. The safest, most efficient manner by which to place the client on the litter properly is to have client first return to bed. The bed can then be raised to the height of the litter, allowing staff to utilize a slide board to easily position the client onto the litter. This method decreases safety risks for both staff and client. 1. INCORRECT. Even with assistance, stepping up onto a stool greatly reduces the client's stability to that small surface area. Crawling on the litter would make it difficult for the client to get properly positioned. The stool may be too short for staff to even assist. 3. INCORRECT. It is never safe for a nurse to lift a client by grasping around the waist, no matter how feet are positioned. This method could potentially injure both the nurse and client while increasing the risk of a fall. 4. INCORRECT. Positioning a Hoyer lift pad under a sitting client is impractical and nearly impossible. Proper placement can best be accomplished with the client supine in bed. This individual is obviously mobile, negating the need for any lifting device. This is not the best action. Everyone seems to be in a hurry these days, including the surgical transport team with the responsibility of delivering a client from room to the pre-op setting ASAP. However, a few extra moments of caution can prevent serious injury to either staff or client! In this scenario, the client is obviously able to get up and sit in a chair. You have most likely seen a transport litter on the clinical floor, noticing the bed is quite narrow and high off the floor. While the transport team's goal is to get the client loaded quickly and wheeled to the surgical suite, consider the logistics needed to accomplish this process safely! A few extra moments to get the client safely and properly loaded onto the litter will ensure a positive outcome. Option 1: No way. A client should never use a foot stool to step up onto a higher surface. A stool has a very small, unstable surface area which can lead to loss of balance while attempting to get on the litter. Because the height of the litter is unknown, the stool may be inadequate for the client to even reach the litter safely, and even more difficult for staff to assist. Option 2: Excellent choice. The safest and most efficient method to place the client on the transport litter begins by having the client return to bed and lie supine. The transport litter should be properly positioned firmly against the mattress while the hospital bed is raised up to the level of the litter. A slide board, or even draw sheet, should be utilized by staff to safely move the client from bed to litter. This method prevents injury to staff or client. Option 3: Definitely not. Were you distracted by the phrase "feet planted"? It is never safe to lift a client around the waist, no matter how the feet are positioned! The nurse could incur a back injury or cause an injury to the client. You do not need to know the height of the litter to determine this method is very unsafe. Option 4: Never! First of all, consider the clues in the scenario. The client is already out of bed in a chair. That type of mobility tells you a Hoyer Lift is not necessary. Secondly, attempting to get the Hoyer pad properly placed under a sitting client would create additional safety issues, especially when attempting to hook the pad to the lift frame. Another choice makes much more sense!
The client expresses concern to the nurse about the ability to provide self-care and perform activities of daily living at discharge. Which member of the healthcare team should the nurse contact to provide information and assist the client with resources for an effective discharge plan? 1. Primary healthcare provider 2. Case manager 3. Physical therapist 4. Occupational therapist
2. Case manager 2. Correct: The client's case manager should be contacted regarding the order for pending discharge from the healthcare facility. The case manager coordinates care and provides the client with information and resources for an individualized discharge plan. 1. Incorrect: The primary healthcare provider does not assume the case management role in the acute care facility setting, and generally does not coordinate the discharge planning process. 3. Incorrect: The physical therapist is a member of the multidisciplinary team and might help evaluate, but does not coordinate discharge planning. They are not responsible for case management and coordination of overall client care for discharge from the facility. 4. Incorrect: The occupational therapist is a member of the multidisciplinary team and might help evaluate, but does not coordinate discharge planning. They are not responsible for case management and coordination of overall client care for discharge from the facility. 1. Identify clues in the stem. Generally, the stem is short and contains only the information needed to make the question clear. A clue is the use of a word or phrase that leads you to the correct answer. The clue shows a relationship to word or phrase in the correct answer.
Which actions should the nurse perform to prevent injury from a needle stick? Select all that apply 1. Recap the needle after use to prevent injury. 2. Clean used instrument trays carefully after every procedure. 3. After drawing up saline to flush an IV, place the syringe in a pocket to prevent possible injury. 4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible.
2. Clean used instrument trays carefully after every procedure. 4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible. , 4. & 5. Correct: Instrument trays should be cleaned carefully after every procedure as sharps may have been left behind. Puncture resistant biohazard containers should be replaced when three-quarters full to prevent hand injury when disposing of sharps. Use of "needleless" devices reduces the risk of needle stick injuries.
A client asks a nurse about the Health Insurance Portability and Accountability Act (HIPAA). When reinforcing teaching to the client about HIPAA regulations, which provisions should the nurse include?
2. Clients have the right to request a copy of their personal health information. 3. Health care agencies must keep a client's personal health information confidential. 4. A client's personal health information may be released to obtain health insurance benefits for the client. 2., 3. & 4. Correct: HIPAA is federal legislation enacted to protect a client's health information and privacy. Clients have the right to request a copy of their personal health information. Health care facilities must keep all client information confidential per federal law. A client's personal health information may be released to obtain insurance benefits for the client.1. Incorrect: HIPAA does not guarantee access to health insurance.5. Incorrect: Only staff members who are providing care directly to the client have legal access to a client's personal health information.
A client suffers from a right radial fracture. The client now reports severe pain in the right arm accompanied with edema in the fingers. The nurse suspects what finding? 1. Carpal tunnel syndrome 2. Compartment syndrome 3. Subsequent ulnar fracture 4. Ulnar nerve palsy
2. Compartment syndrome 2. Correct: This situation best describes compartment syndrome. Compartment syndrome is when edema within a closed space may result in vascular compromise and decreased blood flow with eventual neurologic compromise. There are five Ps of compartment syndrome: pallor, pulselessness, pain, paresthesias, and paralysis. 1. Incorrect: This does not describe carpal tunnel syndrome. The key to this question is that this client has recently sustained a right radial fracture. 3. Incorrect: This does not describe ulnar fracture. The key to this question is that this client has recently sustained a right radial fracture. 4. Incorrect: This does not describe nerve palsy. The key to this question is that this client has recently sustained a right radial fracture.
Which factors should the nurse reinforce with a parent about risk factors for otitis media? 1. Breast-feeding 2. Contact with siblings 3. Day care attendance 4. Season of the year 5. Age over 5
2. Contact with siblings 3. Day care attendance 4. Season of the year 2., 3. & 4. Correct: Contact with siblings, day care attendance, and season of the year all increase a child's risk of developing otitis media. Otitis media usually follows or accompanies an upper respiratory infection or the common cold. The exposure to upper respiratory infections is increased when other siblings are in the home and when the child attends daycare. More upper respiratory infections occur during times when the climate changes and during the winter months. 1. Incorrect: Breast-feeding decreases the incidence of otitis media. Ear infections are more common in children who drink from bottles or sippy cups, especially when lying on their back. 5. Incorrect: Age under 5 is a risk factor. The Eustachian tube is shorter, narrower, and more vulnerable to blockage in the younger children. It also lies more horizontal and does not drain as well as older children and adults. This, along with immature immune systems, puts the younger child at higher risks for otitis media.
An unlicensed assistive personnel (UAP), assigned to take care of a client who is HIV positive, refuses the assignment, stating fear of personal injury. What action should the LPN/VN take first? 1. Re-assign the client to a UAP who does not mind caring for HIV positive clients. 2. Inform the UAP that refusing client care is not acceptable practice. 3. Have the UAP document rationale and support for refusing the client assignment. 4. Transfer the UAP to a unit where there are no HIV positive clients.
2. Correct. Any UAP who feels compelled to refuse to provide care for a particular type of client faces an ethical dilemma. The reasons given for refusal range from a conflict of personal values to fear of personal risk of injury. Such instances have increased since the advent of acquired immunodeficiency syndrome (AIDS) as a major health problem. To avoid facing these moral and ethical situations, a UAP can follow certain strategies. For example, when applying for a job, one should ask questions regarding the client population. If one is uncomfortable with a particular situation, then not accepting the position would be an option. Denial of care, or providing substandard nursing care to some members of our society, is not acceptable nursing practice. 1. Incorrect: This is not the best action for the nurse to take. The nurse should remind the UAP of the responsibility for the agency to provide nondiscriminatory care to all clients. The re-assignment of the client to another UAP does not resolve the ethical dilemma by the UAP refusing to provide care. 3. Incorrect: The UAP can inform the employer of the reluctance to care for a certain population, but must provide strong rationale and documentation to support the necessity for refusal of the assignment. Recognition by the organization of an individual nurse's right to refuse to care for a specific client population sets a major personnel precedent and will not be made lightly. A health care agency has a responsibility to provide care for all clients accepted into the organization. Due to this responsibility, the UAP cannot be guaranteed that he/she will never be asked to provide care for the client in question. 4. Incorrect: This is generally a decision made on a level beyond the charge nurse. This is a last resort after documentation and consideration by management to accept the UAP's request. If honored, the UAP should expect to be transferred. However, the UAP may encounter the situation again.
Which prescription can the LPN/VN implement when assisting an RN with the care of a client diagnosed with an abdominal aortic aneurysm? 1. Obtain vital signs every 15 minutes. 2. Insert a urinary catheter for hourly urinary outputs. 3. Place a PICC line for fluid management. 4. Provide morphine 1 mg per PCA pump at a 10 minute lockout.
2. Correct. Inserting a urinary catheter is within the scope of practice for the LPN. This task does not include further assessment of the urinary output, which the RN will perform. 1. Incorrect. The UAP can do this task as well as the LPN. In order to be most effective with the nurse's time, this task can be delegated to the UAP. 3. Incorrect. The RN with special training can insert a PICC line. The LPN cannot complete this task. 4. Incorrect. The RN must complete this task. The LPN should not initiate PCA morphine.
The nurse is reinforcing teaching to a client, newly diagnosed with diabetes, about the action of regular insulin. The nurse verifies client understanding when the client verbalizes being at greatest risk for developing hypoglycemia at what time following the 8:00 a.m. dose of regular insulin? 1. 8:30 AM 2. 11:00 AM 3. 1:30 PM 4. 4:00 PM
2. Correct: 11:00 AM: Regular insulin peaks 2-3 hours after administration. Clients are at greatest risk for hypoglycemia when insulin is at its peak. 1. Incorrect: 8:30 AM: The onset of action for rapid acting insulin is 30 minutes. 3. Incorrect: 1:30 PM: Intermediate acting insulin begins peaking at 4 hours. So at 1:30 PM this would be a time of worry. 4. Incorrect: 4:00 PM: At 4 PM you would still be worried about intermediate acting insulin. But you would also be worried about long acting insulin as well, which starts to peak at 6 hours.
What information should the nurse reinforce about decreasing the risk of spreading influenza? 1. Influenza is transmitted via the influenza vaccine. 2. Use a shirtsleeve when coughing or sneezing if tissue is not available. 3. Tissues are not effective in decreasing the spread of influenza. 4. Antibiotics are effective in treating influenza.
2. Correct: A shirtsleeve should be used as a barrier when coughing or sneezing if tissue is not available. This prevents germs being spread via the hands. 1. Incorrect: The vaccine contains a dead virus that is not capable of causing influenza. Clients may experience influenza symptoms from the vaccine, but they won't contract the full-fledged virus. 3. Incorrect: Tissues are effective in decreasing the spread of influenza if disposed of in the trash after use. 4. Incorrect: Antibiotics are not effective in treating influenza. Influenza is treated with antipyretics, fluids, and rest.
The nurse is participating in educating a group of parents about the importance of immunizing their daughters against the human papillomavirus (HPV) in an effort to prevent the development of which cancer? 1. Breast 2. Cervical 3. Ovarian 4. Uterine
2. Correct: A vaccine that offers protection from the virus responsible for most cases of cervical cancer is the latest addition to the official childhood immunization schedule. The HPV vaccine is recommended for boys and girls at age 11 or 12 so they are protected before ever being exposed to the virus. 1. Incorrect: This vaccine does not offer protection for breast cancer. HPV does not increase the risk for breast cancer. 3. Incorrect: This vaccine does not offer protection for ovarian cancer. HPV does not increase the risk for ovarian cancer. 4. Incorrect: This vaccine does not offer protection for uterine cancer. HPV does not increase the risk for uterine cancer.
A client with schizophrenia tells the nurse, "I want you to take me to the uniphorum". Which statement would be most appropriate for the nurse to make? 1. "You don't even know what you are saying. Stop making up words". 2. "I don't understand what you mean by that. Would you please explain it to me"? 3. "Think about what you are trying to say, then try again". 4. "I will take you after I finish handing out medications".
2. Correct: Attempt to decode incomprehensible communication patterns. Seek validation and clarification. These techniques reveal to the client how he or she is being perceived by others, and the responsibility for not understanding is accepted by the nurse. 1. Incorrect: Do not argue or belittle clients. This is nontherapeutic. This places all responsibility for communication on the client and suggests that the nurse believes the client is defective. This would likely frustrate and distress the client and reduce self-esteem. 3. Incorrect: Cognitive impairment is persistent rather than momentary, so asking the client to do this will be difficult. 4. Incorrect: Pretending to understand is nontherapeutic because it gives the false impression that the client is communicating effectively.
The family member of a schizophrenic client asks the nurse why the client is receiving chlorpromazine and benztropine. What is the best response by the nurse? 1. The chlorpromazine makes the benztropine more effective so a smaller dose of both drugs can be used. 2. Benztropine is given to treat the side effects produced by the chlorpromazine. 3. Chlorpromazine is used for severe hiccups that can occur with the use of benztropine. 4. Chlorpromazine is used for psychosis, and benztropine is used for preventing agranulocytosis.
2. Correct: Benztropine is used to treat parkinsonism of various causes and drug-induced extrapyramidal reactions seen with chlorpromazine, which is an antipsychotic agent. Extrapyramidal symptoms are neurologic disturbances in the area of the brain that controls motor coordination. This disruption can cause symptoms that mimic Parkinson's disease, including stiffness, rigidity, tremor, drooling and the classic "mask like" facial expression. These symptoms can be treated and are reversible using such medications as benztropine. 1. Incorrect: Chlorpromazine does not potentiate the effects of benztropine, so dosage regulation is not appropriate. 3 Incorrect: Chlorpromazine can be used for severe hiccups, but the hiccups are not the result of using benztropine. Chlorpromazine is also used for psychosis in the schizophrenic client. 4. Incorrect: Benztropine is not used to prevent agranulocytosis.
What precautions should be taken with computer monitors that display client health information to ensure client's confidentiality? 1. Turn the screen facing the client rooms so that healthcare personnel can access the information easily. 2. Have the screen placed facing away from any visitor or client care area. 3. Turn the computer monitors off when the computer is not in use. 4. The computer should be kept in a secured, locked area.
2. Correct: Computer monitors that display client health information should be positioned away from the view of any visitors or unauthorized persons. Even a well-guarded computer monitor, with an authorized employee sitting in front of it, could be a potential breach of confidentiality, depending on the angle of the monitor screen and who was attempting to view the information on it. The responsibility for keeping health information safe is on every member of the healthcare team. 1. Incorrect: No, this would be easily viewed by unauthorized individuals. 3. Incorrect: Not necessary to turn off if proper precautions are taken. 4. Incorrect: Not necessary to keep in secured area if proper precautions are taken.
The nurse is providing care to a 5 year old client who has been experiencing moderate pain. Which intervention is appropriate for the nurse to use with this client? 1. Encourage the client to talk about the pain. 2. Provide distraction by asking the client to sing with the nurse. 3. Suggest that the client try to relax. 4. Tell the client that the pain can be self controlled
2. Correct: Distraction is a good technique to use with the toddler/preschooler. Other distractions might be to read a book, watch TV with the client, or look at pictures. 1. Incorrect: The client at this age does not have the cognitive abilities to discuss pain other than to report the presence and location of the pain. 3. Incorrect: Relaxation requires higher level of skills and attention than this child would have. 4. Incorrect: This child would not have the cognitive grasp of controlling pain.
The nurse, talking with her brother about their aging father, voices concern about hazards that their father may encounter while alone. Which statement by the nurse indicates adequate understanding of health risks common in the elderly? 1. "Dad is not likely to fall as he has carpet on the floor". 2. "Dad may get burned in the shower if the water heater temperature is too high". 3. "We no longer have to worry about him drinking too much". 4. "His herbal supplements are safe to take because they are "all natural."
2. Correct: Elderly clients have decreased sensitivity to heat and pain, and may burn themselves before they realize it. 1. Incorrect: Elderly clients are at risk for falls due to changes in vision, balance, or impaired mental status. 3. Incorrect: Alcoholism in the elderly is a health risk. Many elderly begin drinking as a way of coping with loss of independence, loss of spouse, and physical disability. 4. Incorrect: One must be aware of herbal supplements and possible interactions with prescription medication.
A client reports to the nurse, "I just do not feel well. Something is wrong." The client's vital signs are BP: 130/88, HR: 102, RR: 28. What should the nurse do next: 1. Administer PRN anxiolytic. 2. Connect to oxygen saturation monitor. 3. Reassure the client that everything is okay. 4. Assist with relaxation technique.
2. Correct: Everything is pointing toward hypoxia. Look at HR and RR. This data is telling you that the client is restless and has tachycardia...think hypoxia FIRST when you see these 2 symptoms. 1. Incorrect: Anxiolytic medications are used to treat anxiety. However, in a client with hypoxia, this would decrease the respiratory rate so much that respiratory arrest could occur. Don't be a killer nurse. 3. Incorrect: This would be incorrect because everything is not okay. Remember, you must pick an answer that fixes the problem. This choice ignores it. 4. Incorrect: This will not fix the problem and is unsafe. The client is hypoxic, and this would make you a killer nurse.
Which electrolyte imbalance would be the nurse's priority concern in the burn client? 1. Hypernatremia 2. Hyperkalemia 3. Hypoalbuminemia 4. Hypermagnesemia
2. Correct: Good job. When the cells lyse, they release potassium, and then the serum potassium goes up. And if the kidneys stop functioning, we are in real trouble. 1. Incorrect: Well, hypernatremia does occur when the client becomes very dehydrated, but it's not as dangerous as the potassium one. 3. Incorrect: Low albumin can cause problems keeping fluid in the vascular space, but albumin is not an electrolyte. 4. Incorrect: No, the magnesium doesn't go up unless the kidneys shut down.
The nurse is assigned to care for a client with the diagnosis of schizophrenia. The client tells the nurse, "I am having trouble tuning out the voices." What is the nurse's best response to this statement? 1. "There is nothing to help with this problem." 2. "You might hum when the voices are so troublesome." 3. "Ask your primary healthcare provider to increase your medication." 4. "Wear earplugs to block out the voices."
2. Correct: Humming or listening to music may help to decrease the intrusive voices. This increases time spent in reality based activities and decreases preoccupation with delusional and hallucinatory experiences. 1. Incorrect: There are things that the client may do, such as humming or listening to an iPod. Telling the client that there is nothing to help them is not therapeutic. 3. Incorrect: The medication may need to be adjusted, but further assessment is needed. Remember, stay away from drugs as long as possible on the NCLEX. 4. Incorrect: Earplugs suggest blocking external stimuli; hallucinations are internal voices. Earplugs will not help internal voices and saying this could make the client think that the nurse hears the voices. Remember, the nurse is not supposed to go along with the hallucinations. 1. Nurses need to use interviewing techniques to effectively communicate in a nonthreatening way with clients. 2. The nurse must deliver care in a nonjudgmental manner. The nurse must be nonjudgmental when picking the correct option. Option 1 can be eliminated because there is something to help this problem. Option 3 can be eliminated because you should stay away from medications on this test. Option 4 tells the client that the nurse hears the voices so this can be eliminated. Option 2 is the only option that will help the client.
A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R 36. The client is extremely anxious and crying uncontrollably. Based on this assessment, the nurse should anticipate that this client is likely in which acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
2. Correct: Hyperventilation due to anxiety, pain, shock, severe infection, fever, or liver failure can lead to respiratory alkalosis. With each of these, the client loses too much CO2. The reduction of CO2 creates an excessive loss of acid, resulting in an alkalotic state. Since the problem is respiratory, it is respiratory alkalosis. 1. Incorrect: This problem is respiratory, but there is excessive CO2 loss. CO2 combines with water to form an acid. If too much of the CO2 is lost, the result of the acid forming substance loss would be alkalosis-Not acidosis. 3. Incorrect: The problem in this situation is respiratory in origin and has acid loss. Therefore, it is not metabolic nor acidotic in nature. 4. Incorrect: The problem in this situation is the excessive loss of CO2 from the respiratory system secondary to hyperventilation. Although the CO2 loss creates an alkalotic state, it is respiratory, not metabolic in origin. 1. Identify clues in the stem. Generally, the stem is short and contains only the information needed to make the question clear. A clue is the use of a word or phrase that leads you to the correct answer. The clue shows a relationship to a word or phrase in the correct answer. The clues in the stem are anxiety and the increased respiratory rate (hyperventilation). These are clues that the problem is respiratory, not metabolic. 2. Identify opposites in options. When opposites appear, you need to give them serious consideration. One of them will be the correct answer, or they both can be eliminated from consideration. Options number 1 and 2 are opposites. You would know that at least one of these is incorrect. Also, options number 3 and 4 are opposites. Therefore, at least one if these will be incorrect. This helps you eliminate at least two options.
When reinforcing teaching, what symptom would the nurse include as being the most common initial visual change associated with glaucoma? 1. Central vision is lost. 2. Progressive tunnel vision occurs. 3. Sudden flashes of light in the eyes. 4. Eye floaters begin to be noticed.
2. Correct: If glaucoma is not diagnosed and treated early, an individual starts to lose peripheral vision, or the area of vision outside the central field of sight. People who have glaucoma experience tunnel vision and cannot see objects to the side, near the head, or by their feet. Central vision can be lost later if the disease progresses. 1. Incorrect: Central vision loss is the classic visual disturbance for macular degeneration but peripheral vision is usually maintained. 3. Incorrect: Individuals experiencing retinal detachment may have sudden flashes of light in the affected eye, but this is not an initial visual change related to glaucoma. 4. Incorrect: Eye floaters are more common in eye disorders such as retinal detachment or may occur associated with the aging process.
A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What information should the nurse reinforce to help reduce this side effect? 1. Stop taking the medication. 2. Drink plenty of water with the medication. 3. Take the medication before bedtime. 4. An antacid should be taken with the medication.
2. Correct: Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet. 1. Incorrect: There is no need to stop the medication due to mild heartburn. Measures such as those listed above should be utilized to minimize heartburn. However, if extreme pain or difficulty swallowing develops, this should be reported to the primary healthcare provider. 3. Incorrect: The client should take the medication in the morning, thus preventing prolonged contact with the esophagus. 4. Incorrect: The absorption of the medication is decreased when it is taken with calcium, iron, and magnesium, or antacids containing calcium, aluminum, or magnesium. Thirty minutes should elapse before taking the antacid following administration of the alendronate.
During the insertion of a urinary catheter, the tip of the catheter touches the client's thigh. What action should the nurse take? 1. Wipe the tip of the catheter with alcohol. 2. Call for another urinary catheter and a pair of sterile gloves. 3. Insert the catheter and obtain a prescription for antibiotics. 4. Leave the room to obtain another sterile urinary catheter kit.
2. Correct: Indwelling catheter insertion is a sterile procedure. If contamination occurs, do not turn back on sterile field. Get on the call light to request another urinary catheter and sterile gloves to continue the procedure. Continuing the procedure with contaminated equipment would jeopardize the client's safety. 1. Incorrect: This is a sterile procedure. The catheter needs to be replaced because it is no longer sterile. The client would be at high risk of developing a urinary tract infection. The catheter cannot be made sterile by the use of alcohol. 3. Incorrect: This is a sterile procedure. The catheter needs to be replaced because it is no longer sterile. Inserting the now non-sterile catheter puts the client at risk for infection. There is no reason at this time to start antibiotics. 4. Incorrect: The catheter is contaminated, but the sterile field is still okay. It is more cost efficient to have someone bring the nurse another catheter and pair of sterile gloves rather than getting an entire sterile kit.
The nurse should teach the client with chronic pancreatitis how to monitor for which problem that can occur as a result of the disease? You answered this question Correctly 1. Hypertension 2. Diabetes 3. Hypothyroidism 4. Graves disease
2. Correct: Insulin is produced in the pancreas. When the client has chronic pancreatitis, the pancreas becomes unable to produce insulin, thus resulting in diabetes. 1. Incorrect: No, hypertension is not a sign of pancreatitis. If the client starts losing fluids from the vascular space due to the pancreatitis, the blood pressure would start going down. 3. Incorrect: No, hypothyroidism is not associated with pancreatitis. Hypothyroidism is caused by low levels of thyroid hormones. 4. Incorrect: No, Graves' disease is hyperthyroidism where too many thyroid hormones are produced.
The nurse is working with three clients from all socioeconomic levels, in the day room of the nursing home. Each one has a similar request of the nurse. The nurse responds first to the client whose son is the mayor of the city. Which ethical principle may be compromised with the nurse's action? 1. Beneficence 2. Justice 3. Veracity 4. Nonmaleficence
2. Correct: It seems that the client with the higher social status is getting preferred treatment. The ethical principle of justice means that treatment is equally applied or applied based on need. 1. Incorrect: Beneficence, to do good, is not compromised. 3. Incorrect: Veracity, truth telling, is not compromised. 4. Incorrect: Nonmaleficence, to do no harm, is not being compromised with the nurse's action.
The client has been prescribed hydrochlorothiazide for treatment of hypertension. What client comment indicates adequate understanding of the side effects of the drug? 1. "I must limit my intake of citrus food." 2. "I must increase my intake of foods containing potassium." 3. "I can expect an increase in my potassium level." 4. "I love sitting in the sun in the summer."
2. Correct: Loop diuretics cause an increase in potassium excretion, thus serum potassium levels are decreased.1. Incorrect: Citrus foods, such as oranges contain potassium and would be good for a client taking hydrochlorothiazide. 3. Incorrect: Potassium levels are likely to be decreased unless supplements are prescribed or if there is an increased consumption of potassium rich foods. 4. Incorrect: Some people taking this medication become more sensitive to sunlight. The client should be protected from exposure to the sun by using a sunblock
The client has been prescribed hydrochlorothiazide for treatment of hypertension. What client comment indicates adequate understanding of the side effects of the drug? 1. "I must limit my intake of citrus food." 2. "I must increase my intake of foods containing potassium." 3. "I can expect an increase in my potassium level." 4. "I love sitting in the sun in the summer."
2. Correct: Loop diuretics cause an increase in potassium excretion, thus serum potassium levels are decreased.1. Incorrect: Citrus foods, such as oranges contain potassium.3. Incorrect: Potassium levels are likely to be decreased unless supplements are prescribed or if there is an increased consumption of potassium rich foods.4. Incorrect: The client should be protected from exposure to the sun by using a sunblock.
Which nursing intervention should receive priority after a client has returned from having had eye surgery? 1. Administer pain medication around the clock. 2. Maintain head of bed at 35°. 3. Alternate applying warm and cold compresses. 4. Instruct on importance of turning, coughing, and deep breathing.
2. Correct: Maintaining head of bed in an elevated position will help to decrease intraocular pressure. Do not lie the client supine as this will increase intraocular pressure. If the intraocular pressure increases too much, damage to the eye structures, including the retina and optic nerve, with resulting loss of vision may result. 1. Incorrect: Although pain management is important, it is not the priority here. The priority intervention of maintaining the bed at 35° is to reduce the risk of increased intraocular pressure. Unless the pain becomes out of proportion or suddenly worsens, it is an expected finding and would not be cause for alarm or require "priority" attention. 3. Incorrect: Warm and hot compresses could possibly increase intraocular pressure and cause damage to the eye structures. 4. Incorrect: Coughing will increase intraocular pressure and could result in damage to the surgical site and/or the structure within the eye. Loss of vision could result if pressure becomes too great. Coughing is a type of valsalva movement which results in an increase in the intraocular pressure.
A new LPN/VN is preparing to give a medication to a nine month old client. After checking a drug reference book, the nurse crushes the tablet and mixes it into 3 ounces of applesauce. The new nurse proceeds to the client's room. What priority action should the supervising LPN/VN take? 1. Tell the new nurse to recheck the drug reference book before administering the medication. 2. Suggest that the new nurse reconsider the client's developmental needs. 3. Check the prescription order and the client dose. 4. Observe the new nurse administer the medication.
2. Correct: Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce a new food during an illness. 1. Incorrect: There is nothing in the stem about a problem with the medication dose or route. 3. Incorrect: There is nothing in the stem about a problem with the medication dose or route. 4. Incorrect: This is an appropriate action. However, it is not the priority over ensuring that the new nurse knows how to appropriately prepare the medication for this client.
Which finding would indicate to a nurse that a client receiving chemotherapy may have difficulty maintaining proper nutrition? 1. Fatigue 2. Mucositis 3. Neutropenia 4. Diarrhea
2. Correct: Mucositis is pain and inflammation of the body's mucous membranes along the gastrointestinal tract. Ulcerations in the oral cavity can make it difficult to chew food or be intolerant to certain foods due to discomfort and pain. Intake may be inadequate as a result of this. 1. Incorrect: Fatigue may make the client tire easily, but pain and inflammation in the oral cavity will be the primary reason for not wanting to eat. 3. Incorrect: Someone with neutropenia has an unusually low number of neutrophils, a type of white blood cell. Neutropenia leads to infection. This does not alter intake. 4. Incorrect: Diarrhea may need to be treated by making diet changes. However, the maintenance of nutrition should be focused on intake. The impact of the mucositis should be considered first for maintaining proper nutrition. Identify clues in the stem. Generally, the stem is short and contains only the information needed to make the question clear. A clue is the use of a word or phrase that leads you to the correct answer. The clue shows a relationship to word or phrase in the correct answer. The clue in the stem is "difficulty maintaining proper nutrition". This should guide you to look at options that could reduce intake.
Which action by a new nurse indicates to the supervising nurse that the sterile field has been contaminated? 1. Maintains the sterile field above the level of the waist. 2. Places sterile gauze dressing within the one inch border of sterile field. 3. Remains facing the sterile field throughout procedure. 4. Inspects sterile wrapped instruments for damage.
2. Correct: No sterile object should be within the one inch border of the sterile field, as the object is no longer considered sterile. 1. Incorrect: This is a correct action. Bacteria tend to settle below the level of the waist, so there is less contamination when the field is above the waist and away from the nurse. 3. Incorrect: This is a correct action. The nurse should never turn their back to the sterile field. The fronts of sterile gowns are considered sterile from the chest to the level of the sterile field. 4. Incorrect: This is a correct action. The sterile wrapped instruments and trays should be purposely inspected for small tears that would compromise sterility before opening and placing the instruments on the field.
The nurse is reinforcing discharge instructions to an Asian client following a colonoscopy. During the instructions, the client stares directly at the floor, despite being able to speak English. Based on the client's body language, how would the nurse classify this behavior? 1. Embarrassment. 2. Attentiveness. 3. Disinterest. 4. Confusion.
2. Correct: Nurses must be aware of clients' specific cultural or religious beliefs in order to provide appropriate care and discharge planning. Asian societies have a deep respect for others and making eye contact with the nurse would be considered rude and offensive. The nurse is considered superior to the client, so direct eye contact with a superior shows a lack of respect. This client is displaying attentiveness while also showing respect for the nurse. 1. Incorrect: There is nothing in the question to suggest the client is embarrassed. In Asian cultures, making eye contact is considered disrespectful to the superior; therefore, this client's demeanor is a respectful display of cultural influences. 3. Incorrect: The client's body language does not suggest disinterest. Although staring downward, this client does not display other signs of disinterest. A culturally aware nurse understands that the client's Asian background impacts this behavior and conveys the meaning of respect for the nurses' position. 4. Incorrect: The question indicates that the client does speak English. There is no indication that the client is confused or does not comprehend the discharge instructions. There is a more specific cultural basis for the client's behavior.
A client recently prescribed propranolol returns to the outpatient clinic for follow-up. Which statement by the client should be reported immediately to the primary healthcare provider? 1. "My resting pulse was 60 this morning." 2. "I feel a little short of breath when walking." 3. "I have lost 5 pounds in the last 2 weeks." 4. "My blood pressure (BP) was lower this visit than last time."
2. Correct: Propranolol is a non-selective beta blocker, so it blocks sites in the heart and in the lungs. The shortness of breath could be the result of the adverse reactions of bronchospams or heart failure. This statement requires immediate investigation by the primary healthcare provider. 1. Incorrect: A side effect of propranolol is bradycardia. The nurse will reinforce teaching to contact the primary healthcare provider if their pulse is <50 beats per minute (bpm). A pulse rate of 60 bpm is acceptable. 3. Incorrect: Losing weight is not a side effect of propranolol. Weight loss regimen may be encouraged for hypertension. Losing 5 pounds in 2 weeks is within the acceptable range. 4. Incorrect: The therapeutic effect of propranolol is to reduce BP. If the client is asymptomatic, decreased BP is no big deal.
Which nursing action represents secondary prevention level? You answered this question Incorrectly 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. Correct: 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. 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. 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.
The family of a client receiving treatment for substance abuse asks why they should get involved in treatment plan. Which statement by the nurse would best explain the rationale for including the family in the treatment plan? 1. "The treatment plan consists of having the family confront the client about the harm substance abuse causes." 2. "Family involvement reduces distress in family relationships to lessen the risk for relapse by the client" 3. "Involving the family helps the family learn ways to protect the client from additional harm." 4. "The family assists in ways to help reduce temptations for substances by the client."
2. Correct: Reducing distress in relationships lessens risk of relapse. 1. Incorrect: The family is not responsible for confronting the client. 3. Incorrect: The client is responsible for consequences related to client's behavior. 4. Incorrect: The family is not responsible for reducing temptations. Option 1 is false. It is not the family's responsibility to confront the client about the harm caused by substance abuse. The goal of therapy is to help families become aware of their own needs. Option 2 is true. Reducing relationship distress lessens the client's risk for relapse. One of the goals of therapy is to help improve communication between the family and the client. Option 3 is false. The client is responsible for their own actions. Option 4 is false. The family is not responsible for reducing the client's temptations for abusing substances.
A client, who is having difficulty falling asleep, asks the nurse for a sleeping aid. What is the first action the nurse should provide to the client? 1. Assist client to take a cool bath. 2. Provide a back massage. 3. Administer prescribed triazolam. 4. Give client a crossword puzzle to work.
2. Correct: Research indicates that back massage can enhance client comfort, relaxation, and sleep. This is the least invasive option and should be done first. 1. Incorrect: A cool bath would wake a client, whereas, a warm bath would increase relaxation. 3. Incorrect: Triazolam is a short acting benzodiazepine. Do not go to the sleeping pill first. 4. Incorrect: Distraction is a good strategy for drawing a client's attention away from pain but may increase thinking, thus keeping the client awake.
A newly admitted client with schizophrenia has an unkempt appearance and needs to attend to personal hygiene. Which statement by the nurse is most therapeutic? 1. A shower will make you feel better. 2. It is time to take a shower. 3. Have you thought about taking a shower? 4. I need you to take a shower.
2. Correct: Schizophrenia is a thought disorder. Many clients with schizophrenia are concrete thinkers and have difficulty making decisions. The nurse needs to be direct, clear and concise in communicating with the client. This is a direct, clear and concise statement that guides the client to perform the needed activity. 1. Incorrect: Many clients with schizophrenia are concrete thinkers. The nurse needs to be direct, clear and concise in communicating with the client. The client may not comprehend how the shower improves the overall sense of well-being and would remain reluctant to take the shower. 3. Incorrect: Clients diagnosed with schizophrenia often have trouble making decisions. The client needs to be guided with simple, direct instructions. 4. Incorrect: This focuses on the nurse's need, not the client's need. Do not select answers that focus on the nurse. This does not improve the client's decision making ability nor does it provide guidance to the client for meeting the hygiene needs.
Which baseline data would tell the nurse that a school aged child is at risk for obesity? 1. Spends one hour playing sports or swimming daily. 2. Spends at least two hours watching TV after dinner each day. 3. Assists mom in preparing low carb snacks for the family. 4. Participates in the marching band at school.
2. Correct: Sedentary activities, such as watching television, playing video games, and using a computer to surf the internet or engage with friends can also contribute to obesity and cardiovascular health problems in later life. 1. Incorrect: The more active the child is, the less likely the child is to be overweight. Activity for at least one or more hours per day should be encouraged. 3. Incorrect: Children who are exposed to healthy snacks are less likely to be overweight and are more likely to choose healthy snacks. 4. Incorrect: The marching band is an excellent source of exercise for the child. This information does not support the risk for obesity.
The client at a clinic has voiced suicidal thoughts and has access to firearms at home. Which action by the nurse is priority? 1. Empathize with the client and listen to feelings. 2. Inform the supervisor of client's statements. 3. Chart the thinking pattern and make a follow up appointment. 4. Ask the client to return to the clinic tomorrow for further evaluation.
2. Correct: The LPN should report the client's statements, which indicate a developing crisis, to the supervisor. The family should be notified. Suicidal thinking is one condition that necessitates breach of confidentiality. The client has identified a plan and has access to firearms; therefore, the family should remove them from the house. Client safety is a priority. This client will likely be directly admitted to the hospital. 1. Incorrect: This is appropriate; however, client safety is priority at this time. Suicide risk is higher when a plan is expressed and lethal means are available. 3. Incorrect: Charting the thinking pattern is an appropriate action; however, the priority at this time is the client's safety. Suicide risk is higher when a plan is expressed and lethal means are available. Making a follow up appointment would be delaying care for the immediate action that is needed to protect the client. 4. Incorrect: Suicide risk is higher when a plan is made and lethal means are available. Asking the client to return to the clinic tomorrow would be delaying care for the immediate action that is needed to protect the client. It is likely that this client will be admitted directly to the hospital.
Which nursing intervention can the LPN/LVN safely perform? 1. Assess a client for a hearing loss. 2. Reinforce hand-washing with the client who has bacterial conjunctivitis. 3. Evaluate a client's ability to instill eye medication. 4. Create the plan of care for a client post cataract surgery.
2. Correct: The LPN/VN can reinforce education. The LPN/VN must know the scope of practice of the LPN/VN 1. Incorrect: The LPN/VN cannot instruct, assess, evaluate, or create the plan of care. These are RN tasks only. 3. Incorrect: The LPN/VN cannot instruct, assess, evaluate, or create the plan of care. These are RN tasks only. 4. Incorrect: The LPN/VN cannot instruct, assess, evaluate, or create the plan of care. These are RN tasks only
A client in the long-term care facility has been prescribed hydrochlorothiazide. What side effect should the nurse expect? 1. Increased potassium levels 2. Orthostatic hypotension 3. Increase in weight 4. Decreased urine output
2. Correct: The client may experience drop in blood pressure upon standing, particularly when the medication is first prescribed. The nurse should tell the client to change positions slowly. 1. Incorrect: Hydrochlorothiazide lowers potassium levels, and a potassium supplement may also be prescribed. 3. Incorrect: With the fluid loss resulting from diuretic, the client is likely to see a weight loss. 4. Incorrect: This diuretic may result in rapid diuresis.
Which assigned client should the nurse see first? You answered this question Correctly 1. Diagnosed with urinary tract infection 2 days ago who is to be discharged. 2. Admitted last night with a diagnosis of severe pneumonia. 3. 45 year old who had a hernia repair 24 hours ago. 4. Scheduled for an endoscopy in two hours.
2. Correct: The client with severe pneumonia is at greatest risk for respiratory difficulty and should be seen first. Clients with severe pneumonia may develop the following complications: bacteremia, septic shock, lung abscesses, pleural effusion, empyema, pleurisy, renal failure, and respiratory failure. 1. Incorrect: The client who is being discharged is considered to be stable. A client who was diagnosed with a urinary tract infection is considered to be stable. This client is not exhibiting signs of potential airway complications. 3. Incorrect: This postoperative client of 24 hours is considered stable. The client's age of 45 also does not suggest that the client was a surgical risk. 4. Incorrect: The client admitted for an endoscopy is considered to be stable at this point. There is no data listed to support the client needing to be assessed first.
The client is receiving a prostaglandin agonist for the treatment of glaucoma. Which comment by the client indicates a lack of understanding of the treatment regimen? 1. "I must only use the drops in the eye with the increased pressure." 2. "My eyes may be different colors, so I will use the drops in both eyes." 3. "I must be careful not to overmedicate even if it is just an eye drop." 4. "The eyelashes in the eye with the higher pressure may get longer."
2. Correct: The color of the iris may darken in the eye being treated; however, it is important that the client understand that drops should not be placed in the unaffected eye. To do so may result in a subnormal intraocular pressure. 1. Incorrect: This comment shows adequate understanding. The client should only treat the eye with the increased pressure. 3. Incorrect: This comment demonstrates that the client does understand the treatment regimen. 4. Incorrect: This comment shows understanding. The lashes in the eye being treated will lengthen as opposed to the untreated eye.
The client in the manic phase of bipolar disorder begins climbing onto a table in the dayroom and shouts, "I can fly! I can fly! Watch me fly!" What should be the initial intervention by the nurse? 1. Leave the client alone and remove clients from the dayroom. 2. Call for personnel to escort the client out of the day room. 3. Restrain the client, and notify the primary healthcare provider. 4. Tell the client that there is no way that a person can fly.
2. Correct: The first priority is the safety of the client. If the client jumps off the table, this action may cause an injury to the client. The nurse may need extra help in case the client becomes violent. 1. Incorrect: The client may cause self injury by jumping from a table and should not be left alone. The other clients can be moved away from the table or removed from the dayroom. 3. Incorrect: The primary healthcare provider does not need to be notified at this time. Restraints should be used as a last resort. 4. Incorrect: The safety of the client at this time is the priority intervention. Presenting a client with reality is a therapeutic communication technique.
The nurse is performing a chart audit for clients who were restrained. For which client would the side rails in the up position be considered a restraint? 1. The client who requests that the rails be placed in the up position. 2. The client who is confused and wanders about the unit. 3. The client who is ambulatory and places the side rails up without staff assistance. 4. The client who asks the family to place all the rails up before leaving.
2. Correct: The intent of the side rails in the up position is to limit movement; therefore, they are considered a restraint. The nurse cannot restrain or limit a client's movement without a primary healthcare provider prescription. 1. Incorrect: The client may request that side rails be raised at any time. 3. Incorrect: The ambulatory client can put his/her own side rails up if that increases feelings of security. 4. Incorrect: The family may place the rails up at the request of the client. That action would not be considered a restraint.
The nurse has observed that the client on the skilled nursing unit has been consuming fewer calories over the past three days. There has been no other change in the client's condition. Which intervention is most important for the nurse to initiate? 1. Suggest that the family seek an appointment with the primary healthcare provider. 2. Ask the dietician to visit the client and discuss food preferences. 3. Note any weight loss over the next month. 4. Continue to monitor intake over the next couple of weeks.
2. Correct: The nurse is using the expertise of other team members by requesting that the dietician visit the client. This is the most important measure to address the client's nutritional needs. The problem may be that the client simply does not like the foods that have been served, and the dietician is the best one to address these issues. 1. Incorrect: An appointment with the primary healthcare provider may not be necessary. It is best to first utilize available team members such as the dietician. The nurse would then notify the primary healthcare provider of any pertinent findings. 3. Incorrect: To simply monitor weight loss for a month would not be an appropriate intervention. There could be significant weight loss within a month. This is much too long to wait before taking measures to ascertain the reason for the client consuming fewer calories. 4. Incorrect: The nurse should monitor intake and weight over the next couple of weeks; however, there is a more immediate action that is appropriate. The nurse takes action by asking the dietician to see the client.
A nurse drops a glass bottle, which shatters on the floor in the hallway. What action should the nurse take? 1. Notify housekeeping to clean up the spill. 2. Pick up glass with a broom and dustpan and dispose into a puncture resistant sharps container. 3. Pick up the glass with gloved hands and dispose into a puncture resistant sharps container. 4. Use a wet mop to collect the glass and dispose of it in the garbage can.
2. Correct: The nurse must not be cut by the broken glass. Proper removal of glass includes using a dustpan and broom to collect the glass and disposing of it into a puncture resistant sharps container. 1. Incorrect: While waiting for housekeeping, someone could fall or get cut. The nurse should initiate cleanup. 3. Incorrect: Hands are never used to pick up glass, even if they are gloved, because of the increased risk of getting cut. 4. Incorrect: A wet mop will not pick up the glass, and glass pieces will stick to a wet mop.
The nurse is caring for a client who has the diagnosis of schizophrenia. The nurse enters the room to administer the morning dose of the prescribed antipsychotic medication. The client is drooling and has extreme muscular rigidity. After checking the client for adequate respiratory effort, what is the nurse's priority? 1. Elevate HOB and give the medication as prescribed. 2. Hold the medication and call the primary healthcare provider. 3. Report the behaviors to the on-coming shift. 4. Hold the medication, and check the vital signs.
2. Correct: The nurse should hold the medication, and report the symptoms to the primary healthcare provider. The client may be experiencing neuroleptic malignant syndrome. 1. Incorrect: The client is experiencing symptoms of possible neuroleptic malignant syndrome. The nurse should not give another dose of the medication without consulting with the primary healthcare provider. 3. Incorrect: The symptoms that the client has are very serious and should be reported to the primary healthcare provider immediately. Never delay care. 4. Incorrect: The client may be experiencing neuroleptic malignant syndrome. It is important to notify the primary healthcare provider immediately. There are some situations in which the nurse must notify the primary healthcare provider, and the test taker should not automatically eliminate this as a possible correct option. The test taker must decide if any of the other options will help correct a life-threatening complication. If it doesn't, then the nurse must notify the primary healthcare provider.
The nurse is caring for a client with a fibula fracture. The primary healthcare provider makes rounds and writes prescriptions. What is the nurse's best action? MSO4 8 mg IM now Advance diet as tolerated Hgb and Hct in AM 1. Check the prescription prior to sending it to the pharmacy. 2. Clarify the prescription with the primary healthcare provider. 3. Notify the pharmacy that the prescription is needed immediately. 4. Gather the supplies needed for an injection.
2. Correct: The nurse should notify the primary healthcare provider, because MSO4 is an unapproved abbreviation that presents safety concerns. MSO4 is the abbreviation for morphine sulfate. MgSO4 is the abbreviation for magnesium sulfate. Notifying the primary healthcare provider to clarify the prescription will prevent a medication error. 1. Incorrect: The prescription should not be sent to the pharmacy until after it is clarified with the primary healthcare provider. The Institute for Safe Medication Practices (ISMP) and The Joint Commission recommend using the complete names for morphine and magnesium to eliminate confusion. 3. Incorrect: MSO4 is not an approved abbreviation. Before notifying the pharmacy, make sure you know what the prescription means. The complete drug name should be written out. 4. Incorrect: You might be making a medication error if you assume you know what you are giving. Always seek clarification when in doubt.
A nurse prepares a client for a colonoscopy and presents the consent form to the client. The client states, "I don't know what a colonoscopy is." Which is the best action for the nurse to take? 1. Explain the procedure to the client and inform the client of the risks, benefits, and treatment alternatives. 2. Inform the primary healthcare provider that the client requests additional information related to the procedure. 3. Give the client an information pamphlet about the procedure and tell the client to sign the consent after reading the pamphlet. 4. Instruct the client to sign the informed consent form. The primary healthcare provider will answer any additional questions right before the procedure is performed.
2. Correct: The primary healthcare provider performing the procedure should explain the risks and benefits, recovery time, and reasonable alternatives, as well as the consequences of refusing treatment prior to the client signing a consent form. 1. Incorrect: The nurse should explain the colonoscopy procedure and expectations to the client, but the nurse is not responsible for explaining the risks, benefits, and alternatives to treatment. This responsibility rests with the primary healthcare provider performing the procedure. 3. Incorrect: Providing an information pamphlet to the client may be beneficial, but this should never be substituted for communicating with the client. 4. Incorrect: The nurse should not allow the client to sign the consent form until the primary healthcare provider has provided all necessary information to the client.
What should the nurse monitor in a client with a fracture of the left tibia? 1. Distal pulses of the left leg 2. Distal pulses of each leg 3. Proximal sensation of each leg 4. Proximal sensation of each arm Rationale
2. Correct: The tibia is a bone in the lower leg. The nurse should monitor pulses in the distal legs. Pulses would be monitored in both legs and not just the left leg. The comparison of pulses helps to identify differences in pulse rate and quality. 1. Incorrect: No, not just the left leg. The nurse will monitor pulses on the unaffected and injured extremity. This comparison of pulses on both legs will help to identify differences in pulse rate and quality. 3. Incorrect: No, distal sensation of the affected leg would be monitored. Paresthesia (abnormal sensation such a numbness and tingling) may be reported by the client. Changes in sensation should be reported as it may be a sign of neurovascular damage. 4. Incorrect: No, monitor the distal sensation of the affected extremity. The tibia is the larger of the two bones in the leg below the knee.
A client has been taught guided imagery as a method to relieve pain. How should the nurse monitor for pain relief after completion of guided imagery by the client? 1. Take vital signs 2. Use of pain intensity scale 3. Ask client to describe the pain 4. Observe ability to perform activities of daily living
2. Correct: The use of pain intensity scales is an easy and reliable method of determining the client's pain intensity. 1. Incorrect: Although respiratory and heart rate may decrease with guided imagery and pain reduction, the most objective measure is to ask the client to rate the pain. 3. Incorrect: First, ask the client if pain is present. If present, the client should be asked to rate the pain. Once pain has been rated, the client should be asked to describe the pain. 4. Incorrect: The client may be able to perform activities of daily living and still have pain. Therefore, this would not be an accurate means of monitoring for pain relief. The nurse must deliver care in a nonjudgmental manner.
Which action by two unlicensed nursing personnel (UAPs), while moving the client back up in bed, would require intervention by the nurse? 1. Lowers the side rails closest to them. 2. Places hands under client's axilla. 3. Lowers the head of bed. 4. Raises the height of the bed.
2. Correct: This action is not appropriate and requires intervention by the nurse. This could damage the brachial plexus nerves under the axilla. Use a draw sheet to prevent this from occurring. 1. Incorrect: This is a correct action. The UAPs will need to lower the side rails closest to them to safely move the client up in bed. Not lowering the rails could result in injury to the UAPs' backs. 3. Incorrect: This action is correct. Moving the client upward with the head of the bed raised works against gravity, requires more force, and can cause back strain. 4. Incorrect: This action is appropriate and would not require intervention by the nurse. Raising the height of the bed brings the client close to the UAPs center of gravity and decreases the chance of back injury.
The nurse is caring for a primipara client at 27 weeks gestation. Which client signs and symptoms are priority at this stage of pregnancy for the nurse to tell the client to report? 1. Appropriate nutrition 2. Signs of preterm labor 3. Fetal teratogens 4. Newborn care
2. Correct: This client is entering the third trimester when the risk of preterm labor and delivery are highest. Women who are aware of the consequences of preterm birth may be more likely to take action to prevent it. Signs and symptoms of preterm labor should be recognized and reported immediately to the primary healthcare provider. 1. Incorrect: Appropriate nutrition is a learning need of the first trimester. Nurses should provide nutritional education to women who are considering pregnancy. Nutritional needs should be discussed early in the pregnancy to ensure that essential nutrients are provided and harmful foods are avoided. 3. Incorrect: Appropriate learning need of the first trimester. Ideally, prevention of exposure to harmful influences begins before conception because all major organ systems develop early in pregnancy, often before a woman realizes that she is even pregnant. 4. Incorrect: While this is an important topic for the last trimester, physiological needs have priority.
The nurse has been reinforcing the anxiety education for a client diagnosed with general anxiety disorder (GAD). Which statement by the client indicates the need for further education? 1. "I will avoid caffeine from now on." 2. "When I feel anxious I will increase my breathing." 3. "I will go for a brisk walk when I begin to feel anxious." 4. "I will keep a diary of anxiety attacks to determine what triggers them."
2. Correct: This is an incorrect statement. The client needs to slow breathing down with deep-breathing exercises. An increase in respirations can lead to respiratory alkalosis. 1. Incorrect: Caffeine can increase panic and anxiety in clients whom suffer with GAD. Caffeine is a stimulant and can produce symptoms like those of anxiety. This statement means that teaching has been effective. 3. Incorrect: Physical activities discharge excess energy in a healthful manner. Exercise produces endorphins, which promotes a sense of well-being. This statement means teaching has been effective. 4. Incorrect: Recognition of precipitating factors is the first step in teaching a person to interrupt escalation of anxiety. Also, identifying stressors promotes future change. This statement means that teaching has been effective.
A nurse is caring for a Mexican-American client post stroke. While in the client's room, a curandero visits at the request of client. What is the best action of the nurse? 1. Leave, and return once the curandero has left. 2. Reinforce client care with the client and curandero. 3. Ask the curandero to leave so that the client can be observed. 4. Explain to the client that the curandero is not a reliable healthcare option.
2. Correct: This is the best course of action for the nurse. The health and healing of a client come from many components, including spirituality, religion, folk remedies, alternative therapies, and modern medicine. Unless something is harmful to the client, it is best to incorporate all components into the care of the person. 1. Incorrect: Leaving will not allow the nurse to discuss and reinforce care of the client with all members of the healthcare team and family. This is a good time to learn about the curandero, health beliefs, etc. 3. Incorrect: The client and family have requested the curandero. Asking him to leave would be insulting. The nurse would not develop a good rapport with the client this way. 4. Incorrect: This does not take into account the client's beliefs in health, wellness, and illness. The nurse should work to incorporate folk medicine from the curandero as long as it will not harm the client. 1. Identify key words in the stem that set a priority, such as first, initially, best, priority, safest, most. These words modify what is being asked. This question requires you to put a value on each option and then place them in rank order. If you are having difficulty ranking the options, eliminate the option that you believe is most wrong among the options. 2. Identify client-centered options. The focus of the nurse should be the client. Items that test your ability to be client-centered tend to explore client feelings, identify client preferences, empower the client, provide the client choices, or in some way put emphasis on the client. The client is the priority.
The nurse is conducting a health history with a client who is 10 weeks pregnant. During the interview, the client states, "I'm not so sure I'm really happy about this pregnancy". Which response by the nurse is most appropriate? 1. Many women feel ambivalent about being pregnant. 2. Tell me more about how you are feeling. 3. Why do you feel this way? 4. It seems there is never a good time to get pregnant.
2. Correct: Use of the open ended statement provides the client an opportunity for clarification of her feelings, ideas and perceptions. 1. Incorrect: While it is true that ambivalence about pregnancy is normal, the client should be afforded the opportunity to explore the interwoven feelings of wanting and not wanting to be pregnant. 3. Incorrect: Asking "why" questions can put the client in a defensive position and is not therapeutic. 4. Incorrect: This response reflects a personal opinion and may be irrelevant for this client.
The nurse is preparing to collect a capillary blood specimen for measuring blood glucose. Which action is most likely to result in an adequate stick for the client? 1. Place the finger at heart level. 2. Warm the finger prior to the stick. 3. Keep the injector loose against the skin. 4. Place the finger above heart level.
2. Correct: Warming the finger will increase circulation to the site, thereby increasing blood flow. 1. Incorrect: The finger should be dependent to enhance blood flow to the site, so it needs to be below the level of the heart to be effective. 3. Incorrect: The injector should be placed firmly against the skin; otherwise the client may get an insufficient stick and require another stick. 4. Incorrect: The finger should be in a dependent position to increase blood flow to the site so as to prevent the need for another stick.
The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider? 1. BP 150/108 decreases to 138/86 2. Weight gain of 5 pounds (2.27 kg) in one week 3. Urinary output of 1450 mL in 12 hours 4. Apical pulse of 90/min
2. Correct: Weight gain of 5 pounds in one week is a s/s of an adverse effect of ACE inhibitor use. Weight gain is a sign of fluid retention. 1. Incorrect: This is an expected response of an ACE inhibitor. ACE inhibitors block the normal effects of renin-angiotensin-aldosterone system, thereby decreasing the blood pressure. 3. Incorrect: The urinary output is adequate and indicates good renal function and perfusion to the kidneys. 4. Incorrect: The apical pulse is normal.
Parents, reluctant to immunize their child, state "I feel that since the majority of children with whom my child interacts have been vaccinated, there is no need for my child to be immunized". What would be the best response by the nurse? 1. File a report with social services and notify the primary healthcare provider. 2. Explain that the organisms which cause disease are still prevalent in the environment and may cause illness in the child. 3. Counsel the parents that refusal to vaccinate the child may result in legal charges and possible fines. 4. Notify the school system that the child is not in compliance with immunization regulations.
2. Correct: With few exceptions (smallpox, polio), bacteria and viruses that cause disease have not been eradicated in the United States. An unvaccinated child is at risk for developing a vaccine preventable disease if exposed to the causative organism. 1. Incorrect: Unless state law requires notification of social services when a parent refuses to have a child vaccinated, no report is made. 3. Incorrect: Unless social services file neglect charges against the parents, no legal charges or fine are warranted. 4. Incorrect: The school system is responsible for verifying immunizations.
The drug nadolol is prescribed for a client with chronic stable angina. What findings would the nurse expect? 1. Increased urinary output and increased peripheral pulses 2. Decreased heart rate, decreased blood pressure, and relief of chest pain. 3. Decreased respirations, increased diastolic pressure, and relief of chest pain. 4. Decreased blood pressure, increased heart rate, and reduced coronary vasospasm.
2. Decreased heart rate, decreased blood pressure, and relief of chest pain. 2. Correct: Nadolol is a beta-blocking agent. Beat-blockers block the beta 1 adrenergic receptor cells in the heart, thereby decreasing HR, contractility and BP. These effects decrease the workload on the heart. With decreased oxygen demand (workload on heart) chest pain is relieved. Beta-blockers decrease cardiac contractility thereby decreasing cardiac output. 1. Incorrect: U/O and peripheral pulses do not increase. 3. Incorrect: Beta-blockers may indirectly decrease respirations in that when CP is relieved the respiratory rate will increase. 4. Incorrect: As stated above, beta-blockers lower BP. BP is lowered, HR is decreased NOT increased. Calcium channel blockers, not beta-blockers, are given to reduce coronary vasospasms for clients with angina.
Which signs and symptoms would the nurse expect to observe in a client who has taken prednisone for two months? Select all that apply 1. Weight loss 2. Decreased wound healing 3. Hypertension 4. Decreased facial hair 5. Moon face
2. Decreased wound healing 3. Hypertension 5.Moon face 2., 3. & 5. Correct: Decreased wound healing is a side effect with prolonged steroid use due to the immunosuppressive effects. All steroid medications, such as prednisone, can lead to sodium retention which then leads to dose related fluid retention. Hypertension is seen due to this fluid and sodium retention. Cushingoid appearance (moon face) is a side effect that is created from the abnormal redistribution of fat from prolonged steroid use. 1. Incorrect: Within one month after corticosteroid administration, weight gain is seen rather than weight loss.4. Incorrect: Facial and body hair increase with prolonged steroid use. This excessive growth of body hair, known as hirsutism, is one of the numerous potential side effects of prednisone. 1. Identify clues in the stem. Generally, the stem is short and contains only the information needed to make the question clear. A clue is the use of a word or phrase that leads you to the correct answer. The clue shows a relationship to a word or phrase in the correct answer. Clues in the stem include the type of medication (prednisone, which is a steroid) and the length of time the client has taken the medication. 2. With Select All That Apply questions, look at each option as a true/false statement. Match what is being asked in the stem with the options. If the stem is asking for a true response, then the true options should be selected.
When caring for young adult clients, which developmental tasks would the nurse expect to see? 1. Reflecting on life accomplishments. 2. Developing meaningful and intimate relationships. 3. Giving and sharing with an individual without asking what will be given or shared in return. 4. Developing sense of fulfillment by volunteering in the community. 5. Reaching out to give and to guide the next generation.
2. Developing meaningful and intimate relationships. 3. Giving and sharing with an individual without asking what will be given or shared in return. 2. & 3. Correct: In young adulthood, the developmental tasks involve intimacy versus isolation. Intimacy relates more to sharing than to sex. Intimacy produces feelings of safety, closeness, and trust. 1. Incorrect: During late adulthood, there is refection on life accomplishments. This is the maturity stage of Ego Integrity versus Despair, where there is a reflection of one's life. 4. Incorrect: During middle age, a sense of fulfillment can be found by volunteering in the community. This is part of middle age, where the adult is finding ways to support others. 5. Incorrect: This is a task of middle adulthood. The developmental task is Generativity versus Stagnation. The adult finds ways to support the next generation.
A homeless person has been admitted to the medical unit and placed on airborne precautions for suspected Pulmonary Tuberculosis (TB). The nurse will monitor for which signs and symptoms? 1. Weight gain 2. Fatigue 3. Bloody sputum 4. Diaphoresis during sleep 5. Anorexia
2. Fatigue 3. Bloody sputum 4. Diaphoresis during sleep 5. Anorexia 2., 3., 4. & 5. Correct: Feeling tired all the time or fatigue, weight loss rather than weight gain, loss of appetite, fever, coughing up blood and night sweats are the most common signs and symptoms of active TB.1. Incorrect: Weight gain is not a symptom of TB. Weight loss is a common symptom of TB due to decreased desire to eat.
What symptoms does the nurse expect to see in a client with bulimia nervosa? 1. Amenorrhea 2. Feelings of self-worth unduly influenced by weight 3. Recurrent episodes of binge eating 4. Recurrent inappropriate compensatory behavior to prevent weight gain 5. Lack of exercise
2. Feelings of self-worth unduly influenced by weight 3. Recurrent episodes of binge eating 4. Recurrent inappropriate compensatory behavior to prevent weight gain 2., 3. & 4. Correct: Diagnostic criteria for bulimia nervosa are recurrent episodes of binge eating; recurrent inappropriate compensatory behavior to prevent weight gain such as laxative, diuretic, or enema use, induced vomiting, fasting, and excessive exercise; and feeling of self-worth unduly influenced by weight. 1. Incorrect: Amenorrhea (absence of menstruation) is found in anorexia nervosa. This may be caused by increase exercise and an increase in the corticotropin releasing hormone (CRH). 5. Incorrect: Excessive exercise is found in bulimia nervosa as a means to compensate for the binge eating.
Which menu selection by the client diagnosed with cholelithiasis indicates understanding of a proper diet? 1. Fried chicken, rice and gravy, broccoli and cheese, custard pie 2. Grilled pork chops in peach sauce, baked sweet potato, sherbet 3. Oven roasted bbq ribs, baked beans, tomato slices, ice cream 4. Pasta topped with boiled shrimp and butter sauce, salad, bread pudding
2. Grilled pork chops in peach sauce, baked sweet potato, sherbet 2. Correct: In cholelithiasis, the bile becomes super saturated with cholesterol. This leads to precipitation of cholesterol which presents as gall stones. A client with cholelithiasis should avoid foods high in fat. Foods high in fat include any fried foods, cheeses, milk, custard, cream, ice cream, pies, cakes, red meats, and baked beans. 1. Incorrect: This diet of fried food is high in cholesterol. Foods high in fat should be avoided. 3. Incorrect: This meal seems to be prepared in a healthy manner with being oven roasted; however, the ribs are high in fat (cholesterol). Ice cream is also high in fat content. 4. Incorrect: Butter sauce and bread pudding are high in fat. Boiled shrimp is a seemingly healthy choice; however, butter sauce and bread pudding are high in fat content.
A client sustained a skull fracture in a motor vehicle crash. The nurse knows this client is at risk for increased intracranial pressure and, therefore, would place the client in which position? 1. Head turned to the side 2. Head of bed at 30 to 45 degrees 3. Head midline 4. Neck in neutral position 5. Left sims position
2. Head of bed at 30 to 45 degrees 3. Head midline 4. Neck in neutral position 2., 3. & 4. Correct: Keeping the head elevated, midline, and in a neutral position promotes venous return from the head, preventing a rise in intracranial pressure. 1. Incorrect: Turning the head to the side may obstruct venous outflow, causing an increase in pressure. 5. Incorrect: The sims position is side lying and therefore, the head would be turned to the side. Turning the head to the side may obstruct venous outflow, causing an increase in pressure.
The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action? 1. Is confused and disoriented. 2. Is scared and lonely and grabs the nurse's hand for comfort. 3. Would like to talk with the nurse. 4. Would like to reminisce with the nurse.
2. Is scared and lonely and grabs the nurse's hand for comfort. 2. Correct: This elderly client with no visitors is most likely scared and lonely. The touch of the nurse's hand is comforting for the client. 1. Incorrect: There is no indication of confusion or disorientation. 3. Incorrect: Grabbing the nurse's hand indicates more than just a desire to talk. This is indicative of needing comfort and personal touch. 4. Incorrect: There is no indication of a desire to reminisce from the information in the question.
Which finding in a client 5 hours post open cholecystectomy would require the nurse to notify the surgeon? 1. Absent bowel sounds. 2. Jackson Pratt drain has 90 mL of blood. 3. Urinary output of 200 mL since return from surgery. 4. Client report of abdominal pain of 8/10.
2. Jackson Pratt drain has 90 mL of blood. 2. Correct. An open cholecystectomy will usually result in the placement of a drain. The drainage should be green (bile). Blood is a problem and needs immediate intervention. 1. Incorrect. It is not uncommon for bowel sounds to be absent after abdominal surgery. This client is only 5 hours postoperative. The client needs to remain NPO until bowel sounds return. 3. Incorrect. The urine output is greater than 30 mL/hour which is an acceptable amount. There is not a baseline to compare to, so greater than 30mL/hour is not abnormal. 4. Incorrect. Pain for this client is an expected finding 5 hours after surgery.
A client diagnosed with schizophrenia tells the nurse, "God is going to heal me. I do not need medication." Which response by the nurse would best promote compliance with the prescribed medication regimen? 1. Yes, I believe that God will heal you. 2. Many people of faith believe that one way God works to heal is through medication. 3. We are talking about taking your medications right now. 4. What if God does not heal you and you should have taken the medication?
2. Many people of faith believe that one way God works to heal is through medication. 2. Correct: This allows the client to keep the belief that God will heal but will do it through the medication. This promotes compliance with the prescribed medication regimen. 1. Incorrect: The nurse does not know if God will heal the client and does not promote compliance with the prescribed medication regimen. The nurse is responding in the nontherapeutic technique of agreeing. 3. Incorrect: This approach may make the client angry, which will close the communication between the client and the nurse. It also does not promote compliance with the prescribed medication regimen. The nurse is responding in the nontherapeutic technique of rejecting. 4. Incorrect: This approach is argumentative and puts the client on the defense, which will close the communication between the client and the nurse.
A client who must use crutches, is being assisted by the nurse while performing a three-point gait. What information should the nurse provide? 1. Move right crutch forward, then left foot. Next move left crutch forward, then right foot. 2. Move both crutches forward without bearing weight on the affected leg, then move the unaffected leg forward. 3. Move left crutch and right foot forward together, then move the right crutch and left foot forward together. 4. Move both crutches ahead together, then lift body weight by the arms and swing both legs to the crutches.
2. Move both crutches forward without bearing weight on the affected leg, then move the unaffected leg forward 2. Correct: This method is correct for the three-point gait. Client has to bear weight on the unaffected foot and both crutches. The affected leg does not touch the ground. 1. Incorrect: This is the four-point alternate gait. This type of gait is used commonly when both legs are weakened. 3. Incorrect: This is the two-point alternate gait, used when both limbs can only support partial weight bearing or weight bearing as tolerated. Two point requires at least partial weight bearing on each foot. 4. Incorrect: This is the swing-to gait. The crutches are moved forward together but lower extremities are swung beyond the crutches. This gait is indicated for individuals with limited use of lower extremities and trunk instability.
A prescription is written to give MSO4 8 mg intramuscularly now. What should the nurse do next? 1. Check the order prescription prior to sending it to the pharmacy. 2. Notify the primary healthcare provider for clarification of the prescription. 3. Notify the pharmacy that the prescription is needed immediately. 4. Gather the supplies needed for an injection.
2. Notify the primary healthcare provider for clarification of the prescription. 2. Correct: The nurse should notify the primary healthcare provider, because MSO4 is an abbreviation that is on the Joint Commission's "do not use" list. MSO4 can mean morphine sulfate or magnesium sulfate. Notifying the primary healthcare provider to clarify the prescription will prevent a medication error from occurring.1. Incorrect: The prescription should not be sent to the pharmacy until after it is clarified with the primary healthcare provider.3. Incorrect: MSO4 is not an approved abbreviation. Before notifying the pharmacy, make sure you know what the prescription is for.4. Incorrect: You might be making a medication error if you assume you know what you are giving.
The nurse sees that the new medication noted in a recent prescription is on the client's list of allergies. What actions should the nurse take to ensure client safety? 1. Document the medication with times and doses to be given, then administer the medication as prescribed. 2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Stop the medication on the client's medication administration record. 4. Check the client's allergy band against the list of client allergies documented in the medical record. 5. Call the pharmacy to see if the medication needs to be changed.
2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Stop the medication on the client's medication administration record. 4. Check the client's allergy band against the list of client allergies documented in the medical record. 2., 3. & 4. Correct: Administration of a medication that the client is allergic to could result in harm to the client. The primary healthcare provider should be notified immediately of a medication prescription that conflicts with the client's list of medication allergies. The medication should be discontinued on the medication administration record, and the client's allergy band checked against the list of allergies documented in the medication record for accuracy. All of these actions place the nurse in the role of client advocate and ensure the client's safety. 1. Incorrect: No, this medication could cause harm to the client. The client is allergic to this medication. This will not ensure client safety.5. Incorrect: No, the primary healthcare provider, not the pharmacy, should be notified for medication changes. The primary healthcare provider is responsible for prescribing the medication.
A client has been prescribed chlorpromazine for the treatment of schizophrenia. The nurse makes afternoon rounds and finds the client's temperature to be 104.7º F/40.4º C. The client has extreme muscle rigidity, and the vital signs have been fluctuating for the last four hours. What should the nurse do first? 1. Provide a tepid sponge bath. 2. Notify the primary healthcare provider immediately. 3. Administer an antipyretic immediately. 4. Administer the chlorpromazine as prescribed.
2. Notify the primary healthcare provider immediately. 2. Correct: These symptoms are consistent with neuroleptic malignant syndrome (NMS), which is an adverse reaction to antipsychotic drugs. The symptoms of NMS are fever, altered mental state, muscle rigidity, and autonomic dysfunction. This is a medical emergency, and immediate action should be taken. 1. Incorrect: The symptoms indicate a medical emergency and the need for an immediate response. The nurse should notify the primary healthcare provider first. 3. Incorrect: The high temperature should be assessed, but the extreme muscle rigidity and fluctuating vitals are a medical emergency. The client needs further immediate attention. 4. Incorrect: The nurse should not administer another dose of the antipsychotic medication due to the client's presenting symptoms. Usually, the primary healthcare provider would discontinue the medication immediately. There are some situations in which the nurse must notify the primary healthcare provider, and the test taker should not automatically eliminate this as a possible correct option. The test taker must decide if any of the other options will help correct a life-threatening complication. If it doesn't, then the nurse must notify the primary healthcare provider.
A client in the long-term care facility has been prescribed hydrochlorothiazide. What side effect should the nurse expect to observe? 1. Increased potassium levels 2. Orthostatic hypotension 3. Increase in weight 4. Decreased urine output
2. Orthostatic hypotension 2. Correct: The client may experience drop in blood pressure upon standing, particularly when the medication is first prescribed. The nurse should tell the client to change positions slowly. 1. Incorrect: Hydrochlorothiazide lowers potassium levels, and a potassium supplement may also be prescribed. 3. Incorrect: Since fluid loss results from diuretic use, the client is likely to see a weight loss.4. Incorrect: This diuretic may result in increased diuresis.
After applying oxygen using bi-nasal prongs to a client who is hypoxic, the nurse should implement which action? 1. Have the client take slow deep breaths in through the mouth and out through the nose. 2. Post signs on the client's door and in the client's room indicating that oxygen is in use . 3. Apply vaseline petroleum to nares and gauze around the oxygen tubing at the client's ears. 4. Encourage the client to hyperextend the neck, take a few deep breaths and cough.
2. Post signs on the client's door and in the client's room indicating that oxygen is in use . 2. Correct: This is an oxygen therapy safety precaution that the nurse should implement after applying oxygen. It is also the only correct and safe option in the question. 1. Incorrect: The bi-nasal prongs would mean that the oxygen is going in through the nose. Breathing deeply through the mouth and out through the nose would not increase oxygenation for a client having hypoxia and would disrupt the flow of oxygen through the nose. 3. Incorrect: The nurse should avoid using petroleum products where oxygen is in use because they are flammable. 4. Incorrect: These client actions have nothing to do with oxygen administration and would cause more distress to the client with hypoxia.
Which finding should a nurse expect when collecting data on a healthy 65 year old client?
2. Presbyopia 2. Correct: As the lens becomes less flexible, the near point of focus gets further away. This condition, presbyopia, usually begins in the 40s. Reading glasses to magnify objects are required. 1. Incorrect: Anomia (cannot name objects) is an early sign of Alzheimer's disease. Anomia is not a normal observation of a 65 year old client. 3. Incorrect: Blood pressure (BP) reading of 156/88 is not within normal BP range. The normal blood pressure range for the 65 to 79 year old is 140/90 or less. 4. Incorrect: Apraxia means client cannot perform purposeful movement. We would not expect to observe this in a healthy 65 year old.
The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair? 1. Shaving the hair with a razor. 2. Removing the hair with clippers. 3. Applying shaving cream prior to shaving with a razor. 4. Applying hair removal cream. 5. Trimming the hair with scissors.
2. Removing the hair with clippers. 4. Applying hair removal cream. 2. & 4. Correct: Not removing the hair at all is preferred, but if this is not an option, the use of clippers or a hair removal cream may be used to prevent trauma to the skin before surgery. 1. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 3. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 5. Incorrect: Trimming the hair causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery.
The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate to the nurse that the client should not be advanced to the next level? 1. Facial flushing 2. Report of chest heaviness 3. Heart rate increase of 10 beats/min. 4. Systolic blood pressure increase of 10 mm Hg
2. Report of chest heaviness . Correct: Onset of chest pain indicates myocardial ischemia which can be life threatening. The client should not be advanced to the next level of activity.
A client has an acute onset of fever, chills and RUQ pain. The vital signs are: Temp 99.8°F (37.7°C), HR 132, RR 34, B/P 142/82. Arterial blood gas (ABG) results are: pH 7.53, PaCO2 30, HCO3 22. The nurse determines that this client is in what acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
2. Respiratory alkalosis 2. Correct: This client has a severe infection. Hyperventilation due to such issues as anxiety, pain, shock, severe infection, fever, and liver failure can lead to respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal. 1. Incorrect: With hyperventilation, the client will not have respiratory acidosis because the CO2 is being blown off, not retained. The pH is high (7.53), indicating alkalosis. 3. Incorrect: This acid-base imbalance is not metabolic related. The bicarb is within normal range and the pH is high, indicating alkalosis. 4. Incorrect: This acid-base imbalance is not metabolic related. The increased respiratory rate is the problem and the bicarb is within normal range. The CO2 is low, indicating that it is respiratory related.
The nurse is planning to administer oxycodone with acetaminophen for pain control as prescribed by the healthcare provider. As the nurse enters the room, he checks the client's arm band. The nurse notes that the client is allergic to acetaminophen.What should the nurse do? 1. Give the medication as prescribed. 2. Return to the nurse's station and notify healthcare provider of allergy. 3. Ask the client if she is allergic to acetylsalicylic acid 4. Ask the client to rate her pain on a scale of 1 to 10.
2. Return to the nurse's station and notify healthcare provider of allergy. 2. Correct: Oxycodone and acetaminophen cannot be given if the client is allergic to acetominophen. Call the primary healthcare provider for another medication. 1. Incorrect: The client is allergic to acetaminophen ; therefore the medication should not be given. 3. Incorrect: The drug does not contain acetylsalicylic acid 4. Incorrect: Pain assessment is important; however, there is a more crucial action needed here.
The nurse is preparing to administer oxycodone with acetaminophen for pain control as prescribed by the healthcare provider. The nurse checks the client's arm band and notes that the client is allergic to acetaminophen. What action should the nurse take? 1. Give the medication as prescribed. 2. Return to the nurse's station and notify healthcare provider of allergy. 3. Ask the client about allergies to acetylsalicylic acid 4. Ask client to rate pain on a scale of 1 to 10.
2. Return to the nurse's station and notify healthcare provider of allergy. 2. Correct: Oxycodone and acetaminophen cannot be given if the client is allergic to acetaminophen. Call the primary healthcare provider for another medication.
What is the best position for the nurse to place a client for a thoracentesis of the right lung?
2. Sitting on side of bed and leaning over the bedside table For maximum accessibility for the thoracentesis to be performed, the client should be positioned in a sitting position on the side of the bed, leaning over a bedside table, with arms propped on pillows and the feet supported. If the client is not able to sit up, the alternative position would be to lie on the unaffected side with the head of bed elevated 45 degrees.
The nurse is caring for a client in the outpatient clinic. Based on the lab values, which foods should the nurse recommend that the client avoid? 1. Bananas 2. Spinach 3. Grilled ham and cheese sandwich 4. Black bean soup
2. Spinach 2. Correct: Normal Calcium is 8.6 - 10.2. Foods high in calcium should be avoided such as spinach, green beans, waxed beans, chocolate, and beets. 1. Incorrect: This is a normal potassium, so the client can have bananas. 3. Incorrect: This is a normal sodium, the client needs more sodium. Ham and cheese is high in sodium. 4. Incorrect: This is a normal magnesium, so this is an acceptable food item.
After a thoracotomy, which intervention by the nurse would enable the client to cough most effectively? 1. Allow 4 hours of rest between deep breathing and coughing exercises. 2. Splint the incision during deep breathing and coughing exercises. 3. Have the client drink a glass of water before coughing. 4. Perform percussion and vibration every 2 hours.
2. Splint the incision during deep breathing and coughing exercises. 2. Correct: Holding a pillow firmly over the incision (splinting) when deep breathing and coughing supports the incision and surrounding tissues and reduces pain. This helps so much with the ability to control the pain and produce an effective cough. 1. Incorrect: They have to cough more frequently than every 4 hours. Encourage every 2 hours. Deep breathing and coughing expands the lungs and helps with expectoration of mucous and secretions that accumulate in the airways after surgery. 3. Incorrect: It takes longer than a few minutes to liquefy secretions, and if the stomach is full, vomiting may occur. 4. Incorrect: A thoracotomy is a surgical incision into the chest wall. After the thoracotomy, we don't want to clap and vibrate the incision.
A Hispanic mother and her child visit the primary healthcare provider's office due to a fever that the child has been having for two or three days. Upon entering the room, the nurse immediately asks what is happening with the child and begins to check the temperature. Which response is likely from the mother? 1. Accepts the treatment of the nurse and think that it is appropriate. 2. Takes offense to the abrupt nature of the treatment. 3. Thinks that the nurse is busy and needs to rush. 4. Thinks that the nurse is very efficient.
2. Takes offense to the abrupt nature of the treatment. 2. Correct: The family is likely to be offended by the abrupt manner of the nurse. The Hispanic culture is present time oriented and desire attention and interaction. It would not be relevant that the nurse may be busy. To overlook this cultural variation is rude and does not treat the mother with dignity. 1. Incorrect: The nurse is not demonstrating cultural sensitivity. The family is not likely to accept this abrupt approach due to the cultural differences related to time and the desire for more genuine personal interaction. The Hispanic mother may be offended by the direct interviewing approach of the nurse. 3. Incorrect: The mother is likely to be offended with this abrupt response. Efficiency is not a priority as much as attentiveness and care, particularly with an ill child. The cultural frame of reference is present time in which other events should not interfere with the present situation. Expectations for genuine, personal interaction are also a part of the culture. 4. Incorrect: The mother is likely to interpret the nurse's actions as rude. The American culture is future time oriented and desires efficiency; the Hispanic culture is more interested in relationships and what is occurring at the present time.
A nurse is caring for a client in an outpatient clinic. The client lost her husband of 51 years three months ago. Which findings support that the client is experiencing normal grief reactions rather than clinical depression? Select all that apply 1. The client is experiencing anhedonia. 2. The client states, "I have good and bad days." 3. The client smiles at the nurse while talking about her grandchild. 4. The client has a persistent state of dysphoria. 5. The client states, "I am having fewer crying spells."
2. The client states, "I have good and bad days." 3. The client smiles at the nurse while talking about her grandchild. 5. The client states, "I am having fewer crying spells." 2., 3. & 5. Correct: A client going through a normal grieving process will experience a mixture of good and bad days. The client can enjoy their family. The client experiences moments of pleasure and cries less. 1. Incorrect: Anhedonia is the inability to experience pleasure, and is a symptom of clinical depression. This would not be a positive sign of normal grieving in a client. 4. Incorrect: Dysphoria is a mood of general dissatisfaction, restlessness, depression, and anxiety. This is often seen in clinical depression. 1. A strategy you can draw on to help answer priority questions is to refer to basic guiding theories that are part of the foundation of nursing: Maslow's Hierarchy of Needs, The Nursing Process, Kubler-Ross's Theory of Death and Dying, Teaching/Learning Theory, Therapeutic Communication. 2. With Select All That Apply questions, look at each option as a true/false statement. Match what is being asked in the stem with the options. If the stem is asking for a true response, then the true options should be selecte
After discontinuing a peripheral IV line, it is most important for the nurse to record which information? 1. How the client tolerated the procedure. 2. The length and intactness of the catheter tip. 3. The amount of fluid left in the IV solution container. 4. That a dressing was applied to the insertion site.
2. The length and intactness of the catheter tip. 2. Correct: This is the most important information that needs to be documented. This information would be important in determining if a potential safety issue/complication could occur as a result of the IV line being removed or a portion of the catheter tip breaking off before removal. 1. Incorrect: This is not the most important information that needs to be documented. There are no client safety issues with charting the client's tolerance of the procedure. 3. Incorrect: This would be charted so the intake and output could be calculated. This is not the most important data that needs to be documented related to the removal of the IV line. 4. Incorrect: This would need to be documented because a dressing is applied to the insertion site after removal. However, this is not the most important data that would need to be documented after this procedure.
The nurse is reinforcing teaching to the family of a diabetic client about treatment of hypoglycemia at home. Which guidelines should be given to the family of the client? 1. It is not necessary to treat mild hypoglycemia indicated by irritability. 2. Treat a mild episode with 10-15 grams of carbohydrate. 3. The client should consume 12 ounces of regular cola. 4. The client should consume 2 cups of orange juice without added sugar.
2. Treat a mild episode with 10-15 grams of carbohydrate. 2. Correct. 10-15 grams of carbohydrate should raise the blood sugar 40 - 50 mg/dL. Then the family can check the blood sugar and repeat the carbohydrate if necessary. 1. Incorrect. The blood sugar level may drop rapidly and result in changes in level of consciousness. The family should be taught to always worry about hypoglycemia. 3. Incorrect. Twelve ounces of cola would raise the blood sugar too high. Twelve ounces of cola contains about 39 grams of carbohydrates. 4. Incorrect. Two cups of orange juice would equal approximately 52 grams of carbohydrates. This would raise the blood sugar too high.
The nurse has identified that a client receiving oxygen has nasal irritation. Which client action would require the nurse to intervene? 1. Application of gauze padding beneath the tubing. 2. Use of petroleum jelly on the nares and cheeks. 3. Mouth and nose care every 4 hours as needed. 4. Placement of the oxygen mask straps well above the ears.
2. Use of petroleum jelly on the nares and cheeks. Rationale 2. Correct: Petroleum jelly is a combustible substance. It should not be used with oxygen therapy. 1. Incorrect: The nurse would not need to intervene if the client applied gauze padding beneath the tubing to protect the skin. This is acceptable. 3. Incorrect: The nurse would not need to intervene if the client provided mouth and nose care every four hours as needed to protect the skin and mucus membranes. This is acceptable. 4. Incorrect: The nurse would not need to intervene if the client placed the oxygen mask straps well above the client's ears to protect the skin. This is acceptable.
The nurse is providing care to a client who is infected with Clostridium difficile (C. diff). Which interventions will lessen the likelihood of transmission? Select all that apply 1. Wash hands with alcohol-based hand rub. 2. Use soap and water to perform hand hygiene 3. Remove gown after exiting the room. 4. Change gloves before touching non-contaminated articles. 5. Place client in room with client who has the same microorganism.
2. Use soap and water to perform hand hygiene4. Change gloves before touching non-contaminated articles. 5. Place client in room with client who has the same microorganism 2., 4., & 5. Correct: Using soap and water is the only acceptable way to perform hand hygiene since this is more effective against the microorganism than are alcohol scrubs. Care should be taken not to transfer microorganisms from contaminated gloves to non-contaminated areas. If a private room is unavailable, clients who are infected with the same microorganism may be placed in the same room.
A client reports difficulty sleeping since starting a new job. The nurse's data collection identifies that the client is also working after hours from home. Which guidelines are appropriate to promote sleep in this client? 1. Vary bed times to determine time best to promote sleep. 2. Use the bedroom for only sleep. 3. Schedule meal times earlier in the evening. 4. Avoid caffeine in the evening. 5. Use a white noise machine to help lull to sleep.
2. Use the bedroom for only sleep. 3. Schedule meal times earlier in the evening. 4. Avoid caffeine in the evening. 5. Use a white noise machine to help lull to sleep. 2., 3., 4. & 5. Correct: The client should associate bed with sleep, not work. Eating late in the evening may interfere with sleep, especially if a heavy meal. Caffeine late in the evening may increase alertness and interfere with sleep. Many people respond positively to white noise. Music, on the other hand, may make it more difficult to sleep.1. Incorrect: The same time for bed each day will establish a routine and make sleep easier. Varying sleep times will disturb the client's sleep cycle and circadian rhythm. This would not be helpful to facilitate sleep.
Which meal option should the client diagnosed with gout select? 1. Tuna salad on bed of lettuce, apple slices, coffee 2. Vegetable soup, whole wheat toast, skim milk 3. Roast beef with gravy sandwich, baked chips, diet coke 4. Spinach salad with chick peas and asparagus, apple, tea
2. Vegetable soup, whole wheat toast, skim milk 2. Correct: Gout is manifested by pain and inflammation that occurs when too much uric acid crystallizes and deposits in the joints. This is a good choice as it is low in purine and fat. Purines are broken down into uric acid. A diet rich in purines can raise uric acid levels. Meat and seafood increase the risk of gout. Dairy products may lower risk for gout. 1. Incorrect: The client should not eat tuna, which is high in purine. 3. Incorrect: Gravy is a high purine food and should be avoided. Also avoid artificial sweeteners. 4. Incorrect: Although spinach and asparagus can be consumed in moderation, they still contain purines, so it is not as good of a choice as the vegetable soup, toast and skim milk.
The nurse is cleaning and dressing a foot ulcer of a diabetic client. Which actions are appropriate? 1. Uses a clean basin and washcloth to clean the ulcer. 2. Wears sterile gloves to clean the ulcer. 3. Cleans ulcer with normal saline. 4. Warms saline bottle in microwave for 1 minute. 5. Cleans ulcer in a full circle, beginning in the center and working toward the outside.
2. Wears sterile gloves to clean the ulcer. 3. Cleans ulcer with normal saline. 5. Cleans ulcer in a full circle, beginning in the center and working toward the outside. 2., 3., & 5. Correct: The nurse needs to wear sterile gloves when cleaning the wound. Normal saline solution is the preferred cleansing agent because, as an isotonic solution, it doesn't interfere with the normal healing process. Gently clean the wound in a full or half circle, beginning in the center and working toward the outside. 1. Incorrect: Sterile supplies should be used with this procedure because the client is at risk for infection and gangrene. Gauze and salve should be used instead of a wash cloth. 4. Incorrect: Before you start, make sure the cleansing solution is at room temperature. Do not heat in the microwave. It could scald the client! efore we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are cleaning, dressing, foot ulcer, and diabetic client. Each option stands alone with the question. After reviewing the question, look at each option and identify if it is true or false. Remember client safety is always a priority. Remember that the dressing change is for a client with diabetes. So let's look at the options. Option 1 is false. Because the client has diabetes, the client is at risk for infection and gangrene. The nurse needs to wear sterile gloves when cleaning the wound. Sterile supplies should be used with this procedure. Gauze and prescribed cleaning solution should be used instead of a wash cloth. Option 2 is true. The nurse needs to wear sterile gloves when cleaning the wound. The sterile gloves are to protect the client from acquiring an infection in the foot ulcer. Option 3 is true. Normal saline solution is the preferred cleansing agent because as an isotonic solution, it doesn't interfere with the normal healing process. Option 4 is false. Remember...Client safety is always a priority. It is important for the cleansing solution to be at room temperature. Do not heat in the microwave. It could burn the client! Option 5 is true. Gently clean the wound in a full or half circle, beginning in the center and working toward the outside. A wound is to be cleaned from the least contaminated area such as from the wound to the surrounding skin.
The client has suicidal ideations with a vague plan for suicide. The nurse, who is reinforcing teaching to the family about caring for the client at home, should emphasize which points? 1. Family members are responsible for preventing future suicidal attempts. 2. When the client stops talking about suicide, the risk has increased. 3. Warning signs, even if indirect, are generally present prior to a suicide attempt. 4. One suicide attempt increases the chance of future suicide attempts. 5. Report sudden behavioral changes.
2. When the client stops talking about suicide, the risk has increased. 3. Warning signs, even if indirect, are generally present prior to a suicide attempt. 4. One suicide attempt increases the chance of future suicide attempts. 5. Report sudden behavioral changes. 2., 3., 4. & 5. Correct: A common myth is that the person who doesn't talk about suicide will not attempt it, but this may be a warning sign that the person has a well thought out plan. Warning signs generally exist but may not be recognized by others until after the suicide or attempted suicide. Once a person has made a suicidal attempt, the chances increase that they will attempt it again at a later time. Sudden behavioral changes can signal suicidal intentions, especially if that is the primary focus of their thoughts and feelings. 1. Incorrect: Families should be encouraged to create a safe environment and recognize warning signs, but they may not be able to stop a suicide. Families, in spite of their best efforts, should not be put into a position of guilt if the client is successful with suicide.
A client received a severe burn to the right hand. When dressing the wound, it is important for the nurse to do what? 1. Apply a wet to dry dressing for debridement. 2. Wrap each digit individually to prevent webbing. 3. Open blisters to allow drainage prior to dressing. 4. Allow the client to do as much of the dressing change as possible.
2. Wrap each digit individually to prevent webbing. 2. Correct: Each finger must be wrapped individually to prevent webbing. If not done appropriately, the client could develop contractures and lose functional use of the hand. 1. Incorrect: No debridement is needed if dressing changes are done as ordered. 3. Incorrect: Blisters should be left intact so as not to create an open wound and an environment for infection to easily start. 4. Incorrect: This is not appropriate at this time and is not the most important option for the nurse to do to properly care for the wound and enhance healing.
The nurse is caring for a couple who just experienced a stillbirth. The client's spouse says to the nurse, "I am tired and need to go home. I will probably take the baby's bassinet back to the store while I am gone since we just started to buy furniture for the nursery." Which of the following responses would be most appropriate for the nurse to make? 1."Your wife needs you here with her." 2."There will be plenty of time to return the bassinet." 3."I can help you talk with your wife about the nursery." 4."You need to get some rest instead of working."
2."There will be plenty of time to return the bassinet."
Which tasks would be appropriate for the LPN/LVN to assign to an unlicensed assistive personnel (UAP)? 1. Ask the client diagnosed with dementia memory-testing questions. 2. Collect the urinary output hourly on the client with renal disease. 3. Demonstrate pursed lipped breathing to the client who has emphysema. 4. Give a tepid sponge bath to the client who has a fever. 5. Assess oxygen saturation on a client experiencing angina.
2., & 4. Correct: The UAP can obtain hourly urine output on clients and can give a tepid sponge bath to a client. The LPN/VN must know what tasks can be assigned to the UAP. 1. Incorrect: The nurse cannot delegate assessment, evaluation, or teaching. This would be an assessment function for the RN to perform. 3. Incorrect: The UAP cannot teach. Demonstration is a method of teaching. This is an RN task. 5. Incorrect: The UAP cannot assess the client experiencing angina. This is an RN task.
What characteristics would indicate to the nurse that a client is experiencing false labor? 1. Cervical dilation noted. 2. Contractions decrease with sleep. 3. Bloody show noted. 4. Contraction intensity increases with walking. 5. Contractions felt in abdomen above umbilicus.
2., & 5. Correct: False labor or Braxton Hicks contractions are mild, irregular in frequency, and intermittent; decrease in frequency, duration, and intensity with walking or position changes; and often stop with sleep or comfort measures such as oral hydration or emptying of the bladder. False labor contractions are typically felt as a tightening or pulling sensation of the top of the uterus. In contrast, true labor contractions are more commonly felt in the lower back and gradually sweep around to the lower abdomen. 1. Incorrect: True labor includes progressive effacement and dilation. False labor does not significantly change the cervix in effacement or dilation. 3. Incorrect: Effacement and dilation cause expulsion of the mucus plug, rupturing the small cervical capillaries in the process. False labor does not cause effacement or dilation; therefore, there will be no bloody show. 4. Incorrect: True labor contractions tend to increase with walking. False labor contractions do not change or may decrease with activity (such as walking).
The nurse sees that the new medication noted in a recent medication order is on the client's list of allergies. In the role of client advocate, what actions should the nurse take to ensure client safety? You answered this question Correctly 1. Document the medication with times and doses to be given, then administer the medication as ordered. 2. Notify the primary healthcare provider immediately that the medication ordered is on the client's list of medication allergies. 3. Discontinue the medication on the client's medication administration record. 4. Check the client's allergy band against the list of client allergies documented in the medical record. 5. Administer the medication and monitor closely for side effects.
2., 3. & 4. Correct: Administration of a medication that the client is allergic to could result in harm to the client. The primary healthcare provider should be notified immediately of a medication order that conflicts with the client's list of medication allergies. The medication should be discontinued on the medication administration record, and the client's allergy band checked against the list of allergies documented in the medication record for accuracy. 1. Incorrect: No, if administered, this medication could result in harm to the client. 5. Incorrect: No, if administered, this medication could result in harm to the client.
Which statements should a nurse make when reinforcing education to a client about advance directives? 1. Used as guidelines for client treatment should the client's family deem them necessary. 2. Legally binding document. 3. Should be documented in the client's medical record as to whether or not the client has an advance directive. 4. Specifies a client's wishes for healthcare treatment should the client become incapacitated. 5. Allows the client's spouse to make end-of-life decisions.
2., 3. & 4. Correct: Advance directives are legally binding documents. Documentation is required in the medical record as to whether an advance directive exists. If one exists, a copy should be placed in the medical record. The document is prepared by the client detailing wishes for treatment should the client become unable to make informed healthcare decisions. 1. Incorrect: The family's wishes for treatment of the client do not take the place of or negate the client's advance directive.5. Incorrect: The spouse's wishes for treatment of the client do not take the place of or negate the client's advance directive.
The nurse is participating in a health promotion program. What points about fire safety in the home should be included? 1. Smoking in bed is acceptable if you are not sleepy. 2. Keep matches and lighters away from children by storing them in a locked cabinet. 3. Install carbon monoxide smoke alarms and test monthly. 4. You may leave Christmas lights lit all night as long as the tree is artificial. 5. Have a planned route of exit and place where all family will meet.
2., 3. & 5. Correct: Keeping matches and lighters away from children by storing them in a locked cabinet can prevent fire-related deaths. Carbon monoxide smoke alarms will alarm for smoke and carbon monoxide which is an odorless gas than can kill quickly. Alarms should be tested every month and repaired or replaced immediately if malfunction occurs. A planned exit from the building and place to meet helps identify that all of the family is out of the building. 1. Incorrect: Smoking in bed is never recommended. 4. Incorrect: Lit Christmas lights should be turned off when no one is home and when people go to bed for the night. It does not matter whether the tree is real or artificial.
The parents of a 2 year old child, diagnosed with autism spectrum disorder (ASD), ask the nurse what led the primary healthcare provider to diagnose this disorder for their child. What behaviors will the nurse indicate as signs of ASD? 1. Delusions 2. Twisting 3. Preoccupation with objects 4. Delayed speech 5. Changes are easily tolerated.
2., 3. & 4. Correct: All are behaviors seen in children with ASD. Additionally, they often do not form interpersonal relationships with others or play well with others. They are usually not socially responsive with eye contact and facial expressions. The language characteristics may be delayed, totally absent, echolalia, unusual vocalizations, immature grammatical structures, or idiosyncratic words. Their motor behaviors may include poor coordination, tiptoe walking, peculiar hand movements such as flapping and clapping, and stereotypical body movements of rocking, dipping, swaying, or spinning. 1. Incorrect: Delusions and hallucinations are not characteristic of ASD. These are seen in the schizophrenic client. 5. Incorrect: Changes are met with resistance with ASD. Changes in daily routines or in the child's environment can cause catastrophic reactions. First, think about the child with ASD. Then determine which of the options are behaviors expected with ASD. Option 1: No. Delusions are a symptom of many mental disorders, including schizophrenia, but are not a behavior indicating a sign of ASD. Option 2: Yes! Twisting is a behavior pattern of ASD. The child performs repetitive movements and moves constantly. Option 3: Good one! The child with ASD is fascinated with the details of an object. The objects may include the wheels on a toy truck. Option 4: Yes, correct. The child with ASD has communication impairments which include delayed speech and they may lose language skills. They might say "I" when they mean "you" or vice versa. Option 5: Oh, no! Even minor changes in routine can be very upsetting! Children with ASD thrive on routine, and any change in routine may lead to a tantrum.
As a member of the emergency preparedness planning team at the hospital, which actions should the nurse encourage the team to implement? 1. Developing a response plan for every potential disaster. 2. Providing education to employees on the response plan. 3. Practicing the response plan on a regular basis. 4. Evaluating the hospital's level of preparedness. 5. Assigning all client care duties to the Nursing Supervisor.
2., 3. & 4. Correct: Developing a single response plan, educating individuals to the specifics of the response plan, and practicing the plan and evaluating the facility's level of preparedness are effective means of implementing emergency preparedness. The basic principles of emergency preparedness are the same for all types of disasters. Only the response interventions vary to address the specific needs of the situation. 1. Incorrect: One good response plan, not multiple plans, should be developed. This will ensure adequate understanding of the plan and decrease confusion of roles that could occur with multiple plans. There is no feasible way for the hospital to have a response plan for every potential disaster. 5. Incorrect: All client care duties cannot safely be assigned to one caregiver. The nursing supervisor needs the help of other staff to carry out nursing care for the clients in the hospital. Before we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are emergency preparedness planning team, actions, and implement. Each option stands alone with the question. So let's look at the answers Remember client safety is always a priority. Option 1 Do you think you can develop a plan for every potential disaster? False Different types of disasters have been identified such as natural disasters, severe weather, recent outbreaks, radiation emergencies, chemical emergencies, and bioterrorism. One general response plan should be developed to ensure adequate understanding of the disaster plan. There is no feasible way for the hospital to have a response plan for every potential disaster. The overall disaster plan can be modified for specific intervention for different types of disasters. Option 2 Education is a key component of a response plan. True Educating individuals to the specifics of the response plan is an effective means of implementing emergency preparedness. All members of the emergency preparedness team need to be familiar with their roles and the roles of the other team members. Also the specific interventions for the implementation of the plan. Option 3 Practice, Practice, Practice The members of the team must know how to implement the emergency plan. True A disaster is not a planned event. The members of the emergency team must be able to implement the emergency plan when ever it is needed. Option 4 The last stage of a disaster plan is to evaluate the preparedness of the hospital's emergency plan. True The evaluation of the emergency preparedness plan should be a continual component of the plan to ensure incorporating updated principals of emergency preparedness. Option 5 Is it a safe practice for the nursing supervisor to compete all the client duties during the emergency? False All client care duties cannot safely be assigned to one caregiver. The nursing supervisor needs the help of other staff to carry out nursing care for the clients in the hospital.
Upon admission to a hospital, a client asks a nurse about the Health Insurance Portability and Accountability Act (HIPAA). When teaching the client about HIPAA regulations, which provisions should the nurse include? Select all that apply 1. HIPAA guarantees individual access to health insurance. 2. Clients have the right to request a copy of their personal health information. 3. Health care agencies must keep a client's personal health information confidential. 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., 3. & 4. Correct: HIPAA is federal legislation enacted to protect a client's health information and privacy. Clients have the right to request a copy of their personal health information. Health care facilities must keep all client information confidential per federal law. A client's personal health information may be released to obtain insurance benefits for the client. 1. Incorrect: HIPAA does not guarantee access to health insurance. 5. Incorrect: Only staff members who are providing care directly to the client have legal access to a client's personal health information.
Prior to administering medications, the nurse must identify the client using which identifiers? 1. Room number 2. Date of birth 3. Identification band 4. Client correctly states name 5. Visitor stating client's name
2., 3. & 4. Correct: The client's date of birth and the client's identification band can be used as the two identifiers per Joint Commission standards. The client may also state their name. Two identifiers must be used. 1. Incorrect: The client's room number or visitor statement is not considered a client identifier. 5. Incorrect: The client's room number or visitor statement is not considered a client identifier.
Which strategies should the nurse suggest for the prevention of constipation in older clients? Select all that apply 1. Mild laxatives are appropriate if a bowel movement is not achieved daily. 2. Emphasize the importance of establishing a bowel routine. 3. Introduce abdominal toning exercises. 4. Encourage foods low in bulk. 5. Drink 6-8 glasses of water per day.
2., 3. & 5. Correct: It is important to establish a bowel routine and respond to the urge to defecate. An exercise regimen, increased ambulation, and abdominal muscle toning will increase muscle strength and help propel colon contents. Tone abdominal muscles by contracting 4 times daily and do leg to chest lifts 10-20 times per day. A diet high in fiber is also helpful. Laxatives should be used as a last resort and should not be taken regularly. Over time, laxatives can desensitize the bowel and worsen constipation. Adequate fluid intake is needed in management of constipation. 1. Incorrect: A daily bowel movement is not necessary as long as the bowels move regularly. 4. Incorrect: A diet high in bulk and fiber is needed rather than low in bulk.
The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. Which signs/symptoms are an indication to the nurse that treatment has not been effective? 1. Diuresis 2. Dyspnea on exertion 3. Persistent cough 4. Warm, dry skin 5. Heart rate irregular at 118/min 6. Alert and oriented
2., 3. & 5. Correct: When the cardiac output decreases, renal perfusion decreases, which leads to decreased urine output and fluid retention. This leads to difficulty breathing. Tachycardiac and rhythm irregularity are signs of fluid volume excess (FVE) and decreased output. Persistent cough, wheezing, and pink blood tinged sputum are all signs that the client is still sick. 1. Incorrect: Diuresis is what we want, which indicates that the treatment for FVE is effective. 4. Incorrect: Indication of improved cardiac output. 6. Incorrect: Indication of improved cardiac output.
Post thyroidectomy, the nurse monitors the client for complications by performing which action? 1. Perform blood glucose monitoring every 6 hours 2. Check for a positive Chvostek's 3. Monitor swallowing reflex 4. Monitor neck dressings for change in fit and comfort 5. Administer desmopressin per nasal spray for urinary output (UOP) greater than 200 mL/hr
2., 3., & 4. Correct: A positive Chvostek's and Trousseau's signs are indicative of tetany as a result of low calcium levels. This can occur when one or more of the parathyroids are accidently removed when the thyroid is removed. A weak, raspy voice, swallowing difficulty, and impaired respiratory status can be caused by nerve injury. Change in fit and comfort of the dressing can indicate possible neck swelling, which can affect the airway.1. Incorrect: A possible complication of a thyroidectomy is to remove one or more parathyroid glands. The parathyroids' action is to regulate the serum calcium levels. The parathyroid does not regulate the blood glucose levels. 5. Incorrect: The action of desmopressin is to increase the reabsorption of water in the kidney. A decrease in vasopressin (antidiuretic hormone) is not a complication of a thyroidectomy.
What should the nurse include when reinforcing teaching to a female client prescribed doxycycline for the treatment of acne? 1. Take this medication with food to maximize absorption. 2. Use a non-hormone method of birth control while taking this medication. 3. Wear protective clothing when outside. 4. Drink plenty of fluids while taking this medication. 5. Iron and calcium supplements can be taken with this medication.
2., 3., & 4. Correct: Doxycycline is a tetracycline antibiotic. Doxycycline can make birth control pills less effective. A non-hormone method of birth control (such as a condom, diaphragm, and/or spermicide) should be used to prevent pregnancy while using doxycycline. Avoid exposure to sunlight or tanning beds. Doxycycline can make you sunburn more easily. Wear protective clothing and use sunscreen (SPF 30 or higher) when outdoors. Take doxycycline with a full glass of water. Drink plenty of liquids while taking this medicine. 1. Incorrect: Take on an empty stomach to maximize absorption, although it may not be tolerated unless administered with food. 5. Incorrect: Do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking doxycycline. Absorption will be altered. For instance, iron can bind to doxycycline in the gastrointestinal tract, which may prevent their absorption into the bloodstream and possibly reduce their effectiveness. To avoid or minimize the interaction, iron containing medications and doxycycline should preferably be taken at least three hours apart in most cases.
A nurse is caring for a client who delivered a baby vaginally four hours ago. What signs and symptoms of postpartum hemorrhage should the nurse report to the primary healthcare provider? 1. Two blood clots the size of a dime. 2. Perineal pad saturation in 10 minutes. 3. Constant trickling of bright red blood from vagina. 4. Urinary output of 20 mL per hour. 5. Firm fundus
2., 3., & 4. Correct: Lochia should not exceed an amount that is needed to partially saturate four to eight peripads daily, which is considered a moderate amount. Perineal pad saturation in 15 minutes or less is considered excessive and is reason for immediate concern. Saturation of a peripad in one hour is considered heavy. Also, trickling of bright red blood from the vagina can indicate hemorrhage and is often a result of cervical or vaginal lacerations. Bright red blood indicates active bleeding. Oliguria is a sign of fluid volume deficit. As blood volume goes down, renal perfusion decreases and urinary output (UOP) decreases. The kidneys are also attempting to hold on to what little fluid volume is left. 1. Incorrect: A few small clots would be considered normal and occur due to pooling of the blood in the vagina. Passage of numerous or large blood clots (larger than a quarter) would indicate a problem. 5. Incorrect: We worry about a boggy uterus. Uterine atony is a major cause of postpartum hemorrhage. The fundus feels firm as the uterus and uterine muscles contract to reduce the blood loss.
Which intervention should be made 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. Position the catheter below the level of the bladder. 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., 3., & 4. Correct: Observing urine flow is important as is notation of color, odor and any sediment or blood in the urine. Stagnant urine is prone to infection. Tubing should be free of kinks and without tension on the tubing. Gravity drainage should be maintained at all times. The drainage receptacle should be below the level of the bladder to allow for gravity drainage, 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 to promote the urine flowing from the bladder to the collection bag. 5. Incorrect: There is no need to perform frequent 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 is diagnosed with seizures. Which nursing interventions should the nurse implement? 1. Have an unlicensed assistive personnel stay with the client. 2. Pad the side rails with blankets. 3. Place the bed in low position. 4. Keep a padded tongue blade at the bedside. 5. Instruct client to call for help to ambulate.
2., 3., & 5. Correct: Place a call light within reach, put the client close to the nurses' station, and pad the side rails. Have client call for assistance to BR, maintain bedrest until seizures are controlled, or ambulate with assistance to protect from injury. These interventions will help to protect the client from injury. 1. Incorrect: It is not necessary to have someone stay with this client at all times. After implementing the safety issues and transferring the client closer to the nurses' station, the client can stay alone. 4. Incorrect: Do not stick anything in a client's mouth during a seizure. A padded tongue blade could cause injury.
The nurse has determined that a client is at risk for experiencing dumping syndrome after having had a partial gastrectomy. Which teachings about this condition should the nurse reinforce with this client? 1. "After eating you should assume a right side lying position for 30 minutes." 2. "Drink liquids an hour after consuming meals." 3. "Eat three meals rather than six smaller meals." 4. "Carbohydrates should be decreased in the diet." 5. "The primary healthcare provider may prescribe a multivitamin with iron."
2., 4. & 5. Correct: Fluid intake with meals is discouraged: instead, fluids may be consumed up to one hour before or one hour after mealtime. Carbohydrates increase gastric motility which this client does not need. Therefore the diet should be low in carbs. Supplementary vitamins and iron may be recommended when the client has dumping syndrome. 1. Incorrect: The best position to delay stomach emptying is low Fowler's during mealtime and for at least 20-30 minutes after the meal. 3. Incorrect: The client should eat smaller, but more frequent meals.
The nurse is reinforcing teaching with a client, recovering from a myocardial infarction (MI), about the prescribed diet of low sodium, low saturated fat, and low cholesterol. Which statements, if made by the client, would indicate to the nurse that instructions have been successful? Select all that apply 1. "I should drink fruit juices rather than soft drinks." 2. "A good snack to eat would be unsalted popcorn." 3. "When making homemade tomato sauce, I should not add salt." 4. "I should use 2% milk when cooking." 5. "There is no restriction on egg white consumption."
2., 3., & 5. Correct: Popcorn without salt is a healthy snack choice for clients on a low sodium, low saturated fat, and low cholesterol diet. Homemade tomato sauce can be made without adding salt. The American Heart Association no longer makes recommendations on how many egg yolks to eat or not to eat. A good, general guideline is to eat no more than 1 egg yolk a day, up to 5 total a week. There is no restriction on egg whites (including those used in baking and cooking). 1. Incorrect: Consume whole vegetables and fruits rather than fruit juices. Fruit juices have added sugars and lack fiber. 4. Incorrect: Use skim or 1% milk rather than 2% or whole milk. Clients who have had an MI are advanced to a low sodium, low saturated fat, and low cholesterol diet. Fat intake should be about 30% of calories, with most coming from mono and polyunsaturated fats. Red meat, egg yolks, and whole milk products are major sources of saturated fat and cholesterol and should be reduced or eliminated. Clients with CAD are encouraged to take omega 3 fatty acid supplements. Recommended daily intake of cholesterol is less than 200 mg/day. Popcorn without salt is a healthy snack choice for clients on a low sodium, low saturated fat, and low cholesterol diet. Popcorn is a food coming from whole grain corn, which is encouraged on this diet. Other foods made of whole wheat, oats/oatmeal, rye, barley, brown rice and wild rice are good choices. Homemade tomato sauce can be made without adding salt. The American Heart Association no longer makes recommendations on how many egg yolks to eat or not to eat. A good, general guideline is to eat no more than 1 egg yolk a day, up to 5 total a week. There is no restriction on egg whites (including those used in baking and cooking).
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., 3., 4. & 5. Correct: 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. 1. Incorrect: Feedings should be diluted and the infusion rate should be decreased, not increased. This prevents hyperosmolar diarrhea. 6. Incorrect: Feedings should be administered at room temperature. Extremes in temperatures can stimulate peristalsis.
What nursing interventions should the nurse implement for a client with Addison's disease? 1. Administer potassium supplements as prescribed. 2. Assist the client to select foods high in sodium. 3. Administer Fludrocortisone as prescribed. 4. Monitor intake and output. 5. Record daily weight.
2., 3., 4. & 5. Correct: The client with Addison's disease needs sodium due to low levels of aldosterone. Fludrocortisone is a mineralocorticoid that the client will need to take for life. I&O and daily weights are needed to monitor fluid status. 1. Incorrect: Clients with Addison's disease lose sodium and retain potassium, so this client does not need potassium.
The nurse is identifying home safety issues to prevent injury for a visually impaired elderly client who also has diabetes. Which findings are important for the nurse to include in this process? 1. Episodes of mild anxiety 2. Rugs secured to the floor 3. Adequate lighting 4. Functional eye glasses 5. Client is wearing well-fitting closed toe shoes
2., 3., 4. & 5. Correct: Throw rugs may cause falls, as the client may trip. Diabetes may also impact sensation and the client may be unaware that there is a rug in place. Adequate lighting is important so that the client does not bump into furniture or miss a step when navigating stairs. The visually impaired client needs functioning glasses to maximize sight and safety within the home. Diabetic clients do not need open toed shoes, as injury may occur to the foot and the client may not actually be aware of it. Also, wearing sandals is a risk to the person who is visually impaired and elderly, as the shoe may come off unexpectedly. 1. Incorrect. While depression is common and may result in self harm for elderly clients, anxiety is not likely to result in injury. Data should be gathered regarding depression when caring for elderly clients. Before we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are home assessment, preventing injury, visually impaired elderly client, and diabetes. Each option stands alone with the question. So let's look at the options... Remember client safety is always a priority. 1. This is false because mild anxiety is not likely to result in injury. Symptoms of anxiety may include a feeling of overwhelming fear, trembling or a surge of doom and gloom. 2. Rugs that are secured to the floor can cause the client to trip or slip. True. The rugs should not move when stepped on or have elevated ends that may cause the client to trip. 3 During the night, falls can be reduced by having adequate lighting throughout the home. True. This client has been identified as a high risk for falls. The home fall prevention education program identifies practical interventions to reduce the possibility of the client falling. All obstacles such as furniture cannot be removed but, a night light will make the obstacles more visible at night. This will assist in reducing the client's possibility of falling over them. This is a safety intervention. 4. The visually impaired client needs functioning glasses to maximize sight and safety within the home. True. 5. The client should wear well-fitting closed toes shoes. True. Home fall prevention should emphasize that the client should always wear properly fitting shoes that have nonskid protection. The diabetic client should wear closed toe shoes to prevent injury to the toes. This safety intervention will decrease their risk for falls.
The nurse is educating a group of teenagers who have expressed an interest in using electronic cigarettes (e-cigarettes). What information about electronic cigarettes should the nurse include? 1. Electronic cigarettes are a safe alternative to smoking. 2. It is difficult for consumers to know what electronic cigarette products contain. 3. Nicotine can harm adolescent brain development. 4. Electronic cigarette aerosol generally contains fewer toxic chemicals than the smoke from regular cigarettes. 5. Defective electronic cigarette batteries can cause fires and explosions.
2., 3., 4., & 5. Correct: It is difficult for consumers to know what e-cigarette products contain. For example, some e-cigarettes marketed as containing zero percent nicotine have been found to contain nicotine. Nicotine can harm adolescent brain development, which continues into the early to mid-20s. E-cigarette aerosol generally contains fewer toxic chemicals than the deadly mix of 7,000 chemicals in smoke from regular cigarettes. However, e-cigarette aerosol is not harmless. It can contain harmful and potentially harmful substances, including nicotine, heavy metals like lead, volatile organic compounds, and cancer-causing agents. E-cigarettes can cause unintended injuries. Defective e-cigarette batteries have caused fires and explosions, some of which have resulted in serious injuries. In addition, acute nicotine exposure can be toxic. Children and adults have been poisoned by swallowing, breathing, or absorbing e-cigarette liquid. 1. Incorrect: Teens need to be aware that electronic cigarettes are not a safe alternative to smoking. Nicotine, which is highly addictive, and other harmful chemicals are still absorbed through the lungs and into the body with the use of electronic cigarettes. Electronic cigarettes (e-cigarettes) are battery-powered devices that can deliver nicotine and flavorings to the user in the form of an aerosol. E-cigarettes come in many shapes and sizes. E-cigarettes are not safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products. While e-cigarettes may have the potential to help people quit smoking, scientists still have a lot to learn about whether e-cigarettes are actually effective for quitting smoking. If you've never smoked or used other tobacco products or e-cigarettes, don't start. E-cigarettes are known by many different names. They are sometimes called "e-cigs," "e-hookahs," "mods," "vape pens," "vapes," "tank systems," and "electronic nicotine delivery systems." Some e-cigarettes are made to look like regular cigarettes, cigars, or pipes. Some resemble pens, USB sticks, and other everyday items. E-cigarettes produce an aerosol by heating a liquid that usually contains nicotine—the addictive drug in regular cigarettes, cigars, and other tobacco products—flavorings, and other chemicals that help to make the aerosol. Users inhale this aerosol into their lungs. Bystanders can also breathe in this aerosol when the user exhales into the air. E-cigarettes can be used to deliver marijuana and other drugs. E-cigarette aerosol generally contains fewer toxic chemicals than the deadly mix of 7,000 chemicals in smoke from regular cigarettes. However, e-cigarette aerosol is not harmless. It can contain harmful and potentially harmful substances, including nicotine, heavy metals like lead, volatile organic compounds, and cancer-causing agents. Most e-cigarettes contain nicotine, which has known health effects. Nicotine is highly addictive and is toxic to developing fetuses. Nicotine can harm adolescent brain development, which continues into the early to mid-20s. A recent CDC study found that many adults are using e-cigarettes in an attempt to quit smoking. However, most adult e-cigarette users do not stop smoking cigarettes and are instead continuing to use both products ("dual use"). Because smoking even a few cigarettes a day can be dangerous, quitting smoking completely is very important to protect your health. JUUL, a new form of e-cigarette, became available for sale in the United States in 2015. As of December 2017, JUUL is the top-selling e-cigarette brand in the United States. News outlets and social media sites report widespread use of JUUL by students in schools, including in classrooms and bathrooms. All JUUL e-cigarettes have a high level of nicotine. According to the manufacturer, a single JUUL pod contains as much nicotine as a pack of 20 regular cigarettes.
The nurse is reinforcing teaching to a client who has been prescribed fluticasone/salmeterol. What points are important for the client to understand? 1. Swallow the capsule when having an acute asthma episode. 2. Rinse mouth after medication administration to decrease infection. 3. Take this medication every day, even on days when breathing fine. 4. Administer by inhalation device twice daily. 5. Carry a rescue inhaler, such as albuterol, when leaving home.
2., 3., 4., & 5. Correct: This medication contains a steroid which can increase the risk of oropharyngeal fungal infections. Rinsing will reduce this risk of infection and will also decrease mouth and throat irritation. The medication should be taken every day as directed, even on days when the client feels they are breathing better. This is a preventative medication, not a rescue medication. This medication is administered by an inhaler. It is not given orally. A rescue inhaler, such as albuterol, is needed when the client leaves home. Fluticasone/salmeterol is not a rescue inhaler, but is for long term control and maintenance treatment for the prevention of bronchospasm and airway inflammation associated with asthma, chronic bronchitis, and COPD. 1. Incorrect: This medication must be taken with an inhaler.
A LPN/VN is caring for a client who reports a pain level of 8 on a numeric scale of 1-10. The LPN/VN reports the client's pain level to the RN and administers pain medication as prescribed. Which actions should a nurse take to advocate for this client? 1. Notify the primary healthcare provider. 2. Ensure that bed side rails are raised and locked. 3. Administer naloxone within 30 minutes. 4. Advise the client to call for assistance before getting out of bed. 5. Monitor the client's pain level after administering medication.
2., 4. & 5. Correct: To advocate for this client, the LPN/VN should ensure that client's bed side rails are up and in a locked position and should advise the client to call for assistance before getting out of bed, because pain medication increases the client's risk for falls. The LPN/VN should also monitor the client's pain level after an appropriate amount of time to ensure that the client's pain is under control. 1. Incorrect: The nurse does not need to notify the primary healthcare provider because the LPN/VN reported the client's pain to the RN and had a prescription for pain medication to administer to the client. 3. Incorrect: Naloxone is an opioid antagonist. The question does not identify any adverse symptoms following the administration of the pain medication.
Which tasks would be appropriate for the LPN/LVN to assign to an unlicensed assistive personnel (UAP)? 1. Monitor client for signs of skin breakdown. 2. Take client's vital signs after ambulating. 3. Apply bacitracin ointment to right forearm. 4. Obtain a stool specimen. 5. Determine what activities the client can do independently.
2., 4. Correct. These tasks are within the scope of practice for the UAP. The LPN/VN must know the tasks that are appropriate for the UAP in order to assign tasks. 1. Incorrect. The UAP cannot assess, evaluate, or plan care for the client. The LPN/VN knows that checking for signs of skin breakdown requires data collection through monitoring. 3. Incorrect. The UAP cannot administer medication. Bacitracin ointment is a medication. 5. Incorrect. The UAP cannot assess, evaluate, or plan care for the client. This task involves data collection and evaluation.
The nurse is participating in an education program for a group of clients on how to decrease the risk of developing recurrent renal calculi. What topics should be included when the nurse reinforces the teaching? 1. High-purine foods to consume 2. Diuretic use to prevent urinary stasis 3. Strain urine with each void 4. Maintain a daily water intake of at least 2 liters 5. Foods low in calcium
2., 4., & 5. Correct: Diuretics are often used to prevent urinary stasis and further calculus formation. Daily fluid intake should be 2-3 liters per day to ensure good renal function. Most stones are calcium stones, so decrease calcium in the diet to reduce the chance of calcium stones. 1. Incorrect: Clients with a history of renal calculi should be on a low-purine diet. When purines are digested, they produce a waste product called uric acid, which needs to be decreased in clients with renal calculi and with history of gout. 3. Incorrect: Straining is only necessary for the client with acute signs/symptoms of renal calculi. This action will not decrease the risk of developing renal calculi as the stem of the question asked. Before we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are educate, decrease risk, and renal calculi. Each option stands alone with the question. After reviewing the question, look at each option and identify if it is true or false. Remember, client safety is always a priority. This question is focusing on decreasing risk factors for renal calculi. So let's look at the options. Option 1 is false. Don't consume a high-purine diet. Foods high in purines are organ meats, Other high purine meats will include bacon, beef, pork, and lamb. Also beer, anchovies, sardines, herring, mackerel, and scallops are high in purine. Clients with a history of renal calculi should be on a low-purine diet. When purines are digested, they produce a waste product called uric acid, which needs to be decreased in clients with renal calculi. Straining is only necessary for the client with acute signs/symptoms of renal calculi. Option 2 is true. Diuretics are often used to prevent urinary stasis and further calculus formation. Thiazides decrease calcium excretion into the urine. Option 3 is false. Unless the client has been diagnosed with a renal calculi, there is no reason to strain the urine. Straining is only necessary for the client with acute signs/symptoms of renal calculi. Option 4 is true. When the client drinks at least 2 liters of water per day the client is also producing more urine. This process continues to flush the kidneys and decreases the chance of renal calculi forming. Option 5 is true. Most stones are calcium stones, so decreasing the calcium in the diet will decrease the risk of developing renal calculi.
What interventions should the nurse initiate to keep the airway free of secretions in a client with pneumonia? 1. Obtain results of ABG's and report abnormal findings. 2. Increase oral intake to at least 2000 mL/day. 3. Administer a cough suppressant medication. 4. Reinforce teaching to client on incentive spirometry. 5. Perform percussion to affected area.
2., 4., & 5. Correct: Liquefy secretions by increasing oral intake to at least eight, 8 ounce glasses of liquid/day unless fluid restrictions are required. Incentive spirometry helps keep alveoli open and prevents further pneumonia and atelectasis. Prescribed percussion can assist with loosening secretions for expectoration. 1. Incorrect: This does not get rid of secretions. This monitors respiratory effectiveness. 3. Incorrect: The nurse knows that the client needs to expectorate the sputum to remove bacteria or prevent bacterial growth. If the cough is suppressed, the sputum will remain in the lungs, providing a medium for bacterial growth.
A nurse is discussing with several unlicensed assistive personnel (UAP) about a dietary prescription for clear liquids. Which selections by the UAP indicate to the nurse an understanding of a clear liquid diet? 1. Vanilla custard 2. Lemon jello 3. Tomato juice 4. Sprite 5. Banana popsicle
2., 4., & 5. Correct: These are considered clear liquids. You can see through them. The banana popsicle and lemon jello in a liquid state can be seen through. 1. Incorrect: This would be on a full liquid diet. A full liquid diet allows clear liquids along with thin hot cereals, strained cream soups, juices, milkshakes, custard, pudding and liquid nutritional supplements. 3. Incorrect: This would be on a full liquid diet. A full liquid diet allows clear liquids along with thin hot cereals, strained cream soups, juices, milkshakes, custard, pudding and liquid nutritional supplements.
What symptoms would the nurse anticipate in a client with a calcium level of 3.2 mg/dL (0.80 mmol/L)? 1. Slowed deep tendon reflexes 2. Muscle rigidity and cramping 3. Hypoactive bowel sounds 4. Positive Chvostek's sign 5. Seizures 6. Laryngospasms
2., 4., 5., & 6. Correct: Normal serum calcium is 8.7 - 10.3 mg/dL (2.18 - 2.58 mmol/L). The client with a calcium level of 3.2 mg/dL (0.80 mmol/L) is hypocalcemic. With hypocalcemia, the muscle tone is rigid and tight. Therefore, the client may report muscle cramping. A hallmark sign of hypocalcemia is a positive Chvostek's sign, which is a twitching of facial muscles following tapping in the area of the cheekbone that is indicative of hyperirritability. The client may be at risk of having seizures due to the neuromuscular irritability. Prolonged contraction of the respiratory and laryngeal muscles causes laryngospasm and stridor and may result in cyanosis. 1. Incorrect: With hypocalcemia, the deep tendon reflexes are increased, not decreased. 3. Incorrect: The client with hypocalcemia tends to have increased gastric motility, resulting in hyperactive (not hypoactive) bowel sounds. In addition, abdominal cramping and diarrhea are common with hypocalcemia.
Which clients would be appropriate for the LPN/VN to be assigned by the charge nurse? 1. Client admitted with exacerbation of asthma. 2. Client needing oral antibiotics for a diagnosis of gastroenteritis. 3. Client 4 hours post lobectomy. 4. Client with terminal cancer refusing pain medication. 5. Client with arthritis who needs scheduled pain medication around the clock. 6. Client who has a chronic graft versus host disease.
2., 5, & 6. Correct. The LPN scope of practice includes caring for clients with chronic and stable health problems. These clients are stable. 1. Incorrect. The LPN should not care for an unstable client. This client is having an exacerbation of asthma which would make the client unstable and require ongoing assessment, evaluation and teaching. 3. Incorrect. This client is unstable and requires ongoing assessment, evaluation and teaching. A lobectomy is removal of part of the lung which is a complicated procedure. This is not a client who had a routine surgery which the LPN could care for. 4. Incorrect. This client is unstable and requires ongoing assessment, evaluation and teaching.
Which assignments would be most appropriate for the LPN/VN to accept from the RN? 1. Six year old with new onset diabetes. 2. Ten year old with pneumonia admitted two days ago. 3. Three month old admitted with severe dehydration. 4. Four year old admitted for developmental studies. 5. Twelve year old with post op wound infection taking oral antibiotics.
2.,4. & 5. Correct: The best assignments for the LPN/VN would be the child with pneumonia admitted two days ago and the child admitted for developmental studies. The twelve year old with post op wound infection taking oral antibiotics is also stable. 1. Incorrect: The diabetic requires much teaching and supervision. This is an unstable client that should not be assigned to an LPN/VN. 3. Incorrect: The child with dehydration will require close intravenous fluid (IVF) monitoring, assessment and evaluation of condition. This client is unstable and should not be assigned to an LPN/VN.
The nurse is talking with a parent of a 4-month-old infant. The parent is concerned that the infant may have been exposed to measles. The nurse's response should be based on an understanding that the infant 1.may have passive immunity for rubeola (measles) based on the mother's immune status 1. may have passive immunity for rubeola (measles) based on the mother's immune status 2.needs to be isolated from other children for 4 to 5 days 3.needs to receive immune globulin to prevent rubeola (measles) 4.may need to have blood tests completed to determine whether exposure occurred
3
the nurse in a rehabilitation facility is caring for a client who had a right knee arthroplasty 8 days ago and has been diagnosed with pneumonia is being tranferred to an acute care facility, it will be essential for the nurse to communicate in the transfer report that: 1.the discharge to home is anticipated for the client after 1 more week of physical therapy 2.the client lives in a ranch that requires climbing 2 stairs to get into the house 3.the most recent focused data collection reveals bilateral crakles(rales)ausculated in the clients lungs 4.the clients spouse will be visiting the client at the hospital later today after leaving work
3
The nurse is collecting data from a client with Guillian Barre, the client is experiencing paralysis and paresthesia of the lower extremities, respiratory rate of 18.Which actions should the nurse take? 1. Massage the client's legs every 2 hours 2. Pad the side rails 3. Monitor respiratory rate 4. elevate the head of the bed at 30 degrees
3,4
A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my 3 week old baby. I don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at home." What would be the nurse's best response? 1. "You are experiencing maternity blues, which will go away on its own." 2. "You are just tired. Tell your husband that you need his help." 3. "Come to the clinic now so that we can help you." 4. "Have you thought about getting a family member to help with the baby?"
3. "Come to the clinic now so that we can help you." 3. Correct: This client is exhibiting signs of postpartum psychosis. Post partum psychosis is characterized by depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily functions. There is a lack of interest in or rejection of the baby, or a morbid fear that the baby may be harmed. Risks of suicide and infanticide should not be overlooked. 1. Incorrect: The nurse is diagnosing the client with maternity blues, which consists of tearfulness, despondency, anxiety and subjectivity with impaired concentration. 2. Incorrect: This ignores a potentially life-threatening problem. The client is not just tired. 4. Incorrect: This ignores a potentially life-threatening problem. Assume the worse. Think about the safety of mom and baby.
Which statement would demonstrate to the nurse the highest risk for suicide or self-directed injury? 1. "I can't do anything right anymore." 2. "I am not sure what to do anymore." 3. "I just cannot take this loneliness anymore." 4. "No one cares about me."
3. "I just cannot take this loneliness anymore." 3. Correct: This statement indicates that the person cannot tolerate the current situation. The client is at risk for harm self. 1. Incorrect: The client has a negative outlook about self. This statement indicates low self-esteem. The client is not exhibiting suicidal tendencies. 2. Incorrect: The client is having difficulty making choices. This statement indicates indecisiveness, which is a symptom of depression. Indecisiveness is not a risk for suicide or self-directed injury. 4. Incorrect: This statement indicates possible social isolation and low self-esteem. The client may be physically separated from people or have the perception of being isolated from others. The client does not exhibit a loss of hope that is connected with suicide.
The nurse has been assisting a client to achieve relaxation using deep breathing exercises. What statement by the client requires follow up? 1. "I can perform deep breathing exercises anywhere and at any time that I feel tension and anxiety." 2. "I should sit or lie in a comfortable position, making sure my back is straight." 3. "I will inhale slowly and deeply through my mouth and expand my chest." 4. "After inhaling, I will hold my breath for a few seconds before exhaling."
3. "I will inhale slowly and deeply through my mouth and expand my chest." 3. Correct: The proper method is to inhale slowly and deeply through the nose and allow the abdomen to expand. The chest should be moving only slightly. This statement is incorrect and requires followup.1. Incorrect: Yes, deep breathing exercises can be done anywhere and anytime. This is a true statement. No followup is needed. 2. Incorrect: Yes, this is correct positioning. A true statement that needs no followup. 4. Incorrect: After inhaling, hold breath for a few seconds and exhale. This is a true statement that needs no followup.
A client calls the clinic to ask the nurse if it would be okay to take the herbal medication kava-kava to help reduce anxiety. What is the nurse's best response? 1. "Why do you want to take kava-kava?" 2. "I really doubt your primary healthcare provider will approve you taking kava-kava." 3. "Kava-kava can cause liver damage, so we need to consult your healthcare provider." 4. "Do not take Kava-kava for more than a year without a primary healthcare provider's supervision."
3. "Kava-kava can cause liver damage, so we need to consult your healthcare provider." 3. Correct: Kava-kava can cause liver damage. It is recommended that if if taking kava-kava the client should be under the direct supervision of a primary healthcare provider. 1. Incorrect: The client has already answered that: anxiety. This question will put the client on the defensive. This is an example of the nontherapeutic communication technique of asking for explanations. 2. Incorrect: Judgmental response. This will put the client on the defensive. This is an example of the nontherapeutic communication technique of an aggressive response. 4. Incorrect: You should not take this drug for longer than 3 months without a primary healthcare provider's supervision. There have been recent reports that kava-kava causes liver damage.
The spouse of a sedated client asks the nurse about the client's test results. The client does not have a healthcare proxy or durable power of attorney. How should the nurse respond? 1. "I can't give you those results. You need to ask the primary healthcare provider for this information." 2. "Those test results are confidential, but since you are the spouse, I can give them to you." 3. "The health information of all clients is confidential and protected by law, so I cannot release the data without the client's consent." 4. "I'll ask the client if I can give you the results, since only a light sedative was used."
3. "The health information of all clients is confidential and protected by law, so I cannot release the data without the client's consent." 3. Correct: Each client's health information is confidential and protected by law. The nurse should inform the client's spouse of this fact, and explain the rationale for health information confidentiality. Family members are often offended or angry upon learning that health information cannot be released to them without the client's consent, but healthcare employees are bound by law to confidentiality. 1. Incorrect: The spouse is not automatically able to receive personal health information about the client.The client has to list the spouse as a person who can receive personal health information. The healthcare employees, including primary healthcare providers, are bound by law to keep health information confidential unless the client has provided consent for the information to be released. 2. Incorrect: Healthcare employees, including primary healthcare providers, are bound by law to keep health information confidential unless the client has provided consent for the information to be released. 4. Incorrect: A client who has received sedative medications cannot give legal consent, as these medications alter a client's level of consciousness and impair the ability to make informed decisions.
A nurse is caring for a client who has chest pain. Which statement made by the client leads the nurse to suspect angina versus a myocardial infarction? 1. "I became dizzy when I stood up." 2. "I was nauseated and started vomiting." 3. "The pain started on my walk and stopped after I sat down." 4. "The pain began with a migraine and progressed to numbness in my left arm."
3. "The pain started on my walk and stopped after I sat down." 3. Correct: Brought on by exercise and stopped with rest! Hallmark of angina. 1. Incorrect: Orthostatic hypotension-not definitive for either. 2. Incorrect: No, think MI or GI not Angina. 4. Incorrect: Not picture of Angina or MI-but Migraine.
aPTT (activated partial thromboplastin time)
A typical aPTT value is 30 to 40 seconds. If you get the test because you're taking heparin, you'd want your PTT results to be more like 120 to 140 seconds, and your aPTT to be 60 to 80 seconds. If your number is higher than normal, it could mean several things, from a bleeding disorder to liver disease
A frightened client comes to the nurses' station during the night and reports hearing the voice of the devil speaking to them. Which response by the nurse is priority? 1. "Could you have overheard the staff talking at the desk?" 2. "I will get you some medication for anxiety." 3. "What did the voice tell you? " 4. "You do not have to worry about this. You are safe."
3. "What did the voice tell you? " "RationaleStrategies 3. Correct: The most important thing the nurse needs to find out is what the voice was telling the client. This is a safety issue. The nurse needs to know if the voice was telling the client to harm themselves or others. 1. Incorrect: In this question, this is not the priority response. This is voicing doubt and also presenting reality. This response could come later in the interaction. 2. Incorrect: This is changing the subject, which is non-therapeutic. The nurse needs to do something prior to giving medicine. 4. Incorrect: This is giving reassurance, which can be a non-therapeutic response. However, it could be used later in the interaction if the nurse finds out the client is safe. This statement does not address the voice heard by the client.
Which response by the nurse is appropriate when admitting a 5 year old child who is crying and hugging a stuffed animal? 1. "Hello, I am your nurse. I am going to show you to your room." 2. "Don't cry. Let's go to the playroom where you can meet other children." 3. "You are upset. I see you have your stuffed animal." 4. "Can I hold your stuffed animal? Then, would you like to put your stuffed animal in the bed?"
3. "You are upset. I see you have your stuffed animal." 3. Correct: These statements acknowledge the child's feelings and changes focus. 1. Incorrect: This response does not acknowledge the child's feelings. 2. Incorrect: This response does not alleviate fear. 4. Incorrect: Closed-ended questions are not helpful in getting a child to express fear. Option 1 is false. Introducing yourself and giving directions are not acknowledging the child's feelings and are an attempt to control the child. Option 2 is false. Fear and anxiety will not be alleviated by trying to divert the child by going to the playroom. Option 3 is true. By telling the child they are likely afraid, the nurse is acknowledging the child's feelings. By referring to the child's stuffed animal, the focus is on a familiar object of security. Option 4 is false. This is a closed-ended question by asking yes or no. Because of the child's fear and anxiety, the likely response will be "no."
A client states, "I feel so useless! I know my family thinks I am". What would be the best response for the nurse to make? 1. "Everyone gets down in the dumps at times. I feel that way myself sometimes". 2. "No one in your family feels that way". 3. "You must be very upset. Tell me what you are feeling right now". 4. "Why do you feel this way"?
3. "You must be very upset. Tell me what you are feeling right now". 3. Correct: This statement acknowledges the client's discomfort and conveys empathy and understanding. 1. Incorrect: This is an example of belittling feelings that have been expressed by the client. The nurse may cause the client to feel insignificant or unimportant. When one is experiencing discomfort, it is no relief to hear that others are or have been in similar situations. 2. Incorrect: Attempting to defend someone does not change the client's feelings and may cause the client to think the nurse is taking sides against the client. 4. Incorrect: Asking the client to provide the reasons for thoughts, feelings, behavior, and events can be intimidating and implies that the client must defend his or her behavior or feelings.
A busy LPN instructs an unlicensed assistive personnel (UAP) to obtain daily weights on a client. The LPN provides initial direction for the task, monitors that the task is successfully completed, reviews the results of the daily weight, and reports the results to the RN. Which action has the LPN taken? 1. Failed to supervise the actions of the UAP. 2. Improperly assigned a client care task. 3. Appropriately assigned a client care task. 4. Supervised the performance of a client care task. 5. Functioned outside of the LPN scope of practice.
3. & 4. Correct: The LPN appropriately assigned the performance of a client care task. The LPN appropriately supervised the performance of a client care task. 1. Incorrect: The LPN appropriately supervised the actions of the UAP. 2. Incorrect: The LPN appropriately assigned the task to the UAP. 5. Incorrect: It is within the scope of practice for the LPN to assign daily weights to a UAP if the UAP has been properly trained to carry out the assigned task and is supervised. Identify opposites in options. When opposites appear, you need to give them serious consideration. One of them will be the correct answer, or they both can be eliminated from consideration.
The nurse is discussing information on adolescent obesity with parents of high-school students. What statement by the nurse is most comprehensive regarding obesity among teens? 1. Obesity among teens is often accompanied by psychologic issues like poor self-esteem. 2. Weight issues among teens are often due to excess eating out of boredom or stress. 3. Adolescent obesity is usually an inability to recognize signals of hunger or satiety. 4. Undiagnosed problems of the thyroid or pituitary contribute to teen obesity.
3. Adolescent obesity is usually an inability to recognize signals of hunger or satiety. 3. Correct: While all the options could be true in some cases, the most accurate and comprehensive basis for obesity is an individual's failure to recognize, or acknowledge, signals of hunger or satiety. Neural circuitry, along with specific body hormones, drives sensations of hunger and feeling satisfied. Adolescents experience fluctuating hormones, physical changes and emotional adjustments which can disrupt body functions, including recognition of brain signals. 1. Incorrect: Though self-esteem or concern about physical appearance is common with adolescents, it is not necessarily a cause for obesity. 2. Incorrect: Weight issues are often related to an imbalance between caloric intake and energy expenditure. While adolescent frequently snack on high-calorie junk foods in response to stress or boredom, there are more significant contributing factors for teen obesity. 4. Incorrect: It is possible that undiagnosed issues of the thyroid or pituitary could contribute to adolescent obesity. However, these disorders are not common and might also lead to extreme weight loss.
A client in a manic state is on the inpatient psychiatric unit. The client has a need for adequate sleep and rest due to the fact that the client has been awake for 72 hours. Which intervention should the nurse initiate for the client? 1. Encourage the client to participate in an exercise class after dinner. 2. Offer the client a cup of coffee prior to going to bed. 3. Provide a warm bath and snack before the client goes to bed. 4. Send the client to watch the "unit movie" each evening.
3. Correct: A warm bath and snack may promote sleep. The client who is manic may become exhausted due to lack of sleep. 1. Incorrect: Exercise will stimulate the client and will impede sleep. 2. Incorrect: Caffeinated beverages will disrupt nighttime sleep. 4. Incorrect: A group activity such as watching a movie provides too much stimulation before going to bed.
Which home safety intervention should the nurse advise parents of a toddler? 1. Place the child in the center of an adult size bed when napping. 2. Buckle the child into the high chair if parents leave the room during a meal. 3. Anchor top-heavy furniture or fish tanks so that they cannot be pulled over. 4. Allow the toddler to explore stairs in the home if supervised.
3. Anchor top-heavy furniture or fish tanks so that they cannot be pulled ov 3. Correct: Top-heavy furniture, TVs and fish tanks can be pulled over by the toddler, especially if the child is trying to reach something on top of them. 1. Incorrect: The safest place for the toddler to nap or sleep is in a crib. The toddler may easily fall from an adult size bed. 2. Incorrect: The toddler should never be left unsupervised in a high-chair. It can tip if the child tries to climb out, or the child may push against something, resulting in a fall. 4. Incorrect: Stairs in the home present a risk for falls and accidents for the toddler. Safety gates should be in place, and the adults should hold the toddler's hand when navigating the stairs.
Which intervention can the nurse safely assign to an unlicensed assistive personnel (UAP)? 1. Irrigate a colostomy in a client who is 2 days postoperative. 2. Remove a fecal impaction in a client. 3. Apply a condom catheter to an incontinent client. 4. Insert a urinary catheter to obtain a urine sample.
3. Apply a condom catheter to an incontinent client. 3. Correct: With proper instruction a UAP may be delegated to apply a condom catheter. This is not an invasive procedure. 1. Incorrect: The care of a new postoperative colostomy should not be assigned to the UAP. This is an invasive procedure and assessments of the stoma, incision, and skin are essential. The nurse can not assign assessment to a UAP. 2. Incorrect: Removal of a fecal impaction is an invasive procedure. Because the bowel mucosa can be injured during this procedure, it is not appropriate to assign this to the UAP. 4. Incorrect: Insertion of an indwelling urinary catheter is an invasive sterile procedure. The nurse must have knowledge of detailed anatomy and sterile technique. The UAP should not be assigned to perform this procedure. 1. Follow the 5 rights of assignment: Right task, right person, right circumstance, right direction, right supervision.
The nurse is caring for a burn client 48 hours after the burn occurred. What would be the nurse's priority action?
3. Auscultate the lungs every 2 hours. 3 Correct: After 48 hours, the fluid in the interstitial spaces will begin to shift back into the vascular space and can lead to fluid volume excess. Excess fluid can back up into the lungs, so auscultation of the lungs takes priority. Remember: Airway, breathing, then circulation. 1. Incorrect: No indication of need to measure abdominal girth. Fluid is now shifting out of the tissue and abdominal cavity back to the vascular space. Worry about fluid volume excess now. 2. Incorrect: Not priority over pulmonary function. Pain is a priority from the client's perspective, but remember pain never killed anyone. However, fluid in the lungs will! The lung takes priority. 4. Incorrect: Not priority over pulmonary function. Again, we want to inspect for infection, but it is not the priority over aucultating the lungs.
What vitamin is important in reducing the risk of peripheral neuropathy in a client with alcohol abuse? 1. Vitamin D 2. Fat soluble vitamins 3. B vitamins 4. Potassium
3. B vitamins 3. Correct: Yes! It is the B vitamins. Long term heavy alcohol use puts one at risk for neuropathy. 1. Incorrect: Not vitamin D 2. Incorrect: While the liver is affected, the fat soluble vitamins are affected. The peripheral neuritis is related to the B vitamins. 4. Incorrect: Potassium is an electrolyte.
A client, who received blunt chest trauma from an all-terrain vehicle accident, is admitted to the unit at 7 PM following insertion of a chest tube at 5 PM. The drainage collection chamber has 80 mL of drainage present upon arrival to the unit. Which assessment finding would be of concern to the nurse?
3. CDU is sitting upright on the bedside table with fluid levels as prescribed. 5. 190 mL of drainage noted in drainage collection chamber at 8 PM. Rationale 3. & 5. Correct: Do you see the problem with the bedside table? Yes! It's too high! The chest tube system should always be kept below the level of the chest to prevent backflow of drainage or air into the pleural space. You want to promote gravity drainage. The next problem that we see is excessive drainage. The chest tube was inserted at 5 PM and the client was admitted to the unit 2 hours later. The amount of drainage at upon arrival at 7 PM was 80 mL. At 8 PM, there was 190 mL of drainage. This is 110 ml of drainage in one hour. Drainage of 100 mL or greater any hour after the first hour is considered excessive. The healthcare provider would need to be notified of this amount of drainage.
A hospitalized Native American elder is actively dying and is surrounded by a large group of family members. The client's spiritual beliefs include burning a tiny amount of incense while chanting softly. The roommate summons the nurse, complaining about the noise and the odor despite the fact the curtain is drawn between the beds. What is the most appropriate action by the nurse? 1. Tell the client's family the noise and odor bothers the roommate. 2. Move the elder to a private room so family can continue ceremony. 3. Offer to move the roommate to another room in a quieter area. 4. Explain the client is dying and the family will soon be leaving.
3. CORRECT. The most appropriate action in this situation is to move the roommate to a quieter location, allowing the family and dying client privacy while also fulfilling the roommate's request. 1. INCORRECT. The client and family are dealing with an impending death and have the right to embrace any cultural or spiritual traditions to ease that situation. This comment by the nurse would insult the family and not solve the situation. 2. INCORRECT. Despite the fact that a private room would be ideal for the dying client and family, the stress and chaos of moving to another room would be physically and emotionally overwhelming. In fact, it could even hasten the client's death. 4. INCORRECT. Although the roommate may be aware of the client's condition, the nurse has violated HIPAA regulations by revealing information to the roommate. Even when the elder client does pass away, the family may choose to stay in the room for an extended period of time. This action does not solve the problem.
The nurse is caring for a client who is prescribed a soft diet. Which breakfast food items, if found on the client's tray should the nurse remove? 1. Pancakes 2. Oatmeal 3. Cinnamon-raisin roll 4. Scrambled eggs
3. Cinnamon-raisin roll 3. Correct: Rolls with coconut, raisins, nuts, or whole grains should be avoided on a soft diet.1. Incorrect: This is an acceptable food on a soft diet.2. Incorrect: This is an acceptable food on a soft diet.4. Incorrect: This is an acceptable food on a soft diet.
While the postpartum nurse was in report, four clients called the nurse's station for assistance. Which client should the nurse see first? 1. Client with three dime sized clots on her perineal pad. 2. Breastfeeding client who is reporting uterine cramping. 3. Client reporting blood running down legs upon standing. 4. Client who had an epidural and is now reporting a headache.
3. Client reporting blood running down legs upon standing. 3. Correct: A nurse should see this client first because we are worried about hemorrhage. If the fundus is boggy, a fundal massage will need to be done. Check vital signs for hemorrhage. 1. Incorrect: Clots smaller than a silver dollar are normal. However, do not ignore any bleeding. Always check the client with any signs of bleeding to determine whether the problem is significant. 2. Incorrect: Breastfeeding causes the release of endogenous oxytocin from the pituitary, which causes the uterus to contract. When the uterus contracts, the client may call this discomfort, cramping. This is a normal process necessary for the uterus to return to normal. 4. Incorrect: A post epidural headache can be an indication of inadvertent puncture of the dural membrane. This client will need to be positioned prone, push fluids, given caffeine and may need a blood patch to seal the dural leak. However, the client with possible hemorrhage would be the client that the nurse would need to see first, because this could be more life-threatening.
The nurse is collecting data on a client who is having a breast augmentation. Which client information would be most important for the nurse to report to the surgeon before surgery? 1. Client is concerned about who will care for her two children while she recovers. 2. There is a history of postoperative dehiscence after a previous C-section. 3. Client's last menstrual period was 8 weeks ago. 4. Client is concerned over pain control postoperatively.
3. Client's last menstrual period was 8 weeks ago. 3. Correct: The client may be pregnant, so a pregnancy test will need to be completed prior to administering anesthetic agents. As you look at these options, they are all possible but only one is a priority and, in this case, life threatening. 1. Incorrect: Adequate caregivers can be discussed with the client without contacting the primary healthcare provider. This is important but not the priority to report to the surgeon. 2. Incorrect: Every person who has a surgical wound is at risk for dehiscence, especially in the first two weeks after surgery. Educate the client concerning signs and symptoms and causes of dehiscence, but this is not your priority here. 4. Incorrect: The client's postoperative pain control will be discussed both before and post surgery. Always discuss clients concerns prior to surgery and consult the primary healthcare provider if you are unable to satisfy the client. However, the concern about pain control is not as serious an issue as the possibility of the client being pregnant and would therefore, not be the priority.
parents bring their child to the clinic with left knee pain after suffering a fall on the playground. Which action should the nurse initiate first? 1. Instruct the child to extend the affected knee 2. Perform range of motion exercise on both knees 3. Compare the appearance of the left knee to the right knee 4. Have the child soak the affected knee in warm water
3. Compare the appearance of the left knee to the right knee 3. Correct: Comparing the appearance of the left knee to the right knee is the least invasive action and allows the nurse to see if there is a change in the appearance of the affected knee to the unaffected knee. 1. Incorrect: No. Extending the affected knee may cause further damage.2. Incorrect: You don't want the child to move the extremity prior to checking for broken bones. Range of motion exercises may cause further damage to the affected knee. 4. Incorrect: Soaking the affected knee in warm water will not help the nurse determine whether or not an injury occurred.
The nurse is caring for a client who was admitted to the hospital following a severe motor vehicle crash (MVC) in which the client was trapped in the car for several hours. The client is being closely monitored for the development of renal failure. Which data would warrant immediate reporting? 1. Creatinine 1.1 mg/dl (97.24 mmol/L) 2. Urinary output of 150 mL per hour. 3. Gradual increase of BUN levels. 4. Calcium levels of 9.0 mg/dL (2.25 mmol/L)
3. Correct. Gradual accumulation of nitrogenous wastes results in elevated BUN and serum creatinine. This is an indication of impaired renal function. 1. Incorrect. This is a normal creatinine level. Gradual accumulation of nitrogenous wastes from impaired renal function results in elevated BUN and serum creatinine. 2. Incorrect. This is a normal output level. This level alone would not necessarily be an indicator of acute renal failure, and that value alone would not warrant reporting it to the primary healthcare provider. 4. Incorrect. Calcium level of 9.0 mg/dL (2.25 mmol/L) is considered normal. When observing for renal functioning, you would monitor the BUN and creatinine levels. In addition, the calcium level may drop (hypocalcemia) in renal failure. This drop is an inverse relationship change due to the rising serum phosphate levels. However, the calcium level presented is within normal limits (WNL).
Which task would be appropriate for the LPN/LVN to assign to the unlicensed assistive personnel (UAP)? 1. Check the bladder for distension in the client who had a foley catheter removed 4 hours ago. 2. Obtain BP of client with syncope in the lying, sitting, and standing positions. 3. Prepare a sitz bath for a postpartum client. 4. Monitor for grimacing in the client who has had a stroke.
3. Correct. The UAP can assist clients with hygiene care. 1. Incorrect. This is not within the scope of practice for the UAP. The nurse must assess and evaluate. 2. Incorrect. This client is not stable if having episodes of syncope that could be related to orthostatic hypotension. The nurse should assess the client. 4. Incorrect. The UAP cannot assess or evaluate. This is the RN's responsibility.
While collecting data on an elderly client diagnosed with advancing Alzheimer's disease, the client's spouse begins to sob and states, "After all these years, we won't be together anymore." What would be the best response by the nurse? 1. "You can come to visit anytime you want to." 2. "Would you like to see the room and facilities?" 3. "Let's find a quiet place to sit and talk awhile." 4. "You did the best you could in this situation."
3. Correct. The nurse recognizes that the client's spouse is emotionally distraught at this moment, and is most in need of the nurse's focus at this time. Major life events have affected this family unit, including the client's terminal diagnosis and separation to a new living environment. This spouse is understandably overwhelmed by the changes occurring and, while the nurse will need to gather data, family needs must be met. Focusing on the spouse's emotional needs and allowing time to verbalize feelings could positively affect the client's adaptation to the situation. 1. Incorrect. Although this statement may be factual, it is a closed-ended statement, which belittles the spouse's expression of distress by presuming that unlimited visitation will rectify the situation. Though the spouse is verbalizing sadness because of physical separation, the grief may be a reflection of deeper concerns, considering the client's diagnosis. 2. Incorrect. This response focuses on the facility surroundings, rather than the spouse's distress and expression of sorrow. Changing the topic both ignores and belittles the client's grief. The nurse must address the needs of the family as well as those of the client. 4. Incorrect. Though this response may seem encouraging, a closed-ended statement does not allow the openly distressed spouse an opportunity to verbalize further feelings. Family dynamics can significantly impact the client's well-being and potential to adapt to new surroundings.
Based on expected growth and development for a 7 month old infant, what would the nurse anticipate that the mother would report at the infant's well-baby visit? 1. Has slight head lag when pulled to sitting position. 2. Walks holding onto furniture. 3. Able to sit, leaning forward on both hands. 4. Has neat pincer grasp.
3. Correct: A 7 month old is not expected to be able to sit fully unsupported but is able to sit by leaning forward on both hands. 1. Incorrect: No head lag should be seen when pulled to a sitting position. Head lag should end around 5 months of age. 2. Incorrect: The 7 month old is expected to be able to bear full weight on feet but generally does not walk holding onto furniture until around 11 months of age. 4. Incorrect: A neat pincer grasp does not usually develop until around 11 months of age. A 7 month old would only be expected to rake small objects with the fingers.
A client at a rehabilitation facility states, "No one asked me which rehabilitation facility I preferred. I feel as if this entire process took place without my involvement. I was not informed of alternative options." Which client right is being violated? 1. The right to considerate and respectful care 2. The right to self-determination 3. The right to participate in the plan of care 4. The right to review medical records related to care and treatment.
3. Correct: A client has the right to participate in the plan of care and to refuse a recommended treatment to the extent permitted by law and by hospital policy. In the case of care refusal, the client has the right to alternative care and treatment, and the right to be transferred to another health care facility if that is the client's choice. 1. Incorrect: The right to considerate and respectful care has not been violated in this situation. 2. Incorrect: The right to self-determination relates to resuscitation and advance directive issues. 4. Incorrect: The client's right to review medical records is not addressed in this question.
A nurse is caring for a client who had a total hip replacement 2 days ago. What observation would be a priority concern for the nurse? 1. Small amount of red drainage on the surgical dressing. 2. Continues to report pain in hip when being repositioned. 3. Temperature of 101.8°F (38.7°C). 4. Slight swelling in the leg on the affected side.
3. Correct: A low grade fever is normal following hip surgery but a temperature of 101.8ºF (38.7ºC) two days postoperatively is higher than the expected slight increase and should be a priority concern. The development of an infection is one of the major complications for clients following hip surgery. Therefore, fever that persists above 101ºF that is accompanied by chills, diaphoresis, or increasing drainage and odor from the incision should be reported. 1. Incorrect: A small amount of red, bloody drainage on the dressing is expected as part of the normal healing process. 2. Incorrect: Some pain during repositioning after hip surgery is normal and can generally be managed with analgesics. 4. Incorrect: Swelling in the operative leg is a normal part of the postoperative process after hip surgery. Normal swelling is lessened in the morning but tends to re-accumulate throughout the day. This can be minimized by elevating the client's legs or having the client lie down for approximately 45 minutes during the day.
A client in a manic state is on the inpatient psychiatric unit. The client has a need for adequate sleep and rest due to the fact that the client has been awake for 72 hours. Which intervention should the nurse initiate for the client? 1. Encourage the client to participate in an exercise class after dinner. 2. Offer the client a cup of coffee prior to going to bed. 3. Provide a warm bath and snack before the client goes to bed. 4. Send the client to watch the "unit movie" each evening.
3. Correct: A warm bath and snack may promote sleep. The client who is manic may become exhausted due to lack of sleep. 1. Incorrect: Exercising prior to sleep causes an increased level of physical arousal. Exercise will stimulate the client and will impede sleep. 2. Incorrect: Caffeinated beverages will disrupt nighttime sleep. Caffeine is a stimulant that blocks a person's feeling of being sleepy. The person has an increased alertness. 4. Incorrect: A group activity such as watching a movie provides too much stimulation before going to bed. A more calming activity that is not a group activity is recommended.
What factor would most likely predispose a client with a compound femoral fracture to develop shock? 1. Pooling of the blood in the lower leg 2. Generalized vasoconstriction in the lower extremities 3. Loss of blood into soft tissues surrounding the fracture 4. Depression of the adrenal gland by toxins released at the injury
3. Correct: After a fracture the factor that would most likely lead to shock is loss of blood into the soft tissue surrounding the fracture. When fractures occur major arteries can be severed causing loss of blood into the surrounding tissue. 1. Incorrect: Pooling of blood in the lower extremities is a possibility, but bleeding into the surrounding tissue is more acute. 2. Incorrect: Vasoconstriction in the lower extremities is an appropriate compensatory response for a "shocky" client. Vasoconstriction of the lower extremities will increase blood pressure. 4. Incorrect: Depression of the adrenal glands caused by release of toxins at the injured site is not correct.
What should the nurse do first when caring for a client who is being admitted with a diagnosis of meningococcal meningitis? 1. Perform neurological checks. 2. Collect data for health history. 3. Institute droplet precautions. 4. Orient client to the room and procedures.
3. Correct: Although all the options are appropriate, you should first place the client on droplet precaution to prevent the spread of meningococcal meningitis. 1. Incorrect: Placing client in isolation should be done first (actually prior to arriving to room) since the client has a diagnosis of meningococcal meningitis. Neurological checks can be completed after the client is placed in isolation. 2. Incorrect: Collecting data for the health history can be obtained after placing the client on droplet precautions. 4. Incorrect: Orientation can occur after the initiation of droplet precautions.
A concerned parent is asking the nurse about activities that would be best for her child who has been diagnosed with asthma. In order to minimize the risk of exercise induced asthma, which activity would be best for the nurse to suggest? 1. Track 2. Basketball 3. Baseball 4. Soccer
3. Correct: Baseball is an activity that is considered "asthma friendly". It requires short, intermittent periods of exertion and is therefore tolerated better by children with asthma. 1. Incorrect: This activity requires extended periods of exertion and is not considered "asthma friendly" and often not tolerated by clients with asthma. 2. Incorrect: This activity requires extended periods of exertion and is not considered "asthma friendly" and often not tolerated by clients with asthma. 4. Incorrect: This activity requires extended periods of exertion and is not considered "asthma friendly" and often not tolerated by clients with asthma. Asthma is a condition in which the airways narrow and swell and produce extra mucus. This can make breathing difficult and trigger coughing, wheezing,and shortness of breath. Being active and playing sports is an especially good idea if a client has asthma. Why? Because it can help the lungs get stronger so they work better. Some sports are less likely to bother a person's asthma. Golf and yoga are less likely to trigger flare-ups, and so are sports like baseball, football, and gymnastics. In some sports, you need to keep going for a long time. They include cycling, long-distance running, soccer, and basketball. Cold, dry air can also make symptoms worse, so cross-country skiing and ice hockey might be difficult for people with asthma.
A client with a history of eczema has been admitted with cellulitis of the left forearm. Which admission order should the nurse question immediately? 1. Start IV of normal saline at 100 mL per hour. 2. Keep left arm elevated on pillow at all times. 3. Apply ice packs to affected area every shift. 4. Ibuprophen 800 mg po every 6 hours prn pain.
3. Correct: Cellulitis is a bacterial skin infection resulting in warm, redden and edematous tissue, sometimes accompanied by fever and chills. Swelling in the affected area impedes blood flow and increases pain. In order to decrease the edema, warm, moist compresses are used to stimulate circulation and speed reabsorption of the fluid within the tissue. This order should be questioned immediately. 1. Incorrect: An infection serious enough to require hospitalization indicates this client is either septic or may need intravenous antibiotics. Fluids are a primary treatment for sepsis along with bedrest and antibiotics. A basic solution of normal saline at 100/mL per hour would be an appropriate order for this client. 2. Incorrect: The swelling characteristic in cellulitis in painful and diminishes circulation to the area. Elevation on one or two pillows at all times helps to improve blood flow so that healing can take place. In some facilities, clients are provided with a wedge shaped cushion that provides better support of the affected area. This order is appropriate. 4. Incorrect: Ibuprophen provides relief from both pain and inflammation associated with cellulitis. A dose of 800 milligrams by mouth every 6 hours as needed for pain would be appropriate for this client. This is not an order the nurse should question. Consider the process of cellulitis in the body. You are aware that this is a bacterial infection, usually caused by either staphylococcus or streptococcus, in an open would that was not properly cleaned or treated at the time. This client has a history of eczema, which means there may be many areas of inflamed, itchy dry skin that can easily become infected without proper care. In this scenario, the client's condition is serious enough to require hospitalization, either to prevent or to treat sepsis. Think about what cellulitis looks like: a warm, red, inflamed area of skin, noted here to be the left forearm, where the skin may be taunt and shiny from edema. How should you care for this client? After giving that some thought, look at the Healthcare provider's orders. What order would you question, and be sure you know why. It is crucial to understand the reasons behind specific actions in order to provide good nursing care. When reading all the options, remember that you are looking for an order the nurse should question - you are looking for something incorrect. Therefore, if you as the nurse would implement a particular order, it's not the answer you are looking for! Option 1: Is there anything wrong with this order? A client is in the hospital with cellulitis of the left forearm, and is to be started on an IV of normal saline. Okay, that is a basic isotonic solution that is generally acceptable in most situations. Were you thinking about the rate? This client may be bordering on sepsis, and is certainly sick enough to be hospitalized; therefore, 100 mL/hour is quite reasonable. No problem here. Try another option. Option 2: Cellulitis is an infection in the tissues, which means pain, warmth, redness, and a lot of swelling. The minute you see "swelling", you should think about taunt skin, tightness, and impaired circulation with possible permanent damage. So how do you decrease edema? The first step is to elevate the area, in this case the left forearm. Most often the easiest solution is to place the extremity up on one of two pillows, so that the area of swelling is higher than the level of the heart. Some facilities provide wedge shaped foam bolsters of cushions for elevation since they are less likely to slip out of place. This seems like a perfectly appropriate order too! Option 3: Does something seem not quite right here? Very good! Errors can occur in admission orders, and it is the responsibility of each nurse to carefully review orders, and more importantly, understand the why behind each order! On the surface, ice packs might sound like a comforting and cooling treatment for those hot, inflamed and painful areas of skin. But what happens when ice is applied? Vasoconstriction occurs, which would further impair the circulation and decrease healing in the affected areas. The nurse knows that warm, moist compresses applied a couple times a shift would actually improve circulation, decrease edema and speed healing. This is the order the nurse needs to question! Option 4: Anytime you think about swelling in a body part, remember that there is generally also pain. This client has a history of eczema and now has cellulitis in those fragile tissues. The edema and infection would definitely cause discomfort for this client that requires pain medication. The primary healthcare provider has ordered 800 mg. Ibuprophen every 6 hours as needed for pain. This dose may seem large but it is the prescription dose and every six hours is appropriate for pain control. No need to question this order.
A nurse is caring for a client who has chest pain. Which statement made by the client leads the nurse to suspect angina instead of a myocardial infarction (MI)? 1. I became dizzy when I stood up. 2. I was nauseated and began vomiting. 3. The pain started in my chest and stopped after I sat down. 4. The pain was not relieved after taking 3 nitroglycerine tablets.
3. Correct: Chest pain brought on by exercise and stopped with rest is the hallmark of angina. If it were a MI, the pain would continue even with rest or position changes. 1. Incorrect: This indicates orthostatic hypotension which is not definitive for angina or MI. 2. Incorrect: Vomiting is a symptom of a MI, not angina and is a bad sign related to the acute pain from the MI. This type of pain stimulates the vagus nerve, which causes the heart rate, BP, and cardiac output to decrease and this is never good with a heart client. 4. Incorrect: This is the picture of MI, not angina.
A nurse has reinforced teaching to a client about home dressing changes using a clean technique. Which statement made by a client indicates to the nurse that the client understands this technique? 1. "The wound should be cleaned using a washcloth, soap, and water." 2. "Povidone-iodine should be applied to the wound with each dressing change." 3. "It is important that I wash my hands using soap and water before removing my dressing." 4. "I will use sterile gloves to clean my wound and change the dressings."
3. Correct: Clean technique requires washing hands with soap and water prior to removing the dressing. 1. Incorrect: The wound should be cleaned with 4x4's and sterile water. Soap can be very drying to the wound. A washcloth may not be clean as it has been sitting in a cabinet. 2. Incorrect: Povidone-iodine is harsh and damages healthy tissue, so should not be applied to the wound. 4. Incorrect: Sterile gloves are not needed when using clean technique. Clean gloves may be used.
Which task would be appropriate for the LPN/VN to accept from the Labor, Delivery, Recovery, Postpartum (LDRP) charge nurse? 1. Administer IV pain medication to a client three days postopertive cesarean section. 2. Draw a trough vancomycin level on a client 3 days postpartum with bilateral mastitis. 3. Reinforce how to perform perineal care to a primipara who is four hours postpartum. 4. Draw admission labs on a client admitted in final stages of labor.
3. Correct: Client teaching may be reinforced by an LPN/VN on a stable client. 1. Incorrect: Administering IV pain medications is out of the scope of practice of LPN/VN. 2. Incorrect: This client with a severe infection who is only 3 days postpartum is considered an unstable client. Therefore, this client should have the blood drawn and receive care from the RN. 4. Incorrect: Drawing admission labs on a client in the final stages of labor would be inappropriate, because the client is potentially unstable and needs experienced LDRP nursing care.
A client receives instructions regarding the use of warfarin sodium. Which statement indicates the client understands the possible food interactions which may occur with this medication? 1. I'm going to miss having my evening glass of wine now. 2. I told my daughter to buy bananas for me. I'll have to eat more of those now. 3. I will have to watch my intake of salads, something that I really love. 4. I am going to begin eating more fish and pork and leave beef alone now.
3. Correct: Clients taking warfarin sodium must watch their intake of vitamin K, which is present in leafy green vegetables, tomatoes. 1. Incorrect: Wine does not affect the use of warfarin sodium 4. Incorrect: These clients need to watch intake of bananas which is a source of vitamin K. 5. Incorrect: These clients need to watch intake of fish which is a source of vitamin K.
The nurse is caring for a depressed client. The client has a flat affect, apathy, and slowed physical movement. The client has not bathed in several days and there is a malodorous odor noted. Which intervention would be most appropriate at this time? 1. Explain the rules about daily showers. 2. Leave the client alone since there is slowed movement. 3. Tell the client it is time to take a shower. 4. Ask when he or she would like to take a shower.
3. Correct: Depressed clients often have little energy to do or think. The depression can lead to a lack of self-care as the client lacks motivation and energy. Give short, simple commands during this time. 1. Incorrect: Not very therapeutic. This is difficult for the depressed client to comprehend at this time. Give short, clear, simple commands. 2. Incorrect: Do not ignore the problem. You must do what is best for the client, and this would not be the best decision. Depression does include slowed movement, but being depressed is not a reason for the client to not meet hygiene needs. 4. Incorrect: The client will not want to do anything at this time. It will be put off, and depressed clients often have difficulty making decisions. The depressed client lacks motivation and energy. The depressed client needs short, simple statements. 1. Identify key words in the stem that set a priority, such as first, initially, best, priority, safest, most. These words modify what is being asked. This question requires you to put a value on each option and then place them in rank order. If you are having difficulty ranking the options, eliminate the option that you believe is most wrong among the options. 2. A strategy to help answer priority questions is to refer to basic guiding theories that are part of the foundation of nursing. Maslow's Hierarchy of Needs, The Nursing Process, Kubler-Ross's Theory of Death and Dying, Teaching/Learning Theory, Therapeutic Communication.
Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Encourage client to express grief related to loss of independence. 2. Irrigate a client's ear canal. 3. Disconnect client's nasogastric (NG) tube suction to allow ambulation. 4. Show client who has conjunctivitis how to clean the eyes.
3. Correct: Disconnecting NG tube suction is an appropriate task for the UAP. 1. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. 2. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. It is not a routine task. 4. Incorrect: The nurse cannot assign teaching to the UAP. 1. The RN cannot delegate assessment, evaluation, plan of care development or teaching to an LPN or UAP. 2. Follow the 5 rights of delegation: Right task, right person, right circumstance, right direction, right supervision. Unlicensed assistive personnel (UAP) are unlicensed health care providers trained to function in a supportive role by providing client care activities as assigned by the nurse. The term includes, but is not limited to nurse aides, orderlies, assistants, attendants, or technicians. UAPs function under the nurse practice act of each state. The UAP can perform daily care of a client or group of clients that is frequently recurring and are performed according to an established sequence of steps. The activity should involve little or no modification from one client care situation to another. The activity may be performed with a predictable outcome without inherently involving ongoing assessment, interpretation, or decision making which cannot be logically separated from the procedure itself. The activity should not endanger the client's life or well-being. The UAP must have been properly trained and validated as competent by the RN. Agency policies and procedures must also permit the task, and the nurse must provide appropriate supervision.
Which task would be appropriate for the LPN/VN to complete? 1. Assessing a client who was just admitted to the unit. 2. Administering morphine IV push to a two day post-op client. 3. Feeding a client through a percutaneous endoscopic gastrostomy (PEG). 4. Reinserting a PICC line that was pulled out by the client.
3. Correct: Feeding by way of a PEG tube would be the best assignment for the LPN/VN. This is a nursing action that can be performed by the LPN/VN and does not require verification nor a co-signature by the RN. 1. Incorrect: The LPN/VN can collect data on a new client, but the RN must verify the information and co-sign the assessment. New admits require initial observation and data collection. From this, the RN must evaluate the information and formulate priorities of care. 2. Incorrect: Administering morphine IVP is out of the scope of practice for the LPN/VN. Therefore, this task should not be assigned to the LPN/VN. 4. Incorrect: Reinserting a PICC line is out of the realm of practice for an LPN/VN. Therefore, this task should not be assigned to the LPN/VN. Follow the 5 rights of task assignment: Right task, right person, right circumstance, right direction, right supervision.
The nurse is working with the parents of a preschooler to help promote healthy sleep patterns of approximately 8 - 12 hours of sleep per night. Which intervention should assist the parents to achieve adequate sleep for their preschooler? 1. Offer a time of exercise prior to bedtime. 2. Follow a bedtime routine at least three or four nights per week. 3. Spend about 30 minutes with the preschooler prior to bedtime for stories. 4. Do not encourage preschooler to take a toy to bed.
3. Correct: Rituals help the preschooler to feel secure. Quiet time to read, tell stories, and say prayers prepares the child for sleep. 1. Incorrect: Stimulation of activity before bedtime impedes sleep. 2. Incorrect: The routine should be maintained each night if at all possible. Only through routine does the child feel secure in preparation for bedtime. 4. Incorrect: A special toy helps the child to feel secure and adds to the nighttime routine.
The nurse is observing the work of an unlicensed assistive personnel (UAP). Which observation will require the nurse to intervene? 1. Placing soiled linen in a hazardous waste linen bag outside of the client's room. 2. Closing the door when exiting the room of a client diagnosed with tuberculosis (TB). 3. Going between client rooms wearing the same pair of gloves to collect I&O reports. 4. Cleaning a blood pressure cuff with a disinfectant.
3. Correct: Gloves should be removed and hands washed before leaving each client's room. Gloves quickly become contaminated and then become a potential vehicle for the transfer of organisms between clients. 1. Incorrect: No intervention is needed because this is an appropriate action. Do not carry soiled linen down the hall to place in a receptacle. 2. Incorrect: No intervention is required because this is an appropriate action. Clients with tuberculosis (TB) need to be on airborne precautions in a negative pressure room with the door closed. 4. Incorrect: Equipment used against intact skin should be thoroughly cleaned with low level disinfectant between uses to reduce the load of microorganisms to a level that is not threatening to the next client. Therefore, no intervention is needed since the action is appropriate.
When caring for a client with hepatitis A, what special precautions should the nurse take? 1. Wear gloves when handling blood and body fluids. 2. Wear a mask and gown before entering the room. 3. Use gloves when removing the client's bedpan. 4. Use caution when bringing food to the client.
3. Correct: Hepatitis A is transmitted by the fecal/oral route. 1. Incorrect: Hepatitis B is transmitted by contact with blood and body fluids. 2. Incorrect: Masks are not necessary when a client is placed on contact isolation. Hepatits A is NOT transmitted by airborne or droplet transmission. 4. Incorrect: Use caution in bringing fresh produce to clients placed on reverse isolation.
A client in the manic phase of bipolar disorder is constantly walking around the day room and refuses to sit down to eat the spaghetti and meatballs sent by the kitchen. Which food should the nurse request from dietary? 1. Carrots and apples 2. Donuts 3. Pepperoni pizza sticks 4. Strawberry pastry
3. Correct: High protein, high calorie, nutritious finger foods are required when the client will not sit down to eat. This client needs food they can eat "on the go" because they are burning more calories in this phase of bipolar disorder. 1. Incorrect: Although nutritious, these foods are not high calorie or high protein. 2. Incorrect: Donuts are high in calories but do not have high nutritional valve. 4. Incorrect: Pastries are also high in calories but do not have high nutritional valve. They are also not very easy to eat "on the go".
Which statement by a client diagnosed with infectious mononucleosis indicates to the nurse that education has been successful? 1. "I should let my primary healthcare provider know if I start having pain in the side of my stomach" 2. "I can return to my normal activities in 5 days." 3. "I will not let others drink from my glass." 4. "My immediate family needs to get vaccinated against mononucleosis."
3. Correct: Infectious mononucleosis, caused by the Epstein-Barr virus is transmitted by saliva and intimate physical contact like kissing, sharing of utensils, and eating/drinking after others. 1. Incorrect: The client should observe for left upper quadrant abdominal pain radiating to the left scapula as this is an indicator of splenic rupture, a complication of infectious mononucleosis. 2. Incorrect: This is too soon. Most people get better in 2 to 4 weeks; however, some people may feel fatigued for several more weeks. Occasionally, the symptoms of infectious mononucleosis can last for 6 months or longer. 4. Incorrect: There is no vaccine to protect against infectious mononucleosis. The best way of the Epstein-Barr virus is to eliminate contact with oral secretions.
What important principle should the nurse reinforce with the client performing intermittent self-catheterization? 1. Inserted in an emergency department. 2. Used to treat urinary catheter infections. 3. Is a clean procedure. 4. Requires use of sterile gloves.
3. Correct: Intermittent catheterization is a clean, not sterile, technique when performed in the home environment. Home intermittent catheterization is preferred over continuous use of a Foley catheter, as a Foley catheter increases client risk of urinary tract infections. 1. Incorrect: The client can be taught to do self-catheterization at home. An intermittent self-catheterization does not need to be performed in an emergency department. 2. Incorrect: Performing intermittent self-catheterization at home is recommended for urinary retention. This procedure does not treat urinary tract infections. 4. Incorrect: This procedure is a clean, not sterile, technique when performed in the home environment. Sterile gloves are not required.
A new admit arrives to the nursing unit with one thousand dollars in cash. What would be the best action by the nurse to safeguard the client's money? 1. Insist the money go home with the client's visitor. 2. Place the money in the client's bedside table drawer. 3. Put itemized cash in envelope and place in hospital safe. 4. Lock money up in narcotic cabinet with client's identity and room number.
3. Correct: It is best to have two witnesses (preferably hospital staff) sign the inventory list. The best action by the nurse would be to itemize the valuables, place in an envelope with the record of the inventory, and have it put in the hospital safe. If you fail to properly safeguard the client's property, the trust of the healthcare team for medical care can also be lost. Liability waivers should be signed if for whatever reason, the valuables must remain at the hospital. 1. Incorrect: This is not the best option. The visitor may not be the best person to send the money with. The client also has the right to refuse. Sending the money home with someone else does not safeguard the client's valuables and puts the nursing unit at risk for liability if a liability waiver has not been signed. 2. Incorrect: This is not a safe option. Anyone could retrieve the money. This would be considered careless actions by the nurse and could cause a lack of trust in the entire healthcare team. 4. Incorrect: This is not a safe option. Anyone with access could retrieve the money. Although it is in a locked area, it does not need to be placed with narcotics where the cabinet would be accessed by multiple people. This would still be considered a failure to properly safeguard the client's valuables.
The nurse is contributing to a staff education program about electroconvulsive therapy (ECT). Which of the following information should the nurse recommend including? 1."ECT is commonly used to treat depression prior to prescribing antidepressant medications." 2."ECT may be administered to clients on an outpatient basis." 3."Auditory hallucinations are a common side effect of ECT." 4."ECT lowers the level of norepinephrine in the central nervous system."
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A pregnant teenage client says, "I am not sure that I want to have this baby. What do you think about an abortion?" What should the nurse say? 1. What does the baby's father think about an abortion? 2. I know this is a difficult decision. 3. What are your thoughts about abortion? 4. There are many options other than abortion.
3. Correct: It is important that the client talk about her thoughts regarding abortion. The nurse must be careful to protect the client's right to autonomy without imposing personal values onto the client if not solicited. However, the nurse should talk with the client and explore her fears, feelings, and available options. Once the client's choice is made, the client can be referred to the appropriate services. 1. Incorrect: This is asking about another person's opinions and not assisting the client to formulate her opinion. Decisions that are made based on other's thoughts and opinions may lead to regret or guilt later. 2. Incorrect: The nurse is responding with sympathy and not assisting the client to explore her feelings. Since the client specifically asked the nurse about feelings related to abortion, the nurse should answer the client in a way that gets the client to explore her own feelings, thoughts, and concerns. 4. Incorrect: To move to other options immediately discounts the client's right to autonomy and the need to discuss this very personal issue with the nurse. The nurse should use the opportunity to first explore her concerns, feelings and thoughts. It is appropriate to discuss available options with her in order for her to make her own decisions.
A low income family with children lives in an old, run-down apartment building situated close to a salvage yard in a poor neighborhood. Which risk factor identified by the nurse takes highest priority in the health screening for this family? 1. Immunization status 2. School-related problems 3. Lead poisoning 4. Signs of child abuse
3. Correct: Lead may be found in the soil around rusted cars and can cause lead exposure. Old paint contains lead. Chips of paint may be consumed by young teething children. Old, run-down apartments may also have pipes which contain lead. Exposure to and consuming even small amounts of lead can be harmful. No safe lead level in children has been identified, and lead can affect nearly every system in the body. Mental and physical development can be negatively impacted by lead in the body. 1. Incorrect: Although the nurse does need to check immunizations, the hints in the stem indicate several problems that should direct the focus to lead poisoning, which is the priority. Immunization should be administered if the child is not on schedule, but consequences of lead poisoning is much more serious. 2. Incorrect: There was nothing in the stem indicating school problems. This would not take priority over lead exposure assessment. 4. Incorrect: Although poverty and poor housing conditions have been identified as environmental factors for potential abuse, the stem of this question does not provide additional cues that would indicate abuse. Assessment for lead poisoning would be the priority in this situation based on the environmental issues identified.
The nurse is monitoring the healing of a full-thickness wound to a client's right thigh. The wound has a small amount of blood during the wet to dry dressing change. What action should the nurse initiate next? You answered this questionIncorrectly 1. Notify the primary healthcare provider. 2. Obtain wound culture. 3. Document the findings. 4. Remove dressing and leave open to air.
3. Correct: Look at the clues: full thickness wound, small amount of blood, and wet to dry dressing. With a full thickness wound, there is destruction of the epidermis, dermis, and subcutaneous tissues going down to the bone. So you would expect to see a small amount of blood, or drainage wouldn't you? Yes. This is expected. Simply document this normal finding. 1. Incorrect: Is there really anything to worry about in this situation? No, so you do not need to notify the healthcare provider. Now, with most questions on NCLEX, there is something to worry abou,t but just not with this one. 2. Incorrect: No, bleeding is not a sign of infection, which is what you would be worried about if you got a wound culture. 4. Incorrect: You probably would not remove the dressing and leave the wound open to air. The small amount of blood noted is just a sign of blood flow in the healing wound. Wet to dry dressings help to debride the wound. So, if you remove the dressing, will debridement occur? No. Historically, wet-to-dry dressings have been used extensively for wounds requiring debridement. To create this dressing, place a saline-soaked gauze or cotton sponge within a wound with exudate or drainage. As the dressing dries, it pulls exudate out of the wound. The disadvantages of wet-to-dry dressings are that they are nonselective with debridement; therefore, they take healthy as well as necrotic tissue with them. Wet-to-dry dressings are generally painful to remove. Surrounding wound edges can become macerated because of the moisture contained in the dressing, and that can lead to enlargement of the wound's diameter.
A client is receiving a unit of whole blood. The client begins to complain of lower back pain. What is the nurse's first action? 1. Assess the client's pain 2. Log roll the client to their side 3. Stop the transfusion 4. Take the client's vital signs
3. Correct: Low back pain is a sign of an acute hemolytic reaction. This is the most dangerous and potentially life-threatening type of transfusion reaction. It occurs when the donor blood is incompatible with that of the recipient. 1. Incorrect: It would be an action the nurse would take after stopping the transfusion. Do not delay stopping the transfusion to further assess the client. By allowing the transfusion to continue, while additional assessment data is gathered, the client is at greater risk for more harm. 2. Incorrect: After assessing the client's pain, this may be an indicated action but not the first action for a client receiving blood that begins to complain of lower back pain. Assume the worst and stop the transfusion first, then continue with the assessment. 4. Incorrect: Assume the worst and stop the transfusion first, then continue with the assessment. Vital signs would be obtained after stopping the transfusion.
After the unexpected death of a Jewish teenager, the coroner tells the family that an autopsy has been requested. The teen's mother starts crying hysterically and refuses to allow the autopsy. After calming the mother, what should the nurse do next? 1. Explain that the coroner does not need the family's permission to perform the autopsy. 2. Ask the primary healthcare provider for a sedative for the mother. 3. Notify the charge nurse that the mother refuses the autopsy. 4. Call the rabbi of the family's synagogue to discuss the nature of the autopsy.
3. Correct: Mutilation of the body is forbidden. Autopsy is allowed only when mandated by civil authorities, such as when murder is suspected. If an autopsy is performed, all body parts must be returned for burial. 1. Incorrect: Permission is not needed when foul play is suspected. This is not the best next action. The keyword is "unexpected". The law can require an autopsy be performed when death is the result of foul play, homicide, suicide or accidental causes such as motor vehicle crashes, falls, the ingestion of drugs or deaths within 24 hours of hospital admission. 2. Incorrect: The nurse has calmed the mother. The sedative is not needed and does not solve this problem. Remember to stay away from medications as long as possible. 4. Incorrect: A rabbi is usually requested at the time of death, but this will not solve the autopsy problem. The rabbi may pray in a minyan, a group of 10 adults over the age of 13.
The nurse is caring for an elderly client who is approaching death and expressing intense despair and anxiety. Based on Erikson's theory, the nurse recognizes that this client's despair and anxiety would most likely be based on what? 1. An inappropriate desire for youthfulness and staying young. 2. The decision to never marry. 3. The lack of a sense of wholeness, purpose, and a life well lived. 4. The fear of experiencing a painful death.
3. Correct: Older adults who view their lives as purposeful and full have an increased ability to view death as a meaningful part of life. 1. Incorrect: As people age they lose physical function and don't look as youthful as they once did. But the stage the elder adult faces is despair and anxiety regarding the life lived. 2. Incorrect: Individual choice that may or may not lead to satisfaction. 4. Incorrect: Conversely, older adults who view their lives as meaningless and full of lost opportunities view their approaching death with despair and conflict. "Most" is used in this stem. The client could regret any of these options, but based on Erickson's integrity versus despair, which option is most likely? You were probably able to get rid of options 1 and 2. Additionally, option 3 is more global than the other options. Remember Erickson's stages of growth and development. The integrity versus despair stage begins as the aging adult begins to tackle the problem of mortality. During this period, the person reflects back on the life lived and comes away with either a sense of fulfillment from a life well lived or a sense of regret and despair over a life misspent. People are able to look back at their life with a sense of contentment and face the end of life with a sense of wisdom and no regrets. Those who are unsuccessful during this phase will feel that their life has been wasted and will experience many regrets. The individual will be left with feelings of bitterness and despair.
A client is admitted with an acute episode of diverticulitis. What symptom would the nurse promptly report to the primary healthcare You answered this question Correctly 1. Mid-abdominal pain radiating to the shoulder 2. Nausea and vomiting periodically for several hours 3. Abdominal rigidity with pain in the left lower quadrant 4. Elimination pattern of constipation alternating with diarrhea
3. Correct: Pain in the lower left quadrant with abdominal rigidity indicates the client is experiencing a perforated diverticulum and is a medical emergency. Abdominal rigidity indicates either perforation or internal bleeding. Both of these symptoms are considered an "acute abdomen" and are emergencies. 1. Incorrect: Mid-abdominal pain radiating to the shoulder is a common s/s for a client with cholecystitis but is not a medical emergency. 2. Incorrect: Nausea and vomiting periodically for several hours is often seen with diverticulitis but is not a medical emergency. 4. Incorrect: Elimination pattern of constipation alternating with diarrhea indicates a partial bowel obstruction and may require further investigation, but this is not a medical emergency. The nurse must be aware of risk factors that cause diseases. If the test taker does not know the correct answer, think about which body system the question is asking about may help rule out or rule in some of the options. Diverticulitis is defined as an inflammation of one or more diverticula, which are small pouches created by herniation of the mucosa into the wall of the colon. The clinical presentation of diverticulitis depends on the location of the affected diverticulum, the severity of the inflammatory process, and the presence of complications. Presenting signs/symptoms include: Left lower quadrant pain; Change in bowel habits; Nausea and vomiting; Constipation; Diarrhea; Flatulence; Bloating.
The nurse is assisting an unlicensed assistive personnel (UAP) move an obese and dependent client toward the top of the bed. Which action is most important to prevent shearing forces on the skin? 1. Each person puts hands under the client and slides client toward the top of the bed. 2. Apply powder to the sheet before pulling client toward the top of the bed. 3. Place turn sheet under the client and use it to slide the client toward the top of bed. 4. Seek assistance of another person before pulling up in bed.
3. Correct: Placing a turn sheet under the client before moving will prevent friction and shearing forces which may lead to an abrasion or skin tear. Pressure ulcers are more likely to develop in tissues where shear force injury has occurred. 1. Incorrect: This will not prevent shearing forces on the skin. The shearing force is created by gravity pushing down on the client's body, creating a resistance to movement. It creates a downward and forward pressure on tissues beneath the skin. 2. Incorrect: Using powder may actually irritate the skin as it may be abrasive when client's weight pushes against it and the bed. 4. Incorrect: Another person to assist in controlling the head or holding the lower legs would be helpful; however, using three to move up without protecting the skin would not be beneficial to the client. Shearing force injury to the skin could still result.
A client was prescribed thioridazine five days ago and presents at the clinic with a shuffling gait, tremors of the fingers, drooling, and muscle rigidity. Which adverse reaction to this medication is suspected? 1. Akinesia 2. Neuroleptic malignant syndrome 3. Pseudoparkinsonism 4. Oculogyric crisis
3. Correct: Pseudoparkinsonism may appear 1 to 5 days following initiation of antipsychotic medications and occurs most often in women, the elderly, and dehydrated clients. Symptoms include tremor, shuffling gait, drooling, and rigidity. 1. Incorrect: Akinesia is defined as muscle weakness. This is not an adverse reaction of thioridazine. 2. Incorrect: Neuroleptic malignant syndrome is a rare, but fatal complication of neuroleptic drugs. Routine assessments should include temperature and observation for parkinsonian symptoms (Hyperpyrexia up to 107 degrees, tachycardia, tachypnea, fluctuations in BP, diaphoresis, coma). 4. Incorrect: Oculogyric crisis is uncontrolled rolling back of the eyes and may appear as part of dystonia (Involuntary muscular movements of face, arms, legs, and neck).
A nurse invites a friend home one evening. On arrival, the friend sees the nurse's large, white, long-haired cat sitting on the couch and begins to experience palpitations, trembling, nausea, shortness of breath, and a feeling of losing control. What should the nurse do first? 1. Stay with the friend until the friend feels better. 2. Have the friend breathe into a paper bag. 3. Remove the cat from the room. 4. Dim the lights in the room.
3. Correct: Remove the source of the panic attack first, then continue to assess the person for symptoms. Removing the cat "fixes" the problem. 1. Incorrect: This is a correct answer, but remove the cat first. 2. Incorrect: This will help hyperventilation if it occurs, but the stem of the question said the client was having "shortness of breath" related to seeing the cat. Remove the cat first as this will fix the problem and alleviate the symptoms. 4. Incorrect: This is a correct answer, but remove the cat first.
The nurse is working with the parents of a preschooler to help promote healthy sleep patterns of approximately 8 - 12 hours of sleep per night. Which intervention should assist the parents to achieve adequate sleep for their preschooler? You answered this question Correctly 1. Offer a time of exercise prior to bedtime. 2. Follow a bedtime routine at least three or four nights per week. 3. Spend about 30 minutes with the preschooler prior to bedtime for stories. 4. Encourage preschooler to sleep without a toy.
3. Correct: Rituals help the preschooler to feel secure. Quiet time to read, tell stories, and say prayers prepares the child for sleep. 1. Incorrect: Stimulation of activity before bedtime impedes sleep. 2. Incorrect: The routine should be maintained each night if at all possible. Only through routine does the child feel secure in preparation for bedtime. 4. Incorrect: A special toy helps the child to feel secure and adds to the nighttime routine.
The nurse is caring for a client who is unresponsive during a postictal state. Which position is correct for this client? 1. Orthopneic 2. Dorsal recumbent 3. Sims' 4. Reverse trendelenburg
3. Correct: Sims' position is a semi-prone position where the client is halfway between lateral and prone positions. Often used for enemas or other examinations of the perianal area. Sims' position is used for unconscious clients because it facilitates drainage from the mouth and prevents aspiration. 1. Incorrect: Orthopneic position places the client in a sitting position with arms resting on an overbed table. It allows maximum expansion of the chest. This would not be a safe position for an unresponsive client. 2. Incorrect: Dorsal recumbent is a back lying position where the shoulders are slightly elevated on pillows. it is used after surgeries and anesthetics. 4. Incorrect: Reverse Trendelenburg is where the body is completely straight, but the head is elevated and the feet are down. This position helps with gastroesophageal reflux disease, snoring, and with some surgeries.
A female client considers using spermicidal agents because she wants both birth control and protection from sexually transmitted infections (STIs). What should the nurse explain regarding spermicidal agents? 1. Effective in reducing vaginal fungal infections such as Candida albicans. 2. Eliminates bacterial and viral sexually transmitted infections (STIs). 3. Most effective when used in conjunction with other barrier methods. 4. Are used on an "as-needed" basis and exhibit few side effects.
3. Correct: Spermicidal agents have an approximately 25% failure rate in preventing pregnancy and are not effective in preventing STIs. These agents kill sperm by destroying the protective surface of sperm and preventing metabolic activities necessary for survival. Barrier methods of contraception include the diaphragm, cervical cap, sponge, film, and condoms. 1. Incorrect: They do not kill fungi such as Candida albicans, even in high concentrations.2. Incorrect: Spermicidal agents do not eliminate bacterial and viral STIs. 4. Incorrect: Spermicidal agents are used only when sexual intercourse is expected, but side effects include vaginal and penile irritation, lesions, and ulcerations due to the detergent effect. Disruption of normal protective vaginal flora results in an increased risk of opportunistic vaginal infections and urinary tract infections.
The nurse is caring for a client taking spironolactone. Which needed dietary change should the nurse reinforce to the client? 1. Eat extra helpings of bananas. 2. Increase intake of water. 3. Avoid salt substitutes. 4. Increase intake of green leafy vegetables.
3. Correct: Spironolactone is a potassium sparing diuretic. Salt substitutes have potassium instead of sodium and should be avoided. 1. Incorrect: Bananas have potassium and should be avoided to prevent hyperkalemia and life threatening arrhythmias. 2. Incorrect: Water intake does not affect the use of spironolactone and is not the best answer to the question. 4. Incorrect: Green leafy vegetables contain vitamin K and are not contraindicated. This is a distractor to the answer that could cause the most harm to the client if not chosen. 1. Client safety is always a priority. 2. The test taker must be knowledgeable of prescribed diets for specific disease processes. This is mainly memorizing facts. There is no test taking strategies to help eliminate options.
A licensed practical nurse (LPN) in a long-term care facility assigns the task of feeding a client with dysphagia to an unlicensed assistive personnel (UAP) who is in orientation. Which action should be taken by the LPN to assign this task safely? 1. Verify that the UAP has experience in feeding clients with dysphagia. 2. Ask the UAP if he/she has any questions about the correct procedure. 3. Observe the UAP during the feeding to ensure that the correct technique is used. 4. Confirm that the UAP has the knowledge needed to feed a client with dysphagia by testing.
3. Correct: The LPN should observe the UAP during the feeding to ensure that the correct technique is used. Actually observing the UAP's performance of the task is necessary to validate that correct technique is used. 1. Incorrect: The LPN should observe the UAP feeding the client using the correct technique. Verifying that the UAP has experience would not ensure that the UAP is proficient at the assigned task. 2. Incorrect: The LPN should observe the nursing assistant feeding the client using the correct technique. Simply asking if the UAP has questions would not ensure that the UAP is proficient at the assigned task. 4. Incorrect: The LPN should observe the nursing assistant feeding the client using the correct technique. Confirming that the UAP has the necessary knowledge through testing would be too time-consuming.
A client visits the primary healthcare provider's office and requests a copy of their medical records. The client is angry about being placed on hold several times for over 10 minutes when requesting an appointment. What should the nurse tell this client? 1. All client appointment calls are transferred to the scheduling clerk. 2. The client will have to speak to the primary healthcare provider. 3. A copy of the record may be obtained within 24 hours of the request. 4. Medical records must stay within the facility unless requested by another primary healthcare provider.
3. Correct: The client has the right to the personal medical record. Generally, a period of time is required to get the record copied. The client may be charged for the copy. This assures the client that the request will receive attention. 1. Incorrect: This response dismisses the client's feelings and may only anger the client further. The response does not address the reason for the client's anger. The statement may be true; however, the client does have the right to request and receive a copy of the medical record. 2. Incorrect: The primary healthcare provider does not have to be contacted, as there should be policies in place to grant the request for a copy of the medical record. Also, telling the client to speak to the healthcare provider would not address the reason for the client's anger. This would dismiss the client's feelings. 4. Incorrect: The client has a right to the medical record. Records may also be requested by other providers with consent of the client. The client's feelings should be addressed, and the client should be informed that the medical record will be provided as requested.
A client was admitted to the psychiatric unit with delusions and a history of auditory hallucinations. The client reports, "The FBI has been watching my house and are going to raid it and arrest me." What is the nurse's best response? 1. "The FBI would not be watching you unless there was a good reason." 2. "I don't think that the FBI is watching your house. " 3. "I believe that your thoughts are very disturbing to you." 4. "Tell me more about your thoughts."
3. Correct: The client's delusions can be very distressing. The nurse should empathize with the feelings of the client, but should not validate the belief itself. Empathy displays that the nurse is concerned, interested, and accepts the client but does not support the delusion. 1. Incorrect: Arguing with the client who has delusions only upsets the client and may provoke violence. The client cannot understand the logical argument, so the delusional ideas are not dispelled. Also, the argument can interfere with the development of trust. 2. Incorrect: Disagreement may anger the client. The client needs empathy and understanding from the nurse. This is dismissing the client's feelings. The focus should not be on what the nurse thinks. The focus should always be on the client's feelings. 4. Incorrect: In-depth detail of delusions only reinforces the delusion. The nurse should encourage reality based conversation. Interacting about reality is beneficial for the client to move them away from delusional thoughts.
A nurse from an adult unit was reassigned to the pediatric unit. Which client would be least appropriate to assign to this nurse? 1. Ten year old with 2nd and 3rd degree burns. 2. Five year old that was in a MVA and has a femur fracture. 3. Six year old admitted for evaluation of possible sexual abuse by a parent 4. Two month old with bronchopulmonary dysplasia being admitted for reflux.
3. Correct: The least appropriate client to assign the nurse from the adult unit would be the suspected sexual abuse. Caring for an abused child requires skill that must be developed from understanding the dynamics of abuse as well as working with a certain developmental level. 1. Incorrect: A nurse on an adult unit should understand classification of burns and associated care for the burn client. The manifestations that the pediatric burned client exhibits would be similar to the condition adults might acquire, and the nurse's skill level could transfer to these clients. 2. Incorrect: The nurse who works on an adult unit should understand the concepts for caring for a client with a fracture. The pediatric client with the fracture would have findings similar to those that adults might acquire, and the nurse's skill level could transfer to these clients. 4. Incorrect: The 2 month old with BPD is different, but the concept and care of reflux is similar to that in adult clients. 1. Identify key words in the stem that indicate negative polarity, such as not, except, never, contraindicated, unacceptable, avoid, unrelated, violate, least, further teaching needed. These words indicate negative polarity and the question being asked is looking for what is false. 2. The key to this question is the fact that, although the nurse is an experienced in adult care, the nurse is not experienced in pediatric conditions. The client who could receive a treatment on a medical-surgical floor should be assigned to the nurse. In this case, the abused client does not share characteristics common to pediatric and adult clients and should not be assigned to the nurse from the adult unit due to the unique skill sets needed to monitor abusive situations and intervene at the appropriate developmental level.
When preparing an intramuscular injection for a neonate, which needle should a nurse select? 1. 18 G, 7/8 inch 2. 21 G, 1 inch 3. 25 G, 5/8 inch 4. 25 G, 1.5 inch
3. Correct: The most appropriate needle to select for use in administering IM injection to a neonate would be a 25 gauge, 5/8 inches long. Intramuscular injections are given in the vastus lateralis muscle of the thigh. 1. Incorrect: This needle is too large a diameter for a newborn infant. An 18 gauge needle is appropriate for the intravenous (IV) medication or blood administration in adults. 2. Incorrect: This needle would be too large for a newborn infant. A 21 gauge needle is typically used to draw up medication from vials or ampules (filtered needle required). 4. Incorrect: This needle would be far too long for a newborn infant and also for most children. A 1.5 inch needle is often needed to administer intramuscular injections to obese adults.
What task would be most appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 1. Ambulating a client who has syncopy. 2. Changing a colostomy bag on a client. 3. Serving the diet tray for a diabetic client. 4. Taking the initial vital signs on a client who is to receive blood.
3. Correct: The most appropriate task for a non-licensed person would be serving the diet tray for a client. This does not require experience for a particular skill nor does it require higher level skills that would require a licensed person to perform. 1. Incorrect: A client with syncope is not a stable client. The UAP should not ambulate this client. 2. Incorrect: Changing the colostomy bag on a client will need someone with the experience/skill of performing this task. Although some agencies allow UAP's to change colostomy bags, there may be further assessment needed associated with the ostomy, such as skin condition around the ostomy. This would not be the best option to assign to the UAP. 4. Incorrect: UAPs can take VS, but they must be very cautious in order to note changes and the client receiving blood should be assessed for any s/s of reaction. Therefore, it would be best for the licensed personnel to obtain the initial v/s prior to blood administration to assess the client's status and have a baseline for evaluating the client's response to the blood administration.
Two hours following a lumbar puncture, the client stands up to void and reports a headache rated 8 out of 10 on a pain scale. What priority action should the nurse perform? 1. Instruct the client to drink at least 8 ounces (240 mL) of water. 2. Close room blinds to darken the environment. 3. Assist the client into a supine position in bed. 4. Notify primary healthcare provider of client's complaints.
3. Correct: The most frequent cause of headache following a lumbar puncture is loss of, or leaking, of cerebrospinal fluid from the puncture site. Positioning a client is an important nursing responsibility, particularly in this situation since the supine position could help to stop any leaking. Following this, the nurse will pursue additional actions as prescribed by the primary healthcare provider, which may include increasing fluids or even a blood patch. 1. Incorrect: Although increasing fluids may help clients under specific circumstances, it is not the priority action in this situation. Additionally, the primary healthcare provider may order IV fluids rather than PO fluids. 2. Incorrect: A darkened room can be beneficial for clients with severe migraine headaches, but would not be useful to this client. Headaches following a lumbar puncture are caused by the loss of cerebrospinal fluid and would not respond to a quiet, dark environment. So this would not be the priority. 4. Incorrect: Although the primary healthcare provider should indeed be notified of this situat
An expected outcome for a client with pneumonia is: "The airway will be free of secretions." What should the nurse do to help assure this outcome? 1. Evaluate results of ABG's and report abnormal findings. 2. Assess color of skin, lips, and nail beds for cyanosis. 3. Question an order for a cough suppressant medication. 4. Monitor oxyhemoglobin saturation by oximetry.
3. Correct: The nurse knows the client needs to expectorate the sputum to remove bacteria or prevent bacterial growth. If the cough is suppressed, the bacteria will remain and grow in the lungs. (That's the bad thing.) 1. Incorrect: When the problem is a lung thing we always evaluate the ABG's. 2. Incorrect: Assessing color of skin, lips, and nails beds for cyanosis are important assessments in determining adequate oxygenation. 4. Incorrect: Checking the saturations will assist in determining adequate oxygenation.
What action should the nurse take after entering the room of a client who becomes agitated and combative? 1. Administer prn sedative. 2. Notify the family of client behavior. 3. Speak softly to the client. 4. Apply wrist restraints.
3. Correct: The nurse needs to present a calm manner and speak quietly to the client. This will build trust and decrease tension and stress in the client. 1. Incorrect: This is a form of restraint. The use of positive nursing actions can reduce the use of chemical (drug therapy) restraints. 2. Incorrect: Do not pick an answer that transfers the client away from the nurse's care. 4. Incorrect: Restraints are a last resort and can make the client more agitated. The nurse needs to present a calm manner and speak quietly to the client. This will build trust and decrease tension and stress in the client. When dealing with the difficult client, do not threaten to restrain the client or call the primary healthcare provider. Reassurance involves communicating to the client that he or she will be protected from harm, danger, and embarrassment. These behaviors are often the client's way of responding to a precipitating factor, such as pain, frustration, temperature extremes, or anxiety. When these behaviors become problematic, the nurse must plan interventions carefully.
The nurse prepares a sterile field for a procedure. Fifteen minutes later, the nurse is informed that there will be a 20 minute delay before the primary healthcare provider will arrive. What action should the nurse take? 1. Cover the sterile field with a sterile drape 2. Close and tape the doors so that no one may enter. 3. Monitor the sterile field while awaiting the primary healthcare provider. 4. Take down the sterile field.
3. Correct: The nurse should monitor the sterile field while awaiting the primary healthcare provider. This means keeping the sterile field in your site. 1. Incorrect: Sterile fields should not be covered. Although there are no research studies to support or discount the practice, removing a table cover may result in a part of the cover that was below the table level being drawn above the table level or air currents drawing microorganisms from a nonsterile area to the sterile field. It is important to continuously monitor all sterile areas for possible contamination. 2. Incorrect: There is no specified amount of time designated that a room can remain open and not used and the sterile field still be considered sterile. The sterility of an open sterile field is event-related. An open sterile field requires continuous visual observation. Direct observation increases the likelihood of detecting a breach in sterility. 4. Incorrect: It is unnecessary to take down the sterile field as the delay is minimal. This is also an added cost to discard materials and redo the sterile field when it has not been contaminated. Sterile fields should be prepared as close as possible to the time of use. The potential for contamination increases with time because dust and other particles present in the ambient environment settle on horizontal surfaces over time. Particulate matter can be stirred up by movement of personnel when opening the room and can also settle on opened sterile supplies.
A client was admitted to the medical unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's BP is 198/94. What would be the best action for the nurse to take? 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm in 15 minutes. 3. Administer the 0900 furosemide and enalapril now. 4. Check the client for pain.
3. Correct: The nurse should recognize the need for measures to reduce the blood pressure. Administering the client's blood pressure medicine is aimed at correcting the problem. It is appropriate to administer the medications at this time in relation to the time that the next dose is due. 1. Incorrect: The UAP may put a client back in bed if they are up and the BP is elevated. But this action does not address the client's elevated BP. 2. Incorrect: This is a delay of care. It does not address the problem of lowering the client's blood pressure. 4. Incorrect: Delay of care. This is an appropriate action, but does not address the problem of lowering the client's blood pressure. Never delay treatment or choose an option that ignores client symptoms.
Following surgery, a client refuses to ambulate as prescribed. What action should the nurse take? 1. Notify the primary health care provider of client's refusal to ambulate. 2. Offer the client pain medication. 3. Explain complications associated with bed rest. 4. Perform passive range of motion exercises.
3. Correct: The nurse should tell the client about complications that can be prevented with ambulation, such as constipation, pneumonia, or deep vein thrombosis (DVT). 1. Incorrect: The first action should be for the nurse to tell the client so an informed decision can be made. This would put the nurse in an advocacy role and would more likely persuade the client to comply with ambulation. 2. Incorrect: The first action should be for the nurse to tell the client so that he/she can make an informed decision. Offering pain medication would be appropriate if pain is impeding the client's ability to move; however, pain medications may make the client at risk for falls so safety precautions would be priority. 4. Incorrect: The first action should be for the nurse to tell the client so that an informed decision can be made. Passive range of motion would not be the best option at this time. 1. Identify clues in the stem. Generally, the stem is short and contains only the information needed to make the question clear. A clue is the use of a word or phrase that leads you to the correct answer. The clue shows a relationship to word or phrase in the correct answer. 2. Identify key words in the stem that indicate negative polarity, such as not, except, never, contraindicated, unacceptable, avoid, unrelated, violate, least, further teaching needed. These words indicate negative polarity and the question being asked is looking for what is false.
The nurse observes that the client's respirations have a rhythmic increase and decrease of rate and depth and include brief periods of apnea. How would the nurse document this respiratory pattern? 1. Biot's respirations 2. Ataxic 3. Cheyne-Stokes 4. Cluster
3. Correct: The respiratory pattern described is Cheyne-Stokes, an abnormal pattern of breathing. The respirations pattern is characterized by rhythmic increase and decrease in respirations and brief period of apnea. 1. Incorrect: Biot's respirations is characterized by a pattern of bradypnea and shallow respirations which change to tachypnea and deep respirations, followed by apnea. 2. Incorrect: Ataxic respirations have an irregular, random pattern of deep and shallow respirations with irregular apneic periods. The irregularity of it differentiates ataxic respirations from Cheyne-Stokes respirations. 4. Incorrect: Cluster breathing is characterized by a closely grouped series of gasps followed by a period of apnea. There is no rhythmic increase and decrease as in Cheyne-Stokes respirations.
To determine the standards of care for the institution, the nurse should consult which document? You answered this questionCorrectly 1. Organizational Chart 2. Personnel policies 3. Policies and procedure manual 4. Job descriptions
3. Correct: The standard of care for nurses is defined as what a prudent nurse would do in the same situation. The policies and procedure manual defines standards of care for an institution. 1. Incorrect: An organizational chart identifies which departments exist and their relationship with each other. It also lists the chain of command of positions/jobs. 2. Incorrect: Policies for personnel are not standards of care. Personnel policies are pre-established guidelines that are utilized to govern personnel related issues. 4. Incorrect: A job description is a formal written statement of an employee's work responsibilities. This is not related to the standards of care and therefore, doesn't go into detail about standards of care.
After shift report, which client should the nurse see first? 1. Eight year old that is in skeletal traction. 2. Six year old who is 5 hours postop appendectomy. 3. Unattended two year old admitted for a sleep study. 4. Four year old cerebral palsy child with a urinary tract infection (UTI).
3. Correct: The unattended child should be checked first to make sure he/she is safe and having no complications. A child this age is entirely dependent on someone else. Safety is priority here. 1. Incorrect: An eight year old in skeletal traction does not take priority over unattended 2 year old.. 2. Incorrect: A six year old who is 5 hr post appendectomy should be seen, but not as immediate as an unattended 2 year old. 4. Incorrect: This client has a UTI and is not acutely ill at this time. The major clues in the question are age and unattended. The unattended two year old child's safety is the reason for that child being the priority over this child.
The nurse is reinforcing teaching to a client about foods containing tyramine which should be avoided while taking a monoamine oxidase inhibitor (MAOI). Which meal selection, if chosen by the client, indicates understanding? 1. Smoked turkey and dressing, sweet peas and carrots and milk. 2. Baked chicken over pasta with parmesan sauce, baked potato and tea. 3. Fried catfish, French fries, coleslaw and apple juice. 4. Liver smothered in gravy and onions, rice, squash and water.
3. Correct: These foods are not high in tyramine. Tyramine is an amino acid that helps in the regulation of blood pressure. MAOIs block the enzyme monoamine oxidase which is responsible for breaking down excess tyramine in the body. Eating foods high in tyramine while on MAOIs can result in dangerously high levels of tyramine in the body. This can lead to a serious rise in blood pressure, creating an emergency situation. Tyramine is found in protein-containing foods and the levels increase as these foods age. Food such as strong or aged cheese, cured meats, smoked or processed meats, liver (especially aged liver), pickled or fermented foods, sauces, soybeans, dried or overripe fruits, meat tenderizers, brewer's yeast, alcoholic beverages and caffeine- such as in tea, cokes and coffee are considered to be high in tyramine and should be avoided in clients taking MAOIs. 1. Incorrect: The following foods in the options listed above contain moderate to high levels of tyramine and should be avoided while taking MAOIs: smoked turkey, parmesan cheese, tea and liver. 2. Incorrect: The following foods in the options listed above contain moderate to high levels of tyramine and should be avoided while taking MAOIs: smoked turkey, parmesan cheese, tea and liver. 4. Incorrect: The following foods in the options listed above contain moderate to high levels of tyramine and should be avoided while taking MAOIs: smoked turkey, parmesan cheese, tea and liver.
The nurse is caring for a client who has taken an acetaminophen overdose. Which symptom is the client most likely to exhibit? 1. Expectorating pink frothy sputum 2. Sudden onset of mid-sternal chest pain 3. Jaundiced conjunctiva 4. Diaphoresis and fever
3. Correct: This is a sign of liver damage, which is caused by an overdose of acetaminophen. 1. Incorrect: This is a symptom of pulmonary edema, not liver damage. 2. Incorrect: This is a symptom of myocardial ischemia, not liver damage. 4. Incorrect: Acetaminophen would decrease fever, and fever could cause diaphoresis, so neither of these are expected with acetaminophen overdose.
A client diagnosed with lung cancer is told that the client only has about 6 months to live. The spouse tells the nurse, "I pray every night that God will give me more time with my loved one." Which Kübler-Ross stage of grief does the nurse recognize the spouse to be exhibiting? 1. Anger 2. Acceptance 3. Bargaining 4. Depression
3. Correct: This is the 3rd stage of grief. At this stage, the individual attempts to strike a bargain with God for a second chance, or for more time. The person acknowledges the loss, or impending loss, but holds out hope for additional alternatives. 1. Incorrect: The 2nd stage of grief is when reality sets in. Feelings include sadness, guilt, shame, helplessness, and hopelessness. Self-blame or blaming of others may lead to feelings of anger toward self and others. 2. Incorrect: The fifth and last stage of grief. At this time, the person has worked through the behaviors associated with the other stages and either accepts or is resigned to the loss. Anxiety decreases, and methods of coping with the loss have been established. 4. Incorrect: The 4th stage of grief. The individual mourns that which has been or will be lost. This is a very painful stage, during which the person must confront feelings associated with having lost someone or something of value.
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 pumpimg enough blood to oxygenate body tissues." 4. "Increased daily activity can help increase strength and endurance."
3. Correct: 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. 2. Incorrect: Episodes of cyanosis with exertion are common in children diagnosed with Tetralogy of Fallot. However, the amount of protein or vitamins in the child's diet will not correct this issue, since the cause is related to oxygenation and not diet. 4. Incorrect: Simple activities actually increase periods of cyanosis, which is related to the amount of oxygenated blood available during exertion. Increasing activity prior to surgical repair of the heart would decrease endurance or tolerance. Identify client-centered options. The focus of the nurse should be the client. Items that test your ability to be client-centered tend to explore client feelings, identify client preferences, empower the client, provide the client choices, or in some way put emphasis on the client. The client is the priority. Tetralogy of Fallot is a serious birth defect that incorporates four specific heart defects: pulmonary stenosis, ventricular septal defect (VSD), overriding aorta, and hypertrophy of RIGHT ventricle. There is an outflow obstruction of blood from right ventricle into pulmonary circulation which increases the pressure in the right ventricle, leading to right-to-left shunting of unoxygenated blood, back through the VSD and directly into the aorta. What does this all mean? At birth, these newborns are acutely cyanotic, which is exacerbated with exertion such as crying, feeding, or even moving in the crib. If not repaired, the child will develop clubbing of the finger nails and toenails, growth retardation and a systolic murmur. You recall the most prominent symptom is referred to as "Tet spells", which are periods of cyanosis secondary to hypoxia whenever the oxygen supply cannot keep up with the body's demands during exertion. If the child begins to stand or walk, the parents may note squatting or leaning forward in order to breath during these episodes. These defects are very serious and should be surgically repaired within the first two years of life before permanent damage occurs to the body. Option 1: Close but not quite. The child has Tetralogy of Fallot, a birth defect that includes four separate structural heart defects. Whenever a question uses the word cyanosis, consider hypoxia with lack of oxygen to the body tissues. Because of shunting the UNOXYGENATED blood out through the aorta, body tissues do not receive the enough oxygen. Think quality versus quantity! Try again. Option 2: Definitely not. This child was born with a serious heart defect which has nothing to do with diet. In fact, changing the diet would not solve the issue. Only surgical intervention can correct this defect and help the child lead a normal life. Additionally, surgery should be performed by age two in order to prevent permanent growth damage. Option 3: Excellent! This statement by the LPN is absolutely correct. More importantly, the information is presented in a simple, open-ended statement which will allow the mother to ask additional questions or even share concerns or fears. When parents are given such dramatic, overwhelming information about a newborn, it's difficult to comprehend all the details at once. Consider how scary it would be when this mother witnesses the infant becoming cyanotic during feeding or crying. It is understandable the client would need the information reviewed again. Option 4: Seriously? Increasing activity before surgical repair is counterproductive. Such an action does not help to increase endurance! The more active the child, the worse the hypoxia will be. Until surgical repair is completed, the parents are actually instructed to decrease activity and minimize exertion. Usually a parent quickly learns that activity causes the child to become cyanotic -a scary event for parents!
The nurse is preparing a client for a renal biopsy. Which data is most important to gather prior to this procedure? 1. BUN 2. NPO status 3. Prothrombin time (PT) 4. Serum potassium 5. Activated partial thromboplastin time (aPTT)
3. Correct: Yes, before you insert a needle into an organ for a biopsy it would be best to know their bleeding time and coagulation studies. Prothrombin is a protein produced by the liver. The PT test measures how well and how long it takes for blood to clot. Normally this is 20-30 seconds. aPTT also measures the time it takes for blood to clot. 1. Incorrect: Although BUN is related to renal function, it does not impact the procedure itself. This is not essential for the procedure. 2. Incorrect: Although this is carried out, it does not take priority over the risk of bleeding. Always think what could be life threatening. 4. Incorrect: Although serum potassium is related to renal function, it does not impact the procedure itself. This is not essential for the procedure.
The nurse is caring for an oncology client with a WBC-5.5/mm3, Hgb-12g/dL, PLT- 40,000 /mm3. Which measure should be instituted? 1. Protective isolation 2. Oxygen therapy 3. Bleeding precautions 4. Strict intake and output
3. Correct: Yes. That is the only value that is not a normal level, and it is way too low, so this client is at risk for bleeding. Bleeding precautions are the appropriate intervention. A normal platelet count ranges from 150,000 to 450,000/mm3. Having more than 450,000 platelets is a condition called thrombocytosis; having less than 150,000 is known as thrombocytopenia. 1. Incorrect: The WBC is okay. An average WBC normal range is between 5,000 and 10,000/mm3. Leukopenia is the medical term used to describe a low WBC count. 2. Incorrect: There is no indication of hypoxia in stem, and the Hgb is normal, so the client is not anemic. A low hemoglobin count is generally defined as less than 14 g/dL for men and less than 12 g/dL for women. 4. Incorrect: There is no indication for I & O measurement. I&O should be done with clients who have a fluid volume, cardiac, or renal problem.
A primary healthcare provider has prescribed sterile saline 1.5 mL IM every 4 hours as needed for pain for a client who reports frequent "severe" headaches. What action should the nurse take? 1. Administer the medication as prescribed. 2. Obtain pre-filled syringes from the pharmacy. 3. Discuss client rights with the primary healthcare provider. 4. Tell the client what has been prescribed.
3. Discuss client rights with the primary healthcare provider. 3. Correct: Not only does deceitful use of placebos in place of appropriate pain treatment violate the client's right to the highest quality of care possible, it clearly poses a moral, ethical, and professional danger to healthcare providers. Perhaps the most important reason for not using placebos in the assessment and treatment of pain is that deception is involved. Deceit is harmful to both clients and healthcare professionals. 1. This is causing an ethical dilemma for the nurse. The nurse is now lying to the client by giving the placebo which is clearly wrong. The client is not aware that the solution administered is sterile saline. 2. Obtaining pre-filled syringes does not correct the ethical dilemma faced by the nurse and does nothing to fix the problem. 4. Telling the client will cause mistrust. It is best to discuss the issue with the primary healthcare provider. A discussion with the primary healthcare provider concerning the saline order should occur prior to any discussion with the client.
A term male infant was just delivered vaginally. Which action by the nurse has priority? 1. Apply identification bands. 2. Apply eye ointment. 3. Dry the baby. 4. Obtain footprints.
3. Dry the baby. 3. Correct: Cold stress is the biggest danger to a newborn. A newborn is wet, and evaporation will rapidly cool the baby which can cause hypoglycemia and respiratory distress. 1. Incorrect: Applying the identification bands needs to be accomplished before the baby leaves the delivery room, but this is not the immediate priority. 2. Incorrect: Eye prophylaxis can safely be delayed up to two hours after delivery. 4. Incorrect: Obtaining footprints needs to be accomplished before the baby leaves the delivery room, but this is not the immediate priority.
Which tasks should the nurse assign to the unlicensed assistive personnel (UAP)? . Demonstrate post-operative exercises. 2. Reposition the transcutaneous electrical nerve stimulation (TENS) unit. 3. Empty the indwelling catheter bag. 4. Assist a client with position change every 2 hours. 5. Apply anti-embolism stockings.
3. Empty the indwelling catheter bag. 4. Assist a client with position change every 2 hours. 5. Apply anti-embolism stockings. 3., 4. & 5. Correct. It is within the role of an UAP to empty the indwelling catheter bag, assist with position change, and apply anti-embolism stockings. The nurse should confirm that these tasks have been done, but they are safe to assign to the UAP. 1. Incorrect. This is beyond the scope of practice for the UAP because teaching and teaching reinforcement is required. 2. Incorrect. The physical therapist is the best team member to manage the TENS unit since this is a pain control device that affects nerves and muscles. Follow the 5 rights of assignment: Right task, right person, right circumstance, right direction, right supervision What can an UAP do? The UAP can perform tasks related to activities of daily living and routine tasks. Option 1 says to have the client demonstrate post op exercises. Can the UAP teach or evaluate whether these are done correctly? No. Option 2 wants you to assign repositioning of a TENS unit to the UAP. Is this routine? No. Does it having anything to do with ADL? No. False. Option 3 says empty the indwelling catheter bag. Can the UAP measure urine? Yes, the UAP is trained to do this. Option 4: Help the client change positions. Can the UAP assist with doing this? Yes. Option 5: Apply anti-embolism stockings? Yes, the UAP is trained to do this.The nurse should confirm that these tasks have been done, but they are safe to assign to the UAP.
Which tasks should the nurse assign to the unlicensed assistive personnel (UAP)? 1. Demonstrate post-operative exercises. 2. Reposition the transcutaneous electrical nerve stimulation (TENS) unit. 3. Empty the indwelling catheter bag. 4. Assist a client with position change every 2 hours. 5. Apply anti-embolism stockings.
3. Empty the indwelling catheter bag. 4. Assist a client with position change every 2 hours. 5. Apply anti-embolism stockings. 3., 4. & 5. Correct. It is within the role of an UAP to empty the indwelling catheter bag, assist with position change, and apply anti-embolism stockings. The nurse should confirm that these tasks have been done, but they are safe to assign to the UAP. 1. Incorrect. This is beyond the scope of practice for the UAP because teaching and teaching reinforcement is required. 2. Incorrect. The physical therapist is the best team member to manage the TENS unit since this is a pain control device that affects nerves and muscles. Follow the 5 rights of assignment: Right task, right person, right circumstance, right direction, right supervision. What can an UAP do? The UAP can perform tasks related to activities of daily living and routine tasks. Option 1 says to have the client demonstrate post op exercises. Can the UAP teach or evaluate whether these are done correctly? No. Option 2 wants you to assign repositioning of a TENS unit to the UAP. Is this routine? No. Does it having anything to do with ADL? No. False. Option 3 says empty the indwelling catheter bag. Can the UAP measure urine? Yes, the UAP is trained to do this. Option 4: Help the client change positions. Can the UAP assist with doing this? Yes. Option 5: Apply anti-embolism stockings? Yes, the UAP is trained to do this.The nurse should confirm that these tasks have been done, but they are safe to assign to the UAP.
nurse working in a locked psychiatric unit is caring for a client diagnosed with paranoia. The client becomes very agitated and shouts, "I am not going to my session today!" What action by the nurse would be most appropriate? 1. Sit with the client and say a prayer. 2. Send the client to the session after explaining that shouting is not allowed. 3. Escort the client to an easel and canvas in order for the client to paint. 4. Call for assistance and put the client in seclusion.
3. Escort the client to an easel and canvas in order for the client to paint. 3. Correct: Yes! Get them active. Redirect their activity. This is a much more therapeutic and effective intervention to help the paranoid client. 1. Incorrect: They are agitated and shouting. It is not reasonable to get them to sit and pray. 2. Incorrect: Setting limits is good, but here the client is disruptive and shouldn't go to group at this time. 4. Incorrect: This would not be the best action. Try to redirect the client first. Then, if unsuccessful, seclusion would be considered as a last resort.
The nurse is caring for a client with full thickness burns to the left arm and left leg. What is the priority for this client? 1. Pain 2. Airway 3. Fluid volume status 4. Risk for injury
3. Fluid volume status 3. Correct: Yes! The client will have lots of fluid loss through the burn wound and also the fluid shift.1. Incorrect: Pain is not the priority over fluid volume status. 2. Incorrect: This client does not have airway involvement.4. Incorrect: Risk for a burn? Too late for that one.
What should the nurse include when reinforcing teaching to a client in renal failure about peritoneal dialysis? 1. Instill 250 mL of fluid into the peritoneal cavity over 30 minutes. 2. Use cool effluent when instilling into the peritoneal cavity. 3. Following the prescribed dwell time, lower the bag to allow the fluid to drain out. 4. The fluid that is returned should be clear in appearance. 5. If all the fluid does not drain out, place the bed in the Trendelenburg position. 6. A sweet taste may be experienced when peritoneal dialysis is used.
3. Following the prescribed dwell time, lower the bag to allow the fluid to drain out. 4. The fluid that is returned should be clear in appearance. 6. A sweet taste may be experienced when peritoneal dialysis is used. 3, 4, & 6 Correct: Once the prescribed dwell time has ended, the bag is lowered and the fluids, along with the toxins, are drained out into a bag over a period of 15 - 30 minutes. The fluid should be clear in appearance (should be able to read a paper through it). Cloudy return could indicate infection. Since the dialysate has a lot of glucose in it, the client frequently reports a constant sweet taste. 1. Incorrect: The amount of fluid used in peritoneal dialysis is about 2000 to 2500 mL at a time. This filling of the peritoneal cavity is often completed in 10 minutes. 2. Incorrect: Cool fluids would cause vasoconstriction. The effluent should be warmed to body temperature to promote blood flow to enhance the exchange (the more blood flow, the more toxin removal). 5. Incorrect: If all of the fluid does not come out, the client should turn side to side to promote drainage. The Trendelenburg position would cause the fluids to pool in the upper peritoneal area and not drain adequately.
A client is diagnosed with a duodenal ulcer due to Helicobacter pylori (H Pylori). In addition to antibiotic therapy, the nurse anticipates that the client will also receive what class of pharmacologic agents? 1. Miotic inhibitor 2. Serotonin antagonist 3. H2 antagonist 4. Acetylsalicyclic acid 5. Proton pump inhibitor
3. H2 antagonist 5. Proton pump inhibitor Rationale 3., & 5. Correct: H2 antagonist or receptor blockers are used to decrease excess stomach acid seen with ulcers. Antisecretory agents like proton pump inhibitors are indicated for the treatment of peptic ulcer disease. Antisecretory agents decrease the secretion of gastric acids. Protein pump inhibitors, a combination of antibiotics and bismuth salts are most commonly used for treatment of H Pylori. 1. Incorrect: Mitotic inhibitors are chemotherapeutic agents that are indicated for the treatment of malignancies and cancerous cells. They are most often used in combination chemotherapy regimens to enhance the overall cytotoxic effect. 2. Incorrect: Serotonin antagonists are antiemetic agents that are indicated for the treatment of nausea and vomiting. Serotonin antagonists block the serotonin receptor sites located throughout the body responsible for the mediation of nausea and vomiting. 4. Incorrect: Acetylsalicylic acid is a non narcotic analgesic that inhibits the cox-2 protective mechanisms to the gastric mucosa. This could make the ulcer worse. Clients are advised to avoid the use of NSAIDs and acetylsalicylic acid due to increased bleeding potential.
The nurse just received an arterial blood gas (ABG) report that shows a borderline high PCO2 on a client who had chest surgery. What should be the priority nursing intervention? 1. Tell the client to breathe faster. 2. Medicate for pain and ambulate. 3. Have client use the incentive spirometer. 4. Prepare to administer bicarbonate to buffer.
3. Have client use the incentive spirometer. 3. Correct: This client had chest surgery and the pCO2 is high. What are you worried about? Hypoventilation. Yes, the client is probably hurting due to the incision and does not want to take deep breaths. In order to get rid of the excess CO2, the client needs to turn, cough, and deep breathe. Incentive spirometry can be provided to assist the client with this effort. 1. Incorrect: Breathing faster will only work for a few minutes. The problem is the client needs to breathe deeper to get more oxygen to the tissue and more CO2 out of the lungs. Hyperventilating will lead to respiratory alkalosis. 2. Incorrect: No more sedation! The client is not breathing enough. Walking would be okay. This client needs to take deep breaths. 4. Incorrect: No, we want the client to blow off the CO2. Bicarb will make the pH happy for a short period of time but will not correct the problem. The problem is shallow respirations, so fix the problem.
During evening rounds, the nurse discovers that a violent client with a history of threats against a former girlfriend cannot be located. The client's personal belongings are missing. Based on recent threats of violence against the girlfriend, what is the nurse's initial action? 1. Look for the client quietly to maintain confidentiality. 2. Notify the local police to organize a search party. 3. Initiate the missing client protocol. 4. Complete an "Against Medical Advice" (AMA) form on the client's elopement.
3. Initiate the missing client protocol. 3. Correct. Since the client is missing and is considered to be a risk to himself or others, the missing client protocol is immediately implemented. An organized and escalating search for the client will occur. 1. Incorrect. Although HIPAA is very precise on the issue of confidentiality, privacy is waived in specific, extreme situations that involve the life of a client, staff, or family. While the nurse may alert staff members to help search the building or facility grounds, this is not the initial action of the nurse. 2. Incorrect. Although local police may eventually be asked to assist in locating the client, this decision will be made by the facility's administrative personnel. However, this is not the initial action under the stated circumstances. 4. Incorrect. An Against Medical Advice (AMA) form is signed by a client who decides to leave a facility without treatment, against the advice of the primary healthcare provider. That form does not apply in this situation since the client has already left. This event falls under the category of elopement. 1. Identify key words in the stem that set a priority, such as first, initially, best, priority, safest, most. These words modify what is being asked. This question requires you to put a value on each option and then place them in rank order. If you are having difficulty ranking the options, eliminate the option that you believe is most wrong among the options. 2. Client safety is always a priori
What factor would most likely predispose a client with a compound femoral fracture to develop shock? 1. Pooling of the blood in the lower leg 2. Generalized vasoconstriction in the lower extremities 3. Loss of blood into soft tissues surrounding the fracture 4. Depression of the adrenal gland by toxins released at the injury
3. Loss of blood into soft tissues surrounding the fracture 3. Correct: After a fracture, the factor that would most likely lead to shock is loss of blood into the soft tissue surrounding the fracture. When fractures occur, major arteries can be severed, causing loss of blood into the surrounding tissue. 1. Incorrect: Pooling of blood in the lower extremities is a possibility, but bleeding into the surrounding tissue is more acute. 2. Incorrect: Vasoconstriction in the lower extremities is an appropriate compensatory response for a "shocky" client. Vasoconstriction of the lower extremities will increase blood pressure. 4. Incorrect: Depression of the adrenal glands caused by release of toxins at the injured site is not correct.
A middle-aged client has a strong positive family history of type 2 diabetes mellitus. What is the best recommendation the nurse can reinforce to decrease the client's risk of developing this disease?
3. Obtain a normal body weight and exercise regularly 3. Correct: Genetics and body weight are the most important factors in the development of type 2 diabetes mellitus. The client cannot alter genetics. Therefore, a normal body weight is imperative. Regular exercise reduces insulin resistance and permits increased glucose uptake by cells. This serves to lower insulin levels and reduce hepatic production of glucose.1. Incorrect: Monthly glucose monitoring is not sufficient. Glucose monitoring is a diagnostic test to determine the glucose level. 2. Incorrect: Starch and sugar intake should be decreased, not avoided.The diabetic diet should include vegetables, fruits, nuts, legumes, whole grain and wheat bran.4. Incorrect: Maintaining a normal serum lipid panel may not be achievable in some clients, but it is always the goal. However, the best way to reduce the risk of developing type II diabetes is to obtain a normal body weight and exercise regularly.
The nurse is caring for a male pt who performs frequent urinary self catheterizations. Which of tehy following client assessmets would indicate a potential for latex allergy.
Known allergy to avocados and bananas Lip swelling when blowing uo ballons tomato
The nurse is preparing to provide oral care to an unconscious client. What is the most important step for the nurse to provide? 1. Performing hand hygiene. 2. Explaining the procedure to the family. 3. Positioning the client in side-lying position. 4. Raising the head of bed 30 degrees
3. Positioning the client in side-lying position. Correct: Positioning the client in a side-lying position allows secretions to drain from the mouth and prevents aspiration. The most important aspect of care is the protection of the airway of this unconscious client. This is accomplished through proper positioning of the client in a side-lying position.
An expected outcome for a client with pneumonia is: "The airway will be free of secretions." Which action by the nurse is most important in meeting this goal? 1. Check results of ABG's and report abnormal findings. 2. Monitor color of skin, lips, and nail beds for cyanosis. 3. Question an order for a cough suppressant medication. 4. Monitor oxyhemoglobin saturation by oximetry.
3. Question an order for a cough suppressant medication. 3. Correct: The nurse knows the client needs to expectorate the sputum to remove bacteria or prevent bacterial growth. If the cough is suppressed, the bacteria will remain and grow in the lungs. This option is most important to assure outcome of airway being free of secretions. 1. Incorrect: When the problem is in the lungs we check the ABG's to determine how well the lungs move oxygen into the blood and remove CO2 from the blood. 2. Incorrect: Checking color of skin, lips, and nails beds for cyanosis are important in determining adequate oxygenation. 4. Incorrect: Checking the saturations will assist in determining adequate oxygenation.
The primary healthcare provider (PHP) has prescribed a saline IM injection for a client who requests pain medication every 2-3 hours. What would be the nurse's most appropriate action? 1. Administer the injection. 2. Take vital signs. 3. Question prescription with PHP. 4. Notify the nursing supervisor.
3. Question prescription with PHP. 3. Correct: A placebo is any medication or procedure that produces an effect in clients resulting from its implicit or explicit intent and not from its physical or chemical properties. An example would be a sugar pill or injection of saline. Some professionals try to justify the use of placebos to elicit the desirable placebo effect or they are used in a misguided attempt to determine if the client's pain is real. These reasons cannot be justified on either a clinical or ethical basis, except in an approved research study. It is deceptive and represents fraudulent and unethical treatment. 1. Incorrect: Giving a placebo is fraudulent and unethical treatment. 2. Incorrect: Taking the vital signs does not take care of the problem of giving a placebo. 4. Incorrect: First, the nurse should discuss the prescription with the primary healthcare provider.
What foods should the nurse reinforce to the client to avoid for three days prior to a guaiac test? Select all that apply 1. Chicken 2. Carrots 3. Raw broccoli 4. Steak 5. Turnip greens
3. Raw broccoli 4. Steak 5. Turnip greens 3., 4., & 5. Correct: The guaiac test is used to detect fecal occult blood. Foods that affect this test include raw broccoli, red meats such as steak, turnip greens, cantaloupe, radish, and horseradish. All of these could cause a false positive reading for the guaiac test.
The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's best action? 1. Call the pathology department for directions on formalin's use and precautions. 2. Look formalin up in the drug handbook 3. Read about formalin on the Material Safety Data Sheet (MSDS). 4. Explain to the primary healthcare provider that nurses are not allowed to use formalin.
3. Read about formalin on the Material Safety Data Sheet (MSDS). 3. Correct: All hazardous materials must have a MSDS, which includes the identity of the chemical, the physical and chemical characteristics, the physical and health hazards, primary routes of entry, exposure limits, precautions for safe handling, controls to limit exposure, emergency and first-aid procedures, and the name of the manufacturer or distributor. 1. Incorrect: The nurse should look at the MSDS, the best source of information. Calling another department does not ensure that the nurse will get as comprehensive information as the MSDS provides. 2. Incorrect: The drug handbook is for medication, not handling of hazardous material. 4. Incorrect: The nurse can place the biopsy into a container with formalin and is within the scope of practice for the nurse.
What should the nurse do when taking a telephone prescription from a primary healthcare provider? 1. Document the prescription prior to the end of the shift. 2. Explain to the primary healthcare provider that nurses cannot take telephone prescriptions. 3. Repeat the prescription back to the primary healthcare provider prior to hanging up. 4. Transcribe the prescription in the client's chart. 5. Ask the primary healthcare provider to wait and write the prescription during rounds.
3. Repeat the prescription back to the primary healthcare provider prior to hanging up. 4. Transcribe the prescription in the client's chart. 3. & 4. Correct: Whenever a verbal or telephone prescription is given, the nurse is to transcribe the prescription, and then read it back to the ordering primary healthcare provider during the time the prescription is given. If the prescription is received and repeated back to the primary healthcare provider without transcribing the prescription first, an error may occur. 1. Incorrect: Errors can be made if documentation is not made at the time the prescription is received. 2. Incorrect: Nurses can take telephone prescriptions; however, safety measures include writing down the prescription immediately and repeating the prescription back to the primary healthcare provider. 5. Incorrect: Asking the primary healthcare provider to wait until rounds is not appropriate as nurses can take telephone prescriptions with appropriate safety measures.
Which activities can the nurse safely assign to an unlicensed assistive personnel (UAP)? 1. Administer a nebulizer treatment to a client diagnosed with pneumonia. 2. Obtain vital signs on a postoperative client who required naloxone 5 minutes ago. 3. Report a urinary output (UOP) less than 50 mL/hr on a post-op client. 4. Assist a client with obtaining a clean catch urine sample. 5. Remove an indwelling urinary catheter from a client.
3. Report a urinary output (UOP) less than 50 mL/hr on a post-op client. 4. Assist a client with obtaining a clean catch urine sample 3., & 4. Correct: The UAP can report the amount of UOP but cannot interpret it. A clean catch urine sample is a noninvasive procedure. Therefore, the UAP can assist the client to obtain the clean catch urinary sample. Both activities are the right person and right tasks for assigning to the UAP. 1. Incorrect: A UAP cannot administer medications. This is the wrong task for an UAP.2. Incorrect: The client received naloxone to reverse the action of an opioid medication. A UAP should not be assigned to obtain vital signs on an unstable client. 5. Incorrect: A UAP cannot remove an indwelling urinary catheter.
A client's vital signs, following a bowel resection are: Blood pressure 116/74; heart rate 102 and regular; respirations 26 and shallow. The ABGs are: pH 7.48; PCO2 30; HCO3 24. What disorder do these findings indicate? 1. Metabolic alkalosis 2. Metabolic acidosis 3. Respiratory alkalosis 4. Cardiovascular shock
3. Respiratory alkalosis 3. Correct: With increased respiratory rates, more PaCO2 is exhaled (blown off), decreasing the PCO2 level. PCO2 is an acid. If the client is blowing off CO2, an acid, this leaves them more alkaline. In this case, we see respiratory alkalosis because the lungs are the problem. The pH is high, indicating alkalosis.1. Incorrect: The bicarbonate is normal. In metabolic alkalosis, the bicarbonate will be increased. A pH of 7.48 is alkalosis, but in this case, the problem is respiratory. 2. Incorrect: Normal pH is 7.35-7.45. Anything less than 7.35 is acidosis. Anything greater than 7.45 is alkalosis. Therefore, this client has alkalosis.4. Incorrect: In cardiovascular shock, the BP is decreased well below 116/74
The nurse is caring for a client who is severely depressed and has an extremely low energy level. The client answers questions by using one or two words, and makes no eye contact. Which intervention is most appropriate for this client? 1. Ask the client to go to the group session with you. 2. Remind the client to interact with the nurse today. 3. Sit with the client and make no demands. 4. Allow the client to decide when to talk with the nurse.
3. Sit with the client and make no demands. 3. Correct: The client is severely depressed and does not wish to have one on one interaction. Sitting with the client without demands demonstrates that the client is worthy of your time. The silence may also encourage the client to talk with you. 1. Incorrect: The client's energy level is low, so the client would not respond positively to this request. Depressed clients may speak slowly and have slowed comprehension. Group therapy would not be appropriate at this time. 2. Incorrect: The client may not have adequate energy for spontaneous interaction today. Also, reminding the client to interact is not therapeutic. The client may view this as the nurse thinking they are worthless. 4. Incorrect: When clients are extremely depressed, they cannot make decisions independently. Extreme fatigue interferes with social activities and relationships.
Which action would the nurse need to perform to increase stability while initiating a client transfer? 1. Lift with the back. 2. Put on a back belt. 3. Spread feet to width of the shoulders. 4. Lean forward slightly.
3. Spread feet to width of the shoulders. 3. Correct: In order to increase stability, the nurse will need to increase the base of support. This can be done by spreading the legs to the width of the shoulders. 1. Incorrect: Do not use your back to do heavy lifting. They are not your strongest muscles. Your legs are the strongest muscles and should be used for lifting. 2. Incorrect: A back belt will not increase the base of support and thus will not increase stability. 4. Incorrect: The nurse should not lean forward or backward. The ears, shoulders, hips and feet should be aligned. Leaning forward will not increase stability. Keep a wide base of support. The feet should be shoulder-width apart, with one foot slightly ahead of the other (karate stance). Squat down, bending at the hips and knees only. If needed, put one knee to the floor and other knee in front of you, bent at a right angle (half kneeling). Keep good posture. Look straight ahead, and keep back straight, chest out, and shoulders back. This helps keep upper back straight while having a slight arch in lower back. Slowly lift by straightening hips and knees. Keep back straight, and don't twist while lifting. Hold the load as close to the body as possible, at the level of the belly button. Use the feet to change direction, taking small steps. Lead with the hips as you change direction. Keep shoulders in line with hips while moving. Set down the load carefully, squatting with the knees and hips only.
The nurse cares for a client who is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which precaution is important for the nurse to implement? 1. Perform hand hygiene after shift report. 2. Implement droplet precaution for the client. 3. Stock the client's room with dedicated equipment. 4. Eliminate dairy products from the client's diet.
3. Stock the client's room with dedicated equipment. 3. Correct: The client's room should be stocked with dedicated equipment just for that client to prevent the nurse from spreading MRSA to other clients through cross-contamination. The nurse should perform hand hygiene before and after client contact. Clients that are infected with MRSA should be placed on contact precautions. 1. Incorrect: The nurse should perform hand hygiene before and after client contact. 2. Incorrect: Contact precautions should be implemented. 4. Incorrect: Eliminating dairy products from the client's diet is not necessary.
A client is receiving a unit of whole blood. The client begins to complain of lower back pain. What is the nurse's first action? You answered this questionCorrectly 1. Identify the client's pain level 2. Log roll the client to their side 3. Stop the transfusion 4. Take the client's vital signs
3. Stop the transfusion 3. Correct: Low back pain is a sign of an acute hemolytic reaction. This is the most dangerous and potentially life-threatening type of transfusion reaction. It occurs when the donor blood is incompatible with that of the recipient.1. Incorrect: It would be an action the nurse would take after stopping the transfusion. Do not delay stopping the transfusion to further assess the client. By allowing the transfusion to continue, while additional data is gathered, the client is at greater risk for more harm.2. Incorrect: Determining the client's pain, may be an indicated action but not the first action for a client receiving blood that begins to report lower back pain. Assume the worst and stop the transfusion first.4. Incorrect: Assume the worst and stop the transfusion first, then continue with data collection. Vital signs would be obtained after stopping the transfusion.
A newly admitted client tells the nurse, "I am hearing voices." Which response by the nurse is most appropriate? 1. Your head is turned to the side as if you are listening to voices. 2. I don't hear anyone but you speaking. 3. Tell me what the voices are saying to you. 4. Let's talk about your anxiety right now.
3. Tell me what the voices are saying to you. 3. Correct: The nurse needs to know what the voices are saying to the client. This is the first thing the nurse would ask if the newly admitted client tells the nurse about hearing voices. The nurse does not know the client or the diagnosis that might be affiliated with this statement. 1. Incorrect: The client has already told the nurse about hearing voices. This is non-therapeutic and negates the value of what the client is saying. 2. Incorrect: Upon admission, the nurse would not start out with this comment. This would come later. First the nurse needs to know what the voices are telling the client. 4. Incorrect: Again, this would come later after the nurse finds out what the voices are telling the client.
The nurse is reinforcing teaching about proper foot care to a client who has diabetes. Which statements by the nurse are correct? 1. Cut the toenails in a rounded fashion. 2. Wash the feet with warm water and betadine. 3. Wear appropriate fitting shoes at all times. 4. View the bottom of the feet daily. 5. Protect feet from hot and cold.
3. Wear appropriate fitting shoes at all times. 4. View the bottom of the feet daily. 5. Protect feet from hot and cold. 3., 4., & 5. Correct: Shoes should be worn at all times to prevent injury. The client may step on something and not know that the foot has been injured. Inspection should be done daily, since many diabetics cannot feel if their feet have been injured. Feet may not be sensitive to hot and cold, which could cause injury. 1. Incorrect: Toe nails should be cut straight across to avoid an ingrown toenail. Additionally, any skin cuts on the toes may result in infection. 2. Incorrect: Do not put harsh chemicals, such as betadine, on the feet. Betadine will dry the skin which may lead to cracks in the skin. This creates potential portals for infection to occur.
What independent nursing interventions should the nurse include when contributing to the plan of care for a client who is in a fluid volume excess (FVE)? 1. Monitor Central venous pressure (CVP) 2. Administer diuretic 3. Monitor for orthopnea 4. Raise head of bed (HOB) to 45 degrees 5. Elevate edematous extremities
3., 4. & 5. Correct: These are independent nursing actions that will increase venous return and decrease edema. Also the nurse should assess for crackles, changes in respiratory pattern, shortness of breath (SOB), orthopnea. 1. Incorrect: This is a collaborative intervention. 2. Incorrect: This is a dependent intervention. What are independent nursing interventions? Independent nursing interventions are those sanctioned by professional nurse practice acts. They do not require direction or a prescription from another health care professional. Interdependent nursing interventions are actions that are implemented in a collaboration or consultation with other health care professionals. Dependent nursing interventions are those that require an order from other health care professionals. So which options can the nurse initiate without a prescription? What about option 1? Monitor Central venous pressure (CVP). False. This would be considered an interdependent nursing intervention. The primary healthcare provider would have to place the CVP line in order for CVP monitoring to be done. Option 2? Administer a diuretic? False. This is a dependent intervention as a prescription is needed. Option 3? Monitor for orthopnea? Does the nurse need a prescription to do this? No. Does the nurse need to collaborate with anyone to do this? No. So this is a True statement. Option 4? Elevate the HOB? This is true. The nurse can do this independently. A prescription is not needed. Option 5? Elevate edematous extremities? True. No prescription needed here!
A licensed practical nurse (LPN) is utilizing the nursing process to care for assigned clients. Which nursing actions should the LPN relate to the implementation step of the nursing process? tly 1. Collecting client data for a nursing history. 2. Reporting client response to a new medication. 3. Procuring equipment for a planned medical procedure. 4. Assigning client care activities to unlicensed assistive personnel. 5. Delivering skilled nursing care according to an established health care plan
3., 4., & 5. Correct: The nurse should relate procuring medical equipment, assigning client care activities, and delivering skilled nursing care to the implementation step of the nursing process. Implementation is the third step of the nursing process and consists of delivering nursing care according to an established health care plan and as assigned by the RN or other person(s) authorized by law. 1. Incorrect: This is not the implementation step of the nursing process. LPNs participate in the assessment step of the nursing process by collecting client data for a nursing, psychological, spiritual, and social histories, comparing the data collected to normal values and findings. 2. Incorrect: This is not the implementation step of the nursing process. LPNs participate in the nursing process by reporting client responses to the RN or supervising healthcare provider.
Which client assignments would be appropriate for the LPN/LVN to accept? 1. Seventy four year old client with unstable angina who needs teaching for a scheduled cardiac catheterization. 2. Sixty year old client experiencing chest pain scheduled for a graded exercise test. 3. Forty eight year old client who is five days post right-sided cerebral vascular accident (CVA). 4. Eighty four year old client with heart disease and mild dementia. 5. Newly admitted ninety year old client with decreased urinary output, altered level of consciousness, and temperature of 100.8°F (38.2°C) 6. Sixty six year old client with chronic emphysema experiencing mild shortness of breath.
3., 4., 6. Correct: The client who is five days post CVA is one of the most stable clients and could be assigned to the LPN/LVN. There is nothing in the option to indicate that this client is unstable. There is no indication that the eighty-four year old client with heart disease and dementia is unstable, so this client can be accepted by the LPN/LVN. The client with chronic emphysema will experience shortness of breath. There is nothing to indicate that this client is unstable. 1. Incorrect: This client is unstable and should be cared for by the RN. Additionally, the RN is responsible for teaching. 2. Incorrect: This client is experiencing chest pain and is thus considered unstable and should be cared for by the RN. 5. Incorrect: This client has s/s that could indicate sepsis, so is considered unstable and should not be assigned to the LPN/LVN.
Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Clean client's halo fixation insertion sites with hydrogen peroxide. 2. Insert acetaminophen suppository in client's rectum. 3. Reapply pneumatic compression device to client's legs. 4. Check client's gag reflex prior to feeding. 5. Set up suction equipment in client room. 6. Reposition client every 2 hours.
3., 5., & 6. Correct: The UAP is trained on use of routine equipment such as pneumatic compression devices and can reapply the device to a client. Gathering needed equipment and supplies is within the scope of duties for the UAP. Repositioning a client every 2 hours is within the UAP's ability and can be assigned by the nurse. 1. Incorrect: The UAP can provide routine hygiene. The nurse would be responsible for wound care, including halo insertion pin site care. This requires skill beyond the UAP's knowledge. 2. Incorrect: The UAP cannot administer medications. 4. Incorrect: The UAP cannot assess or evaluate a client. The RN most do this part of the nursing process. Unlicensed assistive personnel (UAP) are unlicensed health care providers trained to function in a supportive role by providing client care activities as assigned by the nurse. The term includes, but is not limited to nurse aides, orderlies, assistants, attendants, or technicians. UAPs function under the nurse practice act of each state. The UAP can perform daily care of a client or group of clients that is frequently recurring and are performed according to an established sequence of steps. The activity should involve little or no modification from one client care situation to another. The activity may be performed with a predictable outcome without inherently involving ongoing assessment, interpretation, or decision making which cannot be logically separated from the procedure itself. The activity should not endanger the client's life or well-being. The UAP must have been properly trained and validated as competent by the RN. Agency policies and procedures must also permit the task, and the nurse must provide appropriate supervision.
The nurse has received the following information about assigned clients. who has the highest risk for developing peritonitis?
3.had appendectomy 1 day ago and has a 0.8 (2cm) area of serosanguineous drainage on the incision dressing Peritonitis is common among people undergoing peritoneal dialysis therapy. Other medical conditions. The following medical conditions increase your risk of developing peritonitis: cirrhosis, appendicitis, Crohn's disease, stomach ulcers, diverticulitis and pancreatitis
24 hour limit of hydrocodone/acetaminophen
4 gms
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 symptom
4. "This inhaler should be used routinely as prescribed even when free of symptom 4. Correct: 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. 1. Incorrect: Salmeterol can be used to help prevent exercise induced bronchospasm, but it should be taken 30 to 60 minutes before exercise. 2. Incorrect: Salmeterol is indicated for asthma only and bronchospasm induced by obstructive pulmonary disease. It is not indicated for seasonal allergies. 3. Incorrect: Salmeterol is a maintenance medication. Albuterol is used as a "rescue inhaler" for bronchospasms. Option 1, 2, and 3 are false. Salmeterol is a beta2-agonist, a maintenance medication that clients with asthma use twice a day every 12 hours. Clients should know that if symptoms occur before next scheduled dose, use a rapid acting inhaled bronchodilator. Clients should be cautioned not to use salmeterol to treat acute symptoms. Clients using salmeterol for prevention of exercise induced bronchospasm should not use additional doses for 12 hours.
The nurse is participating in providing a community education class on alternative therapies. Which alternative therapy that uses substances found in nature should the nurse include? 1. Energy therapies. 2. Mind-body interventions. 3. Body-based methods. 4. Biologically-based therapies.
4. Correct: Biologically-based therapies use substances found in nature such as herbs, foods, and vitamins. 1. Incorrect: Energy therapies use energy fields. Substances found in nature are biologically-based therapies. 2. Incorrect: Mind-body interventions use the mind to help affect the function of the body. Substances found in nature are biologically-based therapies. 3. Incorrect: Body-based methods use movement of the body. Substances found in nature are biologically-based therapies.
What activities should the nurse reinforce to a group of adolescents who have been diagnosed with rheumatoid arthritis? 1. Jogging 2. Volleyball 3. Tennis 4. Bicycle riding 5. Swimming
4. Bicycle riding 5. Swimming 4., & 5. Correct: Rheumatoid arthritis is an autoimmune disease that affects the joints and other body symptoms. Low impact activities on joints are best such as swimming and bike riding. 1. Incorrect: Jogging is a high impact activity for joints. This is not appropriate for a client with rheumatoid arthritis. 2. Incorrect: Playing volleyball is a high impact activity for joints and would not be appropriate for a client with rheumatoid arthritis. The pressure on the joints may result in additional damage to the joints. 3. Incorrect: Playing tennis is a high impact activity for joints, and tennis should not be a recommended sport for a client with rheumatoid arthritis.
A registered nurse (RN) is delegating nursing activities to a licensed practical nurse (LPN) on a medical-surgical unit. If assigned by the RN, which activities can the LPN legally perform? 1. Nursing care plan 2. Blood transfusion 3. Physical assessment 4. Blood glucose testing 5. Intramuscular injection
4. Blood glucose testing 5. Intramuscular injection correct: The LPN can perform blood glucose testing at the bedside. Blood glucose levels that fall outside of the normal range, however, should be reported to the RN who retains responsibility for overall client care. The LPN can give intramuscular injections as well as administer medications via other common routes.1. Incorrect: The RN is responsible for developing the plan of care for the client; this is outside of the legal scope of practice for the LPN.2. Incorrect: Blood transfusions must be performed by the RN; two RNs must verify that the blood type is correct prior to administration.3. Incorrect: The RN is responsible for performing the client physical assessment; this is outside of the legal scope of practice for the LPN.
A registered nurse (RN) is delegating nursing activities to a licensed practical nurse (LPN) on a medical-surgical unit. If assigned by the RN, which activities can the LPN legally perform? 1. Nursing care plan 2. Blood transfusion 3. Physical assessment 4. Blood glucose testing 5. Intramuscular injection
4. Blood glucose testing 5. Intramuscular injection 4. & 5. Correct: The LPN can perform blood glucose testing at the bedside. Blood glucose levels that fall outside of the normal range, however, should be reported to the RN who retains responsibility for overall client care. The LPN can give intramuscular injections as well as administer medications via other common routes.1. Incorrect: The RN is responsible for developing the plan of care for the client; this is outside of the legal scope of practice for the LPN.2. Incorrect: Blood transfusions must be performed by the RN; two RNs must verify that the blood type is correct prior to administration.3. Incorrect: The RN is responsible for performing the client physical assessment; this is outside of the legal scope of practice for the LPN.
Which member of the multi-disciplinary team oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client? 1. Clinical nutritionist 2. Primary nurse each shift 3. Primary healthcare provider 4. Case manager
4. Case manager 4. Correct: An important role of the case manager in the multi-disciplinary team care approach is coordination of client care. The case manager oversees the process of healthcare delivery and organizes and coordinates the delivery of healthcare services to the client. 1. Incorrect: The clinical nutritionist is a member of the multi-disciplinary team, but does not coordinate and organize the delivery of care outside of the client's nutritional needs. 2. Incorrect: The primary nurse each shift develops and executes the plan of care for the client, but is not the organizer and coordinator of all the services to the client.3. Incorrect: The primary healthcare provider is a member of the multi-disciplinary team, but is responsible for prescribing healthcare for the client, not organizing the services. 1. Identify clues in the stem. Generally, the stem is short and contains only the information needed to make the question clear. A clue is the use of a word or phrase that leads you to the correct answer. The clue shows a relationship to word or phrase in the correct answer.
The nurse is working on the inpatient mental health unit and determines that one of the clients has suicidal thoughts. The nurse reports the client's suicidal thought to the charge nurse. Which rationale best validates the action? 1. The client has the right to a safe care environment. 2. The nurse may be sued for malpractice if injury occurs. 3. All clients on mental health units are placed on suicide precautions. 4. Clients are most likely to act on suicidal thoughts when energy is low.
4. Clients are most likely to act on suicidal thoughts when energy is low. 1. Correct: Verbalizing suicidal thoughts is a risk factor for client suicide. Safety must be maintained while the client is in this vulnerable state. The nurse monitors clients at risk of suicide and intervenes to prevent harm for those identified as being at risk. 2. Incorrect: Client safety is the primary issue here. 3. Incorrect: This is not a true statement. All clients have the right to a safe environment; however, not all clients on the mental health unit are placed on suicide precautions. Only clients identified at risk for suicide are placed on suicide precautions. 4. Incorrect: This is an untrue statement. Clients are likely to act on suicidal thoughts as energy levels improve. The issue here is client safety, and the client's right to a safe environment.
The nurse is providing care to a client who has returned to the long-term facility following cataract surgery. Which finding would indicate a possible complication? 1. Minimally swollen eyelid 2. Mild discomfort of the eye 3. Slight red appearance of the eye 4. Extreme pain in the eye
4. Correct. The postoperative cataract client usually experiences little to no pain, and it can be managed with mild analgesics. If the pain is severe, there may be an increase in intraocular pressure, hemorrhage, or infection, and the surgeon should be notified. 1. Incorrect. Slight swelling of the eyelid is considered a normal finding following cataract surgery. 2. Incorrect. The postoperative cataract client usually experiences little to no discomfort following surgery. This is a normal finding. 3. Incorrect. Slight redness is an expected finding. Pay attention to the word "slight". Increased redness is cause for concern. Compare it to the non-operative eye.
Which client is appropriate to be assigned in the room with a 6 year old prescribed chemotherapy? 1. Twenty-two month old diagnosed with respiratory syncytial virus (RSV). 2. Two year old with nephrotic syndrome. 3. Three year old admitted with febrile seizures. 4. Four year old who has a fractured tibia.
4. Correct. This child is not infectious. Place children within the same age group together whenever possible. 1. Incorrect. Respiratory syncytial virus (RSV) is a common and highly contagious virus that infects the respiratory tract of many children before their second birthday. This client requires contact and droplet precautions and should not be in the room with the client who is receiving chemotherapy. 2. Incorrect. This child could possibly be infectious. Additionally, this child is too young to be placed in the same room as the 6 year old. 3. Incorrect. Febrile seizures are one of the most common neurologic childhood problems, often caused by a fever associated with a viral infection. Although the underlying infection is not identified, this child with a probable infection should not be placed in the room with the client who is immunocompromised.
A nurse is at highest risk for blood-borne exposure during which situation? 1. When removing a needle from the syringe. 2. While placing a suture needle into the self-locking foreceps. 3. Prior to inserting the intravenous (IV) line, the client moves causing a needle stick to the nurse. 4. A clean needle sticks the nurse through blood-soiled gloves.
4. Correct: A clean needle that moves through blood-soiled gloves to stick the nurse is considered to be potentially contaminated and results in a blood-borne exposure. All other answers are considered a clean stick. 1. Incorrect: This is considered a clean stick. The needle is sterile initially and has not been contaminated prior to removal of the needle from the syringe. 2. Incorrect: This is considered a clean stick since the suture needle has not been inserted into the client prior to the needle stick. 3. Incorrect: This is considered a clean stick. The IV insertion device is sterile and has not been contaminated since it was not inserted into the client.
The nurse makes selections from the hospital menu for a client who is confused and suspicious of others. Which menu choice is best? 1. Ham and vegetable casserole 2. Cheese and crackers 3. Caffeine free tea 4. Packaged sugar free Jell-O
4. Correct: A client who is suspicious of others needs foods that are packaged and can see them opened. 1. Incorrect: A client who is suspicious of others needs to be able to identify the ingredients in the food that is being eaten. A casserole contains many ingredients, and the client may fear that something has been added to the food. 2. Incorrect: Finger foods are best for clients that are manic. 3. Incorrect: Drinks and foods with no caffeine are okay for the confused and suspicious client, but this menu choice is not the best choice from the list here.
Which nursing intervention should the nurse include when caring for a client with Alzheimer's disease being admitted to a long term care facility? 1. Offer multiple environmental stimuli at the same time to provide distraction. 2. Encourage the client to participate in activities such as board games. 3. Restrain the client in a chair to prevent falls when sundowning occurs. 4. Involve the client in supervised walking as a routine.
4. Correct: A regular routine and physical activity help clients with Alzheimer's disease maintain abilities for a longer period of time. Physical activities promote strength, agility, and balance. The client's walking should be supervised for client safety issues. 1. Incorrect: Environmental stimuli should be limited with clients with Alzheimer's disease. The client can become agitated and/or more disoriented with an increase in environmental stimuli. 2. Incorrect: Board games would not be appropriate due to the client's cognitive and memory impairment. Board games require complex cognitive actions. 3. Incorrect: Restraints should be avoided because they increase agitation. The client may become agitated by the restriction of the restraints. Also the client may perceive the restraints as a threat. 1. Stay away from restraints, wheelchairs, and invasive drugs as long as possible when choosing an answer. The NCLEX lady does not like nurses who tie people down or nurses who run to the medication cart for every little thing. 2. Identify client centered options. The focus of the nurse should be the client. Items that test your ability to be client-centered tend to explore client feelings, identify client preferences, empower the client, provide the client choices, or in some way put emphasis on the client. The client is the priority. Option 1 is false. A calm, predictable environment helps people with dementia interpret their surroundings and activities. Over reaction can occur to excessive stimulation. Option 2 is false. People with dementia are encouraged to participate in simple activities such as walking and caring for plants. Option 3 is false. Wandering behavior can often be reduced by gentle persuasions or distraction. Restraints should be avoided because they increase agitation. Option 4 is true. Physical activity is demonstrated to slow some of the cognitive decline of Alzheimer's disease. A regular routine helps minimize confusion and disorientation.
An unlicensed assistive personnel (UAP) has been assigned to take vital signs on several clients. Which instruction would be most important for the LPN/LVN to provide to the UAP? 1. "Notify me if the pulse oximetry reading drops below 95% in the client who has emphysema." 2. "The client in room 210 has dizziness and faintness when standing, so I need you to obtain a blood pressure reading with the client in the lying, sitting, and standing position." 3. "The client in room 212 has a pacemaker. Let me know if the apical heart rate is greater than 70 bpm." 4. "Let me know immediately if any client has a temperature of 101. 5 degrees F (38.6 degrees C) or higher."
4. Correct: A temperature of 101. 5 degrees F (38.6 degrees C) or higher is reported to the primary healthcare provider. The client is likely to need cultures and antibiotic therapy. 1. Incorrect: The client with emphysema will likely have a pulse oximetry reading less than 95%. This is not the most important instruction to give the UAP. 2. Incorrect: This client is likely experiencing orthostatic hypotension, so is unstable. This task should not be assigned to the UAP. The RN should perform this task. 3. Incorrect: The nurse should worry if the heart rate drops below the set pacemaker rate. It is normal for the rate to be greater than the set rate. Follow the 5 rights of task assignment: Right task, right person, right circumstance, right direction, right supervision.
A client was admitted to the medical unit with pneumonia 2 days ago. There is a history of drinking 5-6 martinis every night for the past 2 years. Today, the nurse notes that the client is disoriented to time and place and is seeing imaginary spiders on the ceiling. The nurse cannot understand what the client is saying. What is this client most likely experiencing? 1. Wernicke's Encephalopathy 2. Korsakoff's Psychosis 3. Alcohol Withdrawal 4. Alcohol Withdrawal Delirium
4. Correct: Alcohol Withdrawal Delirium usually occurs on the second or third day following cessation of or reduction in prolonged, heavy alcohol use. Symptoms are the same as for delirium: Difficulty sustaining and shifting attention; extremely distractible; disorganized thinking; rambling, irrelevant, pressured, and incoherent speech; impaired reasoning ability; disoriented to time and place; impairment of recent memory; and delusions and hallucinations. 1. Incorrect: Wernicke's encephalopathy represents the most severe form of thiamine deficiency in alcoholics. Symptoms include paralysis of the ocular muscles, diplopia, ataxia, confusion, somnolence, and stupor. If thiamine replacement therapy is not given, death will ensue. 2. Incorrect: Korsakoff's psychosis is identified by a syndrome of confusion, personality changes, loss of recent memory, and confabulation (filling in some memory gaps with different life events or created thoughts). It is frequently encountered in clients recovering from Wernicke's encephalopathy. Coordination may be affected, so the client may have difficulty maintaining balance. Treatment is parenteral or oral thiamine replacement. 3. Incorrect: Alcohol withdrawal typically begins 4-12 hours after cessation of or reduction in heavy and prolonged alcohol use. Symptoms include: coarse tremor of hands, tongue, or eyelids; nausea and vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood or irritability; transient hallucinations or delusions; headache; and insomnia.
A client diagnosed with alcoholism was admitted to the medical unit with substance-withdrawal delirium. Two days later, the client decides to leave the hospital against medical advice. What action should the nurse take? 1. Hide the client's clothes so that the client cannot leave. 2. Administer the ordered sedative. 3. Place restraints on the client. 4. Determine why the client wants to leave.
4. Correct: Always assess why the client wishes to leave first. This is the only way to fix the problem. 1. Incorrect: By confining a client against his or her wishes, and outside of an emergency situation, the nurse may be charged with false imprisonment. Actions that may invoke these charges include locking an individual in a room, taking a person's clothes for the purposes of detainment, and restraining in mechanical restraints a competent, voluntary client who demands to be released. 2. Incorrect: By confining a client against his or her wishes, and outside of an emergency situation, the nurse may be charged with false imprisonment. Actions that may invoke these charges include locking an individual in a room, taking a person's clothes for the purposes of detainment, and restraining in mechanical restraints a competent, voluntary client who demands to be released. 3. Incorrect: By confining a client against his or her wishes, and outside of an emergency situation, the nurse may be charged with false imprisonment. Actions that may invoke these charges include locking an individual in a room, taking a person's clothes for the purposes of detainment, and restraining in mechanical restraints a competent, voluntary client who demands to be released. Nurses are required to practice within the laws of the state and within federal laws, such as HIPAA.
The nurse asks if the client has an advance directive. The client responds by saying, "I have heard of advance directives, but I do not have one. What is an advance directive?" Which response by the nurse is appropriate? 1. Specifies your wishes regarding your personal effects and finances should you become unable to make decisions. 2. Specifies your wishes regarding healthcare and your finances should you become incapacitated. 3. Similar to a will, it specifies your wishes for burial should you die during hospitalization. 4. A form of a living will. It specifies your wishes regarding healthcare and treatment options should you become incapacitated.
4. Correct: An advance directive is a legal document prepared by a competent individual that specifies what treatments, if any, the client desires should the client become incapacitated or unable to make informed healthcare decisions in the future. The document includes wishes regarding resuscitation measures, withdrawing treatment and life support, and end-of-life care. 1. Incorrect: An advance directive does not address client personal effects and finances. These might be included in a last will and testament, but are not part of an advance directive. 2. Incorrect: An advance directive does not address client personal effects and finances. These might be included in a last will and testament, but are not part of an advance directive. 3. Incorrect: An advance directive does not address burial wishes.
An infant has been prescribed Bryant's traction for a diagnosis of developmental dislocated hips (DDH). At what degree of hip flexion should the nurse maintain the infant's hip for proper traction alignment? 1. 15 2. 30 3. 45 4. 90
4. Correct: Bryant's traction is used for DDH. The child's body and the weights are used as tension to keep the end of the femur in the hip socket. Traction helps position the top of the femur into the hip socket correctly. This is accomplished with 90 degrees of hip flexion. 1. Incorrect: Fifteen degrees of flexion is not adequate to keep the femur end in the hip socket. 2. Incorrect: Thirty degrees of flexion is not adequate to keep the femur end in the hip socket. 3. Incorrect: Forty-five degrees of flexion is not adequate to keep the femur end in the hip socket. In order to answer this question correctly, you have to know what Bryant's traction is used for and what it looks like. In Bryant's traction, the child's body and the weights are used as tension to keep the end of the femur in the hip socket. Traction will help position the top of the femur into the hip socket correctly.
A client in a psychiatric unit sings over and over, "It is hot, I am a hot tot in a lot, I sit all day on a cot drinking a pop." How should the nurse document this form of thought? 1. Neologisms 2. Dissociation 3. Fugue 4. Clang Association
4. Correct: Clang association involves the choice of words governed by sounds, often taking the form of rhyming even though the words themselves don't have any logical reason to be grouped together. 1. Incorrect: The psychotic person invents new words, or neologisms, that are meaningless to others but have symbolic meaning to the psychotic person. 2. Incorrect: Dissociation is the splitting off of clusters of mental contents from conscious awareness. It is a mental process that leads to a lack of connection in the client's thoughts, memory and sense of identity. In its mild form, it is similar to day dreaming. In a more severe form, it can be manifested as multiple personalities. 3. Incorrect: Fugue is sudden, unexpected travel away from home or customary place of daily activities, with inability to recall some or all of one's past. The person is unaware that anything has been forgotten. Following recovery, there is no memory of the time during the fugue.
Which snack selection should the nurse provide to a client receiving chemotherapy? 1. Fresh salad with cucumbers, carrots, and tomatoes. 2. Orange slices with yogurt. 3. Strawberries with whipped cream. 4. Milk shake with a packet of instant breakfast added.
4. Correct: Clients with cancer often experience a combination of increased energy expenditure, but the nutritional intake is decreased and inadequate to meet the caloric and protein needs. The decreased intake may be, in part, due to the side effects of the chemotherapy. Cold drinks, like shakes, can be soothing, especially if the client has no desire to eat solid foods or is experiencing mouth pain. Shakes will also offer more calories for the client and more protein if a packet of instant breakfast or protein powder is added. Cold, high protein foods are generally tolerated better and have less offensive odors than hot foods. 1. Incorrect: Although raw vegetables are full of fiber, vitamins and minerals, this is not the best option because they can contribute to food borne illness, especially in a person who is immunosuppressed from receiving chemotherapy. Their immune system is weakened. To minimize the risk of infection, vegetables should be cooked for these clients. It is recommended that all fruits and vegetables be washed thoroughly in cold water and dried on a clean paper towel. 2. Incorrect: Oranges, grapefruits, and tangerines should be avoided in favor of softer, blander fruits such as bananas. Mouth sores are a common side effect of chemo treatment which can be extremely painful when even the blandest food rubs up against the sore. The citrus nature of oranges can cause discomfort if stomatitis is present. 3. Incorrect: Raw fruit with rough texture such as strawberries and raspberries should not be eaten. The rough texture on the strawberries can hide dirt and other contaminants that washing cannot clean well enough.
The nurse is caring for a 5 year old client who is 12 hours post tonsillectomy. The client is pain free and has advanced to a soft diet. What is the priority nursing intervention? 1. Apply warm compresses to the throat. 2. Encourage gargling to reduce discomfort. 3. Position the child supine. 4. Monitor for frequent clearing of the throat.
4. Correct: Continuous swallowing and frequent clearing of the throat are signs of bleeding. 1. Incorrect: This would increase blood flow, causing edema and bleeding, so this should not be done. 2. Incorrect: Gargling increases motion of throat and may cause bleeding. This is also something that could be a developmental challenge for a 5 year old. 3. Incorrect: The blood can drip down into the stomach, and the client will wake up and vomit the old blood while lying flat. This puts the client at risk for aspiration, so the nurse should place the client in a side lying position.
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. Correct: 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. 1. Incorrect: A gluten free diet is not associated with cystic fibrosis. This special diet is generally required for clients with Celiac disease and certain food allergies, although clients with either of these diseases will need the addition of fat soluble vitamins A, D, E and K. This statement by the parents indicates the need for further teaching. 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. You will recall that cystic fibrosis (CF) is an inherited disorder in which viscous secretions impair breathing and impede the body's ability to absorb nutrients in the digestive track because of malfunctioning pancreatic enzymes. Caring for this child involves a consistent daily routine with a special diet, frequent pulmonary toilet, and multiple categories of medications daily, including anticholinergics, bronchodilators and possibly steroids. So many areas for parents to learn about that it can be quite overwhelming. It is very important that the nurse verify the parents understood the discharge instructions, since this chronic disease has serious and potentially fatal complications. The question is asking you to select the option in which the parents made a correct statement; quite simply, if the statement in the option is wrong, it's not the right option. Option 1: Definitely wrong. A grave concern in cystic fibrosis is that the intestinal tract is unable to absorb nutrients, and the child can become malnourished. Remember that these children excrete a great deal of needed fat in those large, fatty, foul-smelling stools referred to as "steatorrhea". Fat is needed by the human body for digestion and growth. A gluten-free diet is not necessary and, in fact, would not be healthy for this child. Gluten free diet is generally used in children with Celiac disease or those with gluten allergies. Option 2: Recall that in cystic fibrosis, abnormally thick secretions occur not only in lung tissue but also in the pancreas, causing damage and fibrosis of pancreatic tissue. Ultimately, the pancreas cannot secrete the necessary digestive enzymes, resulting in malabsorption of vitamins and nutrients. Weight loss is a serious issue with CF clients. Supplemental enzymes, such as Creon or Pancreaze, must be administered with every meal and even with snacks. Option 3: Does this sound familiar? When you studied fluids and electrolytes, you learned about the function of sodium in the body and its relationship to fluid. For a large number of clients, we focus on the balance of sodium and water, monitoring for adequate cardiac output, or any evidence of fluid overload. However, that is definitely not the issue with these children. An abnormally large amount of salt is eliminated because the sweat glands cannot properly return sodium to the rest of the body. The problem becomes even worse with exercise, hot weather, or fever. Extra salt intake is encouraged, along with additional fluids. Remember that normally sodium and water follow each other; but, since these children do not have enough sodium, they can quickly dehydrate. Lots of water and salt are important aspects of this client's care. Option 4: Great choice. Think about the pathophysiology occurring in this disease process. We worry about nutrition, weight loss, malabsorption, and excretion of fat. A child needs proper nourishment for adequate growth and development. The most appropriate diet would be high calorie and high fat provided in small frequent meals along with the appropriate digestive enzymes. In-between meals, snacks and lot of water are also important to maintaining hydration and helping to thin those viscous secretions.
Which initial behavior by the client on a mental health unit demonstrates to the nurse that the client is assuming responsibility for anger management? 1. Plans to use exercise to work off anger. 2. Apologizes to those individuals to whom anger has been directed. 3. Develops a plan on how to react when feeling stressed. 4. Identifies stressors of past violent behavior.
4. Correct: Demonstrates client is assuming responsibility for anger management. 1. Incorrect: The client would have to identify precipitating factors first. 2. Incorrect: This does not indicate a change in behavior. It just shows that the client is aware of anger after the fact. 3. Incorrect: The client must identify stressors first. Option 1 is false. Before coping skills can be addressed, the client would have to identify precipitating factors. Assessment comes before planning. Option 2 is false. Apologizing for past behavior does not indicate a change in the client's current behavior. Option 3 is false. Before a plan can be addressed, the client must first identify stressors. Option 4 is true. The client must first identify stressors before the client can begin to act on controlling anger created by the stressors. This is the initial behavior demonstrating the client is assuming responsibility for anger management.
A client diagnosed with heart failure (HF) currently takes furosemide 40mg every morning, potassium 20meq daily, and digoxin 0.25 mg daily. Which client comment should be the nurse's first concern? 1. "My fingers and feet are swollen." 2. "My weight is up 1 pound (0.45 kg)." 3. "There is blood in my urine." 4. "I am having trouble with my vision."
4. Correct: Did you see the sign of Dig toxicity? Good Job! Digoxin toxicity happens when you have too much digoxin in the body. Certain medical conditions like heart disease and medications like diuretics increase the risk of digoxin toxicity. Changes in vision is one symptom of digoxin toxicity. 1. Incorrect: With a history of HF, edema is common. The client may need bed rest or additional diuretic therapy. However, this is not usually life threatening. 2. Incorrect: The weight should not vary more than 3-5 pounds (1.36-2.27 kg), so a 1 pound (0.45 kg) gain would not be our first concern. 3. Incorrect: Having blood in the urine may be from many causes which would need to be investigated, but digoxin would be the first concern. It is life threatening.
Which is a risk factor for developing breast cancer in women? 1. Menopause before the age of 50 2. Drinking one glass of wine daily 3. Multiparity 4. Menarche at age 10
4. Correct: Early menarche, before age 12, is a known risk factor for breast cancer. The increased risk of breast cancer linked to a younger age at the first period is likely due, at least in part, to the amount of estrogen a woman is exposed to in her life. A higher lifetime exposure to estrogen is linked to an increase in breast cancer risk. The earlier a woman starts having periods, the longer her breast tissue is exposed to estrogens released during the menstrual cycle, and the greater her lifetime exposure to estrogen. 1. Incorrect: Studies show women who go through menopause after age 50 have increased risk of breast cancer. The risk for breast cancer increases as the time period between menarche and menopause increases. 2. Incorrect: There is a small increase in risk with moderate alcohol consumption, not one glass of wine daily. Drinking low to moderate amounts of alcohol, however, may lower the risks of heart disease, high blood pressure, and death. But, drinking more than one drink per day (for women) and more than two drinks per day (for men) has no health benefits and many serious health risks, including breast cancer. Alcohol can change the way a woman's body metabolizes estrogen (how estrogen works in the body). This can cause blood estrogen levels to rise. Estrogen levels are higher in women who drink alcohol than in non-drinkers. These higher estrogen levels may, in turn, increase the risk of breast cancer. 3. Incorrect: Nulliparity (no pregnancies) is a known risk factor for breast cancer. Factors that increase the number of menstrual cycles also increase the risk of breast cancer, probably due to increased endogenous estrogen exposure. Factors that are associated with an increased risk of breast cancer include: being female, increasing age, a personal history of breast cancer, a family history of breast cancer, inherited genes, such as BRCA1 and BRCA2 that increase cancer risk, radiation exposure to chest as a child or young adult, obesity, menarche at a younger age (before 12), beginning menopause at an older age, having first child at an older age (after 35), having never been pregnant, postmenopausal hormone therapy, and drinking alcohol.
What is the priority nursing action for a pregnant client in labor who is having an epidural catheter inserted for pain management? 1. Perform a thorough skin prep of the insertion site. 2. Obtain the client's consent for the procedure. 3. Assure the client that residual effects of the procedure won't be felt. 4. Monitor maternal blood pressure.
4. Correct: Epidural anesthesia may result in distal vasodilation and a precipitous drop in maternal blood pressure, which will adversely affect placental blood flow. Evidence-based practice guidelines from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) suggests assessing the maternal blood pressure and fetal heart rate every 5 minutes during the first 15 minutes after initiation of epidural medication. 1. Incorrect: Preparing the insertion site is the responsibility of the primary healthcare provider. 2. Incorrect: Obtaining consent is the responsibility of the primary healthcare provider. This is not the priority nursing action. 3. Incorrect: Residual effects of epidural anesthesia include infection and headache. So this is an incorrect statement.
What should the nurse calculate as the estimated due date of a pregnant client, whose last menstrual period started on August 31st? 1. July 1st 2. May 6th 3. May 31st 4. June 7th
4. Correct: Estimated date of delivery is calculated by counting back 3 months, adding seven days, and adding a year if needed. August 31st - 3 months would be May 31st. Add seven days. The estimated date of delivery would be June 7th. 1. Incorrect: Estimated date of delivery is calculated by counting back 3 months, adding seven days, and adding a year if needed. 2. Incorrect: Estimated date of delivery is calculated by counting back 3 months, adding seven days, and adding a year if needed. 3. Incorrect: Estimated date of delivery is calculated by counting back 3 months, adding seven days, and adding a year if needed.
What personal protective equipment should the nurse wear into the room of a client who has been placed on droplet precaution? 1. Gloves 2. Gown 3. Goggles 4. Mask
4. Correct: For a client on droplet precautions, a facemask is worn for close contact with the client. 1. Incorrect: The only requirement for droplet precautions is that a mask needs to be worn. However, if there is a reasonable expectation of contact with secretions, such as through contact or spraying, additional standard precautions would be needed, such as gown, gloves, and goggles. There is not indication in this stem about additional precautions needed. 2. Incorrect: The only requirement for droplet precautions is that a mask needs to be worn. However, if there is a reasonable expectation of contact with secretions, such as through contact or spraying, additional standard precautions would be needed, such as gown, gloves, and goggles. There is not indication in this stem about additional precautions needed. 3. Incorrect: The only requirement for droplet precautions is that a mask needs to be worn. However, if there is a reasonable expectation of contact with secretions, such as through contact or spraying, additional standard precautions would be needed, such as gown, gloves, and goggles. There is not indication in this stem about additional precautions needed.
The nurse is reinforcing teaching to a client who has been prescribed glucocorticoids for the treatment of Addison's disease. What points should the nurse emphasize? 1. Be aware of the development of hypoglycemia. 2. Test the urine for albumin or other proteins. 3. Take the medication 30 minutes prior to bedtime. 4. Maintain the prescribed dose without interruption in therapy.
4. Correct: Glucocorticoids should not be abruptly discontinued due to the risk of adrenal suppression with prolonged use. Doses should be tapered before being discontinued. 1. Incorrect: Increased blood sugar is an adverse effect associated with glucocorticoid therapy, not hypoglycemia. 2. Incorrect: Protein in the urine is not associated with glucocorticoid therapy. 3. Incorrect: Insomnia is an adverse effect associated with glucocorticoid therapy. Daily dosing of glucocorticoids should be done in the morning to decrease this effect.
The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given? 1. "The action of the medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you do not break a bone." 4. "Glycopyrrolate will decrease stomach secretions."
4. Correct: Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease the risk of aspiration. 1. Incorrect: The client has a right to be told the reason the drug is given. This is a nontherapeutic communication response. The nurse should not refuse the client's desire to understand their medications. 2. Incorrect: Glycopyrrolate blocks the secretions in the mouth, throat, airway and stomach. The medication does not prevent the client from having a seizure. The ECT will induce a seizure, which is the desired action. 3. Incorrect: This is not the drug's purpose, so this would be incorrect information to give to the client.
The nurse is caring for a client with hyperemesis gravidarum. What electrolyte imbalance is most likely? 1. Hypocalcemia 2. Hypomagnesemia 3. Hyponatremia 4. Hypokalemia
4. Correct: Hyperemesis gravidarum is characterized by persistent, severe pregnancy related nausea and vomiting. There is a large amount of potassium in the upper GI tract. A client with prolonged vomiting will lose potassium in the emesis. Additionally, the client is unable to replace the lost potassium due to the persistent nausea and vomiting. 1. Incorrect: Hypocalcemia results from any condition that causes a decrease in the production of parathyroid hormone (PTH). Hyperemesis gravidarum does not affect PTH levels. 2. Incorrect: The lower GI tract has a lot of magnesium. Therefore, this client is at risk for hypomagnesemia, but not more than hypokalemia. The client with hyperemesis gravidarum is losing upper GI contents. 3. Incorrect: The client with hyperemesis gravidarum is at high risk for being dehydrated. The electrolyte imbalance associated with dehydration is hypernatremia, not hyponatremia. Remember, this client's blood will be concentrated, and concentrated makes numbers go up (i.e. sodium, hematocrit, and specific gravity).
The nurse is caring for a client with hyperemesis gravidarum. What electrolyte imbalance is most likely? 1. Hypocalcemia 2. Hypomagnesemia 3. Hyponatremia 4. Hypokalemia
4. Correct: Hyperemesis gravidarum is characterized by persistent, severe pregnancy related nausea and vomiting. There is a large amount of potassium in the upper GI tract. A client with prolonged vomiting will lose potassium in the emesis. Additionally, the client is unable to replace the lost potassium due to the persistent nausea and vomiting. 1. Incorrect: Hypocalcemia results from any condition that causes a decrease in the production of parathyroid hormone (PTH). Hyperemesis gravidarum does not affect PTH levels. 2. Incorrect: The lower GI tract has a lot of magnesium. Therefore, this client is at risk for hypomagnesemia, but not more than hypokalemia. The client with hyperemesis gravidarum is losing upper GI contents. 3. Incorrect: The client with hyperemesis gravidarum is at high risk for being dehydrated. The electrolyte imbalance associated with dehydration is hypernatremia, not hyponatremia. Remember, this client's blood will be concentrated, and concentrated makes numbers go up (i.e. sodium, hematocrit, and specific gravity). 1. Identify key words in the stem that set a priority, such as first, initially, best, priority, safest, most. These words modify what is being asked. This question requires you to put a value on each option and then place them in rank order. If you are having difficulty ranking the options, eliminate the option that you believe is most wrong among the options. 2. The test taker would need basic knowledge about hyperemesis gravidarum to answer this question easily, but some clues may be found in the stem.
What electrolyte imbalance should the nurse monitor for in a client diagnosed with hyperosmolar hyperglycemic state (HHS)? 1. Hypocalcemia 2. Hypermagnesemia 3. Hyperkalemia 4. Hyponatremia
4. Correct: Hyperglycemia can cause dilutional hyponatremia, so Normal Saline is administered to replace both fluid and sodium lost through increased urinary output. 1. Incorrect: Calcium is not affected in the client who is in HHS. 2. Incorrect: HHS does not specifically cause hypermagnesemia. We do know that magnesium is lost through the kidneys, so hypomagnesemia is possible with uncontrolled diabetes. 3. Incorrect: Serum potassium levels are usually normal when the client arrives with HHS. The potassium will drop as the large volume of NS is administered with IV insulin. Then we worry about hypokalemia. Hyperosmolar hyperglycemic state (HHS) is a serious condition most frequently seen in older persons with type 2 diabetes that is not being controlled properly. HHS is usually brought on by something else, such as an illness or infection. Normally, the kidneys try to make up for a high glucose level in the blood by allowing the extra glucose to leave the body in the urine. If the client does not drink enough water, or fluids that contain sugar and keep eating foods with carbohydrates, they become very dehydrated. When this occurs, the kidneys are no longer able to get rid of the extra glucose. As a result, the glucose level in the blood can become very high. The dehydration makes the blood concentrated causing hypernatremia. This draws the water out of the body's other organs, including the brain. Treatment consists of IV saline, correction of hypokalemia, and IV insulin.
A client admitted with a diagnosis of end stage kidney disease (ESKD) has been prescribed a diet containing no more than 1 gram of phosphate per day. Which food item, if found on the client's meal tray should be removed by the nurse? 1. Skinless chicken breast 2. Green beans 3. Asparagus 4. Ice cream
4. Correct: Ice cream, a milk product is high in phosphate. This is not appropriate for a diet limited in phosphate. This item would need to be removed. 1. Incorrect: One ounce of skinless chicken breast contains 60 mg of phosphorus and 6.3 gm of protein, which makes it a good choice for a kidney diet. On average, other fresh meat contains 65 mg of phosphorus per ounce and 7 grams of protein per ounce. A 3 ounce serving would have 150 mg of phosphorus. 2. Incorrect: Green peas, green beans and wax beans are low in phosphate, whereas black-eyed peas, lima beans, kidney beans, pinto beans, and lentils are high in phosphate. 3. Incorrect: A serving of asparagus has approximately 20 mg of phosphorus. As kidney function deteriorates, phosphate elimination by the kidneys is diminished and the client begins to develop hyperphosphatemia. By the time a client reaches ESKD, phosphate should be limited to approximately 1 gram/day. Foods that are high in phosphate include meat, dairy products (milk, ice cream, cheese, yogurt), and foods containing dairy products (pudding). Many foods that are high in phosphate are also high in protein. Since some clients on dialysis are encouraged to eat a diet containing protein, phosphate binders are essential to control phosphate. One ounce of skinless chicken breast contains 60 mg of phosphorus and 6.3 gm of protein, which makes it a good choice for a kidney diet. On average, other fresh meat contains 65 mg of phosphorus per ounce and 7 grams of protein per ounce. A 3 ounce serving would have 150 mg of phosphorus. Most fruits and vegetables are low in phosphorus, except for black-eyed peas, lima beans, kidney beans, pinto beans, and lentils.
The nurse is caring for an employee after a chemical explosion at the local tire factory. The client reports a foreign body in the right eye. The right eye is watery, and the client reports photophobia. Which nursing action takes priority? 1. Evert eyelid and examine for foreign body. 2. Measure visual acuity. 3. Notify the receiving hospital immediately for transfer of the client. 4. Place an eye shield over eye.
4. Correct: If a foreign body is the result of explosion or blunt or sharp trauma, the eye should be protected from further damage by placing an eye shield over the eye (or if a shield is not available, a paper cup to prevent rubbing of the eye). Then make arrangements to transport the client for emergency care by an ophthalmologist. If movement of the unaffected eye creates movement in the affected eye, it may be necessary to cover the unaffected eye also to prevent further injury to the eye from movement. 1. Incorrect: Everting the eyelid and examining for a foreign body are not measures that should be performed before placement of eye shield. You should never attempt to remove a foreign body, so examination would not be needed at this point. 2. Incorrect: Measuring visual acuity is not a priority and is not performed before placement of eye shield. The goal is to protect the eye from further injury and reduce movement of the eye. The shield will help accomplish this goal. 3. Incorrect: Notifying immediately for transfer should not be done before placement of the eye shield. The eye should be protected first to reduce further injury.
A client has an intestinal obstruction and a NG tube to low suction. Blood gases are ph 7.54, pCO2 40, HCO3 35. The client is weak, shaky, and reports tingling of the fingers. The nurse knows that this client is most likely in which acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
4. Correct: Metabolic alkalosis happens when there is a loss of acid or a gain in bicarbonate. Metabolic alkalosis occurs from gastric losses via vomiting, NG tubes to suction, or lavage, and potent diuretics. Signs and symptoms include n/v, sensorium changes, tremors, and convulsions. pH > 7.45, pCO2 normal between 35-45, HCO3 > 26. 1. Incorrect: This is not a respiratory related acid-base imbalance 2. Incorrect: This is not a respiratory related acid-base imbalance 3. Incorrect: This is not acidosis. There is loss of gastric acid from the stomach due to the NG tube to low suction.
Which pain scale should the nurse use to monitor the pain level of a 3-year old client after surgery? 1. Numerical scale 2. Verbal descriptive scale 3. Visual analog scale 4. FACES scale
4. Correct: Monitoring pain in children requires special techniques. The nurse should use the FACES scale as a tool to assess this client's pain level. Children as young as 3 years of age can use the FACES scale to communicate their pain level to the medical team. The scale has six faces ranging from smiling face to sad, tearful face. 1. Incorrect: Not age appropriate. This scale uses numbers. 2. Incorrect: Not age appropriate. Young children may not understand the word pain. 3. Incorrect: Not age appropriate. This scale requires reading. If age, sex, nationality are identified in the stem, it is important to the question and will generally direct you to an answer. Remember Erickson's stages of psychosocial development and growth and development.
A post-operative client has received morphine for pain. The nurse checks the client 10 minutes later. Which data warrants further action by the nurse? 1. Blood pressure 94/60 2. Pulse rate 72/min 3. Pain level 3/10 4. Respiratory rate at 8/min
4. Correct: Normal respiratory rate is 12-20 per minute. The respiratory rate indicates respiratory depression following administration of an opioid. Care should be taken to titrate the dose so that the client's pain is controlled without depressing the respiratory function. 1. Incorrect: Respiratory rate warrants immediate action. However, blood pressure will continue to be monitored. 2. Incorrect: Pulse rate warrants no further action. Pulse rate is normal. 3. Incorrect: The pain level is expected following surgery. The client should continue to have a reduction on pain, as 10 minutes is not long enough to fully evaluate.
A client is brought into the emergency department (ED) with nausea, vomiting and diarrhea after eating chicken at a picnic. The nurse suspects that this client has most likely contracted which infection? 1. Shigella 2. Escherichia coli 3. Clostridium Difficile 4. Salmonella
4. Correct: Salmonella is a gram negative bacillus found in animal sources such as chicken products, eggs, turkey, and some beef. Nausea, vomiting, and diarrhea after ingesting infected chicken would be the classic signs/symptoms. 1. Incorrect: Shigella infection is a gram negative organism that invades the lumen of the intestine and causes severe runny, bloody diarrhea which can be transmitted through the fecal/oral route. Improper hygiene is most likely cause. 2. Incorrect: Escherichia coli is the most common aerobic organism colonizing the large bowel. It is often linked to ingestion of undercooked contaminated beef and vegetables that have been contaminated by animal waste water. Signs and symptoms of E. coli include bloody diarrhea, severe cramps, nausea and vomiting, and renal failure. 3. Incorrect: Clostridium Difficile is a spore-forming bacterium usually preceded by antibiotics, which disrupt normal intestinal flora and allow the C. Difficile spores to proliferate within the intestine. C. difficile signs and symptoms can range from mild diarrhea to severe colitis.
Which nursing action is likely to improve client satisfaction and demonstrate acts of beneficence? 1. Allowing clients to make their own decisions about care 2. Answering all questions posed by 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. Correct: Sitting and listening demonstrates kindness and compassion that are consistent with the ethical term "beneficence." Beneficence is taking positive action to help others and desiring to do good which are the core principles of client advocacy. 1. Incorrect: Autonomy is the ethical principle illustrated here by supporting independent decision making with clients. 2. Incorrect: Fidelity is the ethical principle illustrated here and refers to the concept of keeping a commitment. It is based upon the virtue of caring. 3. Incorrect: Reporting faulty equipment is an act to promote nonmaleficence or to do no harm. This is the core of nursing ethics.
The nurse is preparing the sterile field to assist the primary healthcare provider with a procedure. Which flap of the sterile pack should the nurse open first? 1. Closest to the nurse. 2. To the left of the nurse. 3. To the right of the nurse. 4. Farthest from the nurse.
4. Correct: The flap farthest from the nurse should be opened first so that the nurse's arm or hand does not cross the sterile field. 1. Incorrect: The flap closest to the nurse should be opened last so that the sterile field is not crossed by the nurse's arm or hand. 2. Incorrect: The sides should be opened in the 2nd and 3rd steps so that the nurse's hand does not cross the sterile field. 3. Incorrect: The sides should be opened in the 2nd and 3rd steps so that the nurse's hand does not cross the sterile field.
A client diagnosed with arachnophobia is prescribed alprazolam 0.5 mg orally three times daily. The nurse knows that reinforcement of teaching about this medication is successful when the client makes what statement? 1. Alprazolam will take up to two weeks to start working. 2. The drug does not cause drowsiness, so my daily activities will not suffer. 3. This medication cannot be taken with food. 4. I should not stop taking alprazolam suddenly.
4. Correct: Suddenly stopping alprazolam could produce serious withdrawal symptoms, such as depression, insomnia, anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, and delirium. 1. Incorrect: Alprazolam works relatively quickly. 2. Incorrect: Drowsiness, confusion, and lethargy are the most common side effects. The client should not drive or operate dangerous machinery while taking the medication. 3. Incorrect: If the client experiences nausea and vomiting, take with food or milk.
During evening rounds on a medical unit, a client is discovered in cardiac arrest. After activating the code button, the nurse initiates chest compressions. A second nurse enters the room to assist. What priority task could be assigned to the second nurse? 1. Retrieve the crash cart. 2. Document the code events. 3. Notify the primary healthcare provider to discontinue the haloperidol. 4. Begin oxygenating the client.
4. Correct: The chest compressions, airway, and breathing (CAB) sequence is always of primary concern. The first nurse correctly activated a code and then began chest compressions. The second nurse will assist by oxygenating the client, using a bag valve mask. 1. Incorrect: Although it will be necessary to bring the crash cart into the room, the initial priority should focus on the client's needs. In the case of a client in cardiac arrest, the first personnel to respond must focus on CPR protocols, including compressions and oxygenation. Other personnel can bring the crash cart into the room. 2. Incorrect: Documenting all the events that occur during a code is vital for both legal and quality assurance purposes; however, the initial priority must focus on stabilizing the client. 3. Incorrect: The Healthcare Provider does need to be notified, but it is not an immediate priority for either nurse. Ancillary personnel, such as the unit secretary, can complete this task. Professional personnel must focus on the client's immediate needs at this critical point.
An 18 year old football player is admitted to the ortho unit after a femur fracture. He is scheduled for a rod to be placed in the morning, but suddenly develops severe shortness of breath, a petechial rash on his chest, and unstable vital signs. What should the nurse do first? 1. Decrease rate of IV fluids. 2. Neurovascular checks of affected leg. 3. Elevate the head of the bed. 4. Call the active response team.
4. Correct: The client is exhibiting symptoms of a fat embolism, particularly with the petechial rash on his chest and severe shortness of breath. Due to his age, high risk behaviors with contact sports, and the large long bone fracture, he is the classic example of a client that may experience a fat embolus. This constitutes a medical emergency and activation of the response team. 1. Incorrect: This does not affect breathing here and will do nothing to resolve the fat embolism. 2. Incorrect: Neurovascular checks of the leg will not help the client's breathing and are not the first priority for the nurse. 3. Incorrect: The nurse may elevate HOB to assist with breathing unless client is hypotensive. Either way, this is not the best first answer.
The client needs assistance to apply anti-embolism stockings each day in the long-term care facility. Today, as the nurse enters the room to apply the stockings, she finds that the client has been walking about the unit for 30 minutes. What should the nurse do first to lessen the risk of swelling of the lower extremities? 1. Ask the client to lie down and place the stockings on the legs. 2. Ask the client to sit on the bedside and place the stockings on the legs. 3. Tell the client that the nurse will return later to assist with the application. 4. Elevate the extremities in bed for 30 minutes before application.
4. Correct: The client should have extremities elevated to encourage venous return and reduce the risk of swelling before the stockings are applied. 1. Incorrect: To place the stockings on immediately will cause further venous stasis and swelling. 2. Incorrect: The extremities should be elevated for a period of time before application. 3. Incorrect: This instruction alone does not give the client adequate information about the need to keep the lower extremities elevated before applying the stockings.
The nurse is preparing to make an occupied bed. Which action by the nurse is important to preserve client's self-esteem during this procedure? 1. Remove the top sheet first and replace with a clean one. 2. Inform the client that they will be uncovered only for a short time. 3. Ask the client to relax as the top sheet is removed and the bottom sheet is changed. 4. Cover the client with a bath blanket before removing any of the sheets on the bed.
4. Correct: The client should not be exposed during the bed change. Cover with a bath blanket as the top sheet is removed. 1. Incorrect: The client's self-esteem will not be preserved if uncovered during the procedure. Being exposed to the nurse is very troubling for most clients. 2. Incorrect: The client should be covered throughout the procedure. 3. Incorrect: The client's self-esteem will not be preserved by relaxing. Being exposed is anxiety provoking, and exposure is unnecessary. 1. Identify clues in the stem. Generally, the stem is short and contains only the information needed to make the question clear. A clue is the use of a word or phrase that leads you to the correct answer. The clue shows a relationship to word or phrase in the correct answer. 2. Identify options that deny client feelings, concerns, and needs. Options that imply everything will be all right deny clients' feelings, change the subject raised by the client, encourage the client to be cheerful, or transfer nursing responsibility to other members of the healthcare team usually are distractors and can be eliminated from consideration.
A fully alert and competent client is in end-stage cardiac disease. The client says, "I'm ready to die," and refuses to take nourishment. The family urges the client to allow the nurse to insert a feeding tube. What action should the nurse take? You answered this question Correctly 1. Tell the family that the feeding tube will be inserted after the client becomes unresponsive. 2. Ask the primary healthcare provider to insist the client have a feeding tube. 3. After sedating the client, insert a feeding tube. 4. Inform the client that no feeding tube will be inserted.
4. Correct: The client's decision should be honored by the nurse. This client alert and competent, and has the right to make healthcare decisions and the right to die with dignity. 1. Incorrect: This is inappropriate as it does not follow the client's wishes. 2. Incorrect: This again is inappropriate. The client has the right to make an informed decision about dying. 3. Incorrect: This is a form of battery. The nurse is not following the client's wishes.
Which client assignment could the LPN/VN accept? 1. Eight year old in diabetic ketoacidosis (DKA) 2. Six year old in sickle cell crisis 3. Two month old with dehydration 4. Five year old in skeletal traction
4. Correct: The fracture would be most appropriate for an LPN/VN and is within the scope of practice. This LPN/VN would need minimal assistance from the RN. Possibly, the other clients could have intravenous fluid (IVF) needs and medications that would require skill from an RN. 1. Incorrect: The child with DKA is in metabolic acidosis. The child is also at risk for other problems such as dehydration and electrolyte disturbances. Therefore, the child will need close observation and the RN's assessment skills. 2. Incorrect: IV fluid management is crucial for clients in a sickle cell crisis Assessment of the child's cardiovascular status, tissue perfusion and neuro status are priorities. Pain management is also very important in these clients. Therefore, the child with sickle cell will need close observation and the RN's assessment skills. 3. Incorrect: The baby with dehydration will need close observation and the RN's assessment skills, including monitoring for impending shock. Renal function and electrolyte levels should be monitored closely. The care of the child will likely involve IV fluids.
A client who is occasionally confused states that the medication is the wrong color when the nurse hands it to the client. What action should the nurse take? 1. Encourage the client to take the medication. 2. Tell the client that the medication is correct. 3. Explain that generic medications may be different colors. 4. Double check the medication before administering.
4. Correct: The nurse cannot assume that the client is confused. Assessing orientation, LOC and asking client to state his/her name would help identify if the client is confused. The nurse must double check. An error may be prevented by doing this. Seeking clarification is the safest option. 1. Incorrect: The nurse may make a medication error if the client is encouraged to take the medication without double checking. To prevent errors, the nurse must adhere to the five rights of medication administration: right drug, right dose, right time, right route and right patient. 2. Incorrect: The client may be identifying an error. The nurse should double check that this is the correct medication. Simply telling the client the medication is correct is not enough. Double check the medication. 3. Incorrect: This statement is true; however, to maintain safety of the client, the medication should be checked. Seeking clarification is the safest option.
The client states, "I really do not want to have surgery. I have told my children this, but they still want me to go through with the surgery. I do not know what to do." What is the best response for the nurse as client advocate? 1. "Your children are concerned about you. The surgery is the best thing for your health." 2. "You have some genuine concerns about the surgery, and you feel as if your children are not addressing your concerns. You and your family will need to resolve this before you go to surgery." 3. "I can contact your primary healthcare provider so that you can discuss your concerns regarding surgery." 4. "You have some genuine concerns about the surgery, and you feel as if your children are not addressing your concerns. Tell me more about your concerns."
4. Correct: The nurse has a duty to advocate for the client if there is a discrepancy between the care or proposed care and the client's wishes regarding treatment. It is important to acknowledge the client's feelings and to demonstrate compassion and a willingness to understand. This presents an opportunity for additional communication to help answer some of the client's questions or set up a client-family conference with the client, the client's family, and the primary healthcare provider. 1. Incorrect: When the nurse agrees with the client's children, the nurse ignores the client's feelings and does not address the issue of the client's treatment wishes. 2. Incorrect: When the nurse restates the client's comment without investigating the client's concerns, the issue goes unresolved. 3. Incorrect: Offering only to contact the primary healthcare provider is an incomplete solution and hints of the nurse not taking responsibility to investigate the client's concerns. The client may be uncomfortable addressing concerns with the primary healthcare provider before resolving the issue of treatment wishes with family members.
The nurse is working with a new unlicensed assistive personnel (UAP) on a postoperative floor. The first vital sign check on a new postoperative client was performed by the nurse. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. In planning care for the postoperative client, the nurse decided to retain the task of vital sign assessment. What was the rationale for this plan? 1. The nurse did not trust the new UAP. 2. The nurse prefers to check all vital signs on clients. 3. The nurse's role includes assessment of vital signs of post-op clients. 4. The nurse does not know the skills of the new UAP.
4. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. When the licensed person cannot do this, the task should not be delegated 1. Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the staff member. 2. Incorrect: When a floor is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. 3. Incorrect: The nurse can measure vital signs; however, agency policy usually states that the UAP can perform this task also.
A client diagnosed with Celiac disease is on a gluten-free diet. What statement by the client would indicate to the nurse that reinforcing of diet instructions is needed? 1. "I will still have occasional abdominal discomfort." 2. "I may need to take iron or vitamin supplements." 3. "I can have eggs but no wheat toast for breakfast." 4. "I should avoid fresh apples and strawberries."
4. Correct: The nurse is evaluating client statements for any lack of understanding and the need to provide further instruction. With Celiac disease, intestinal villi become inflamed whenever gluten is introduced to the gut through food intake. However, fresh fruits and vegetables do not contain gluten; therefore, fresh apples and strawberries would definitely be acceptable foods for this client. This statement by the client is inaccurate, indicating the need for reinforcing diet instructions by the nurse. 1. Incorrect: The client correctly acknowledges that some episodes of abdominal discomfort may still occur, since it is nearly impossible to totally eliminate gluten. Despite buying "gluten-free" products, occasionally small amounts of gluten may contaminate foods and cause symptoms to resurface. Eating in a restaurant may also be a challenge for those with Celiac disease. The client recognizes these possible symptoms. 2. Incorrect: This is an accurate statement by the client about Celiac disease. Because inflammation of the intestinal villi may lead to poor absorption of nutrients or anemia, clients may, indeed, need to take supplements for extended periods of time. This response does not indicate any problems with the client's comprehension of diet. 3. Incorrect: It is important for a client with Celiac disease to eat as healthy and diverse a diet as possible, since malnutrition occurs secondary to poor nutrient absorption in the bowel. Protein is a vital component in the diet, including such choices as eggs, dairy, and beans. Those foods creating the worst symptoms include grains like wheat, rye, and barley as well as the "malt barley" used as a thickening agent in certain products. The client has precisely stated that a breakfast including eggs but minus the wheat toast would be appropriate, evidence the client understands the diet. Identify key words in the stem that indicate negative polarity, such as not, except, never, contraindicated, unacceptable, avoid, unrelated, violate, least, further teaching needed. These words indicate negative polarity and the question being asked is looking for what is false. Celiac disease is an immune response that tends to have a familial connection. Remember that the disease causes an inflammation of the intestinal villi, resulting in poor nutrient absorption. When any type of gluten is introduced into the digestive track, the client experiences severe symptoms such as gas and bloating, diarrhea, weight-loss, and chronic fatigue with weakness. Over time, the client may develop anemia, osteoporosis, or even pancreatic problems. So, this is a very serious disease that has no known cure. Clients are taught how to live with this process by following a strictly gluten-free diet. Until recent years, it was difficult to find enough gluten-free foods to plan a nourishing, tasty diet. Gluten free products are now more readily available. Now, examine the stem of the question. The nurse is looking for a statement by the client indicating that reinforcement of diet instruction is needed - so the nurse is looking for an inaccurate comment by the client. When reading each option, ask yourself, is this a truthful statement about Celiac disease? You are looking for what the client said that was incorrect. Option 1: Well this is certainly an accurate statement by the client - no matter how carefully the client with Celiac disease tries to eat gluten-free, there may be hidden gluten not indicated on the packaging in some foods. The inadvertent ingestion of gluten can produce uncomfortable or even painful symptoms such as bloating, gas, or severe headaches. The client acknowledges this might happen, making this an accurate comment by the client. No reinforcement of teaching needed here - try again! Option 2: The scenario states the client has just been diagnosed with Celiac disease, and teaching has been initiated. Because diagnosing this disease can be challenging to a healthcare provider, the client may have developed complications over time such as osteoporosis or anemia. Therefore, it would not be unusual for a client to need to take fat soluble vitamins or iron tablets, among other replacements, to correct any pre-existing complications. This is an accurate statement by the client, indicating the client understands the diet. But you are looking for evidence the client needs more reinforcement of teaching! Try again. Option 3: This statement indicates the client definitely understood the nurse's explanation! Gluten is very prominent in grain products such as wheat, rye, and barley and when ingested, causes extreme pain, bloating, and diarrhea in those with Celiac disease. The appropriate diet for these clients includes dairy and eggs, meat and poultry, seafood, soy and beans, among other foods. The biggest offenders for causing discomfort are wheat, rye, and barley products. This statement definitely indicates the client understands that eggs are acceptable, while avoiding wheat toast. Not the option you are looking for! Option 4: Great choice! It is obvious from this statement by the client that reinforcement of teaching is certainly necessary. While a gluten-free diet does have many foods to be avoided, fresh fruits and vegetables are not only fitting but encouraged for their vitamin content. Fresh apples and strawberries are a great addition for client with Celiac disease because of poor nutrient absorption. This client need to be cautious about canned fruits or veggies, because sometimes malt barley (high in gluten) is added as a thickening agent - that would cause a problem! But fresh fruits and veggies are a great idea! This statement indicates the client needs reinforcement of teaching on the basics of the gluten-free diet.
Upon receiving a diagnosis of Stage 4 lung cancer, an elderly client expresses regret for having chosen to smoke. Which response by the nurse would best help the client cope at this time? 1. "You are lucky to have lived a very long life." 2. "We have younger clients in worse shape than you." 3. "The doctor will make sure to treat any pain." 4. "You are regretting your decision to smoke."
4. Correct: The nurse responds with an open-ended statement that reflects back to what the client has stated. This allows the client to continue expressing concerns and feelings about the diagnosis or past choices. At this time, encouraging the client to verbalize is the best choice to help with coping. 1. Incorrect: This is a closed-ended statement that diminishes the client's feelings about the diagnosis or possible personal choices that may have led to this situation. The response infers that the client should be grateful for the life lived and belittles the client's response. 2. Incorrect: Such a non-therapeutic statement does not address the client's feelings and, in fact, devalues the client by comparing this situation to that of other clients. The nurse should focus on helping the client to cope at this time by encouraging the expression of feelings. 3. Incorrect: Rather than allowing the client to verbalize concerns or emotions, the nurse has responded with a close-ended statement that addresses a topic not initiated by the client's comments. This option does nothing to help the client cope, but rather may instill fear by referring to pain that may or may not occur. 1. Nurses need to use interviewing techniques to effectively communicate in a nonthreatening way with clients. 2. Identify client-centered options. The focus of the nurse should be the client. Items that test your ability to be client-centered tend to explore client feelings, identify client preferences, empower the client, provide the client choices, or in some way put emphasis on the client. The client is the priority.
The nurse is checking a two year old's developmental status. What finding would be of concern to the nurse? 1. Unable to use "me" and "you" correctly. 2. Has trouble focusing on one activity for more than 5 minutes. 3. Does not follow a 3-part command. 4. Does not know what to do with a spoon.
4. Correct: The nurse should be concerned if a 2 year old does not know what to do with common things such as a brush, phone, fork, or spoon. 1. Incorrect: The nurse should be concerned if the 4 year old doesn't use "me" and "you" correctly. 2. Incorrect: The nurse should be concerned if the 5 year old has trouble focusing on one activity for more than 5 minutes. 3. Incorrect: The nurse should be concerned if the 4 year old doesn't follow 3-part commands. The nurse should be concerned if the 2 year old doesn't use 2-word phrases (for example, "drink milk"), doesn't know what to do with common things (brush, phone, fork, spoon), doesn't copy actions and words, doesn't follow simple instructions, doesn't walk steadily, or loses skills the toddler once had. The nurse should be concerned if the 4 year old can't jump in place, has trouble scribbling, shows no interest in interactive games or make-believe, ignores other children or doesn't respond to people outside the family, resists dressing, sleeping, and using the toilet, can't retell a favorite story, doesn't follow 3-part commands, doesn't understand "same" and "different", doesn't use "me" and "you" correctly, speaks unclearly, or loses skills once possessed. The nurse should be concerned if the 5 year old doesn't show a wide range of emotions, shows extreme behavior (unusually fearful, aggressive, shy or sad), unusually withdrawn and not active, is easily distracted, has trouble focusing on one activity for more than 5 minutes, doesn't respond to people, or responds only superficially, can't tell what's real and what's make-believe, doesn't play a variety of games and activities, can't give first and last name, doesn't use plurals or past tense properly, doesn't talk about daily activities or experiences, doesn't draw pictures, can't brush teeth, wash and dry hands, or get undressed without help or loses skills he once had.
A nurse is caring for a client who complains of fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis. The nurse immediately puts the client in isolation. The nurse suspects that the client is suffering from which condition? 1. Bronchitis 2. Pneumonia 3. Pneumothorax 4. Tuberculosis
4. Correct: The nurse suspects that the client is suffering from tuberculosis. Early pulmonary tuberculosis is asymptomatic. When the bacterial load increases, nonspecific constitutional symptoms of fatigue,weight loss, afternoon fevers, and night sweats may set in. As disease burden advances, cough, sputum production, and localized symptoms such as hemoptysis may appear. This client has the classic symptoms of tuberculosis and should be placed in respiratory isolation. 1. Incorrect: Bronchitis does not classically present with the symptoms listed and is not on respiratory isolation. 2. Incorrect: Pneumonia does not classically present with the symptoms listed and is not on respiratory isolation. 3. Incorrect: Pneumothorax does not classically present with the symptoms listed and is not on respiratory isolation.
A client has a diagnosis of major depression and began taking a selective serotonin reuptake inhibitor (SSRI) three days ago. The client says, "I am just not feeling well. My medicine is not working. Which reply by the nurse indicates adequate understanding of treatment? 1. "I agree, your medication is not working." 2. "Your treatment may have to be changed." 3. "Most SSRIs take about 5 days to work." 4. "You should reach desired effect in 1-3 weeks."
4. Correct: Therapeutic effect is usually reached in one to three weeks, or longer. 1. Incorrect: This response demonstrates that the nurse is not familiar with the time for therapeutic onset. 2. Incorrect: It is too soon to determine if treatment should be changed. 3. Incorrect: While some clients may be more calm within a short period of time, therapeutic effect cannot be evaluated at this point.
The nurse monitors a multigravida who is four hours postpartum. Findings include that fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The lochia is moderately heavy and bright red. Which nursing intervention has priority? 1. Massage the fundus. 2. Administer intravenous oxytocin. 3. Document these normal findings. 4. Assist the client up to void.
4. Correct: These findings are caused by a full bladder, which prevents the uterus from contracting down and achieving homeostasis. Once the bladder is empty, the fundus will contract adequately and return to its normal location at level of umbilicus or 1 finger breadth below the umbilicus and in the midline. A distended bladder will displace the uterus, usually to the right. 1. Incorrect: The nurse may check fundus after client voids to ensure that this fixes the problem. 2. Incorrect: Administering oxytocin is not the first intervention for this issue. 3. Incorrect: These are not normal findings, so this would be incorrect information for the nurse to document. 1. Whenever a client problem is identified, nursing interventions must address the specific problem. 2. Identify key words in the stem that set a priority, such as first, initially, best, priority, safest, most. These words modify what is being asked. This question requires you to put a value on each option and then place them in rank order. If you are having difficulty ranking the options, eliminate the option that you believe is most wrong among the options.
The nurse is caring for a client 28 weeks pregnant who reports swollen hands and feet. Which additional sign or symptom would cause the greatest concern? You answered this questionIncorrectly1. Nasal congestion 2. Hiccups 3. Blood glucose of 130 4. Muscle spasms
4. Correct: This client could have preeclampsia and would be at risk for seizures. 1. Incorrect: This is a common occurrence during pregnancy and is not the greatest concern. 2. Incorrect: Hiccups would be the second best answer, indicating nerve/muscle irritation, but not a common symptom associated with preeclampsia. 3. Incorrect: Not the greatest concern with presenting signs and symptoms of swelling. The blood glucose is elevated, but the priority data is the possibility of muscle spasms which may progress to seizures due to eclampsia.
A client is being cared for in the intensive care unit following a traumatic amputation of the left lower arm. As the nurse enters the room for a routine check, the client begins to cry and states "This is so overwhelming." What statement by the nurse would be most appropriate at this time? 1. "You have been through a lot, but look on the bright side; you are doing better now." 2. "Try to be optimistic. You are going to be fitted for a prosthesis once you are healed." 3. "I understand that you are upset, but crying is not going to help your situation." 4. "This must be very difficult for you. What seems to be the hardest part for you now?"
4. Correct: This client has experienced a very significant personal loss and can go through the grieving process, similar to those who experience the death of a loved one. The nurse should be very sensitive to the feelings of loss being felt by this client due to the loss of a body part. This client is reporting feeling overwhelmed. The best way for the nurse to respond to this client's feelings would be to first acknowledge that the situation must be very difficult for the client. The nurse can further explore this by asking what seems to be the hardest part for the client currently. This will guide the nurse with how to best assist the client at the current time and meet the most immediate emotional needs of this client. By addressing what is most overwhelming at the present time, the nurse can more effectively assist the client in gradually working through the grief process and dealing with the loss. 1. Incorrect: The nurse's comment starts out with an acceptable comment of acknowledging that the client has been through a lot but then immediately negates the client's feelings of being overwhelmed by telling the client to look on the bright side and that the client is doing better now. This statement discounts the client's feelings of loss and being overwhelmed with all that it entails. 2. Incorrect: This comment by the nurse that tells the client to be optimistic because a prosthesis will be fitted does not address the client's current feelings. This is a total disregard to the overwhelming feelings of loss that the client is experiencing. As the client works through the feelings of loss over time, the nurse can help provide a sense of hope and optimism about the use of a prosthesis, but the client's current feelings should be addressed first. 3. Incorrect: Again, the nurse's comment about recognizing that the client is upset could be appropriate, but the comment following this about crying not helping the situation could cause the client to feel belittled and may actually cause the client to become bitter or reluctant to share true feelings with the nurse. The nurse should support the client and explore how to best help the client work through these feelings of extreme loss. Amputations create a significant loss to clients and can cause the client to actually grieve as those who have experienced a loss due to death. The nurse has the privilege of caring for clients in very vulnerable situations such as these. It is crucial for the nurse to assess the signs that the client is experiencing feelings of extreme loss and grief and address these appropriately. Therapeutic communication and establishing a good rapport with the client can be the key to assisting positive resolution of overwhelming feelings. Clients should be encouraged to share their feelings openly and honestly. Responses by the nurse should be based on active listening and be nonjudgmental. In this case, the client is upset and shares with the nurse that the situation seems overwhelming. The nurse can most appropriately respond to this client by acknowledging how the client is feeling and then further exploring what seems to be the hardest aspect at the present time. The nurse can help guide the client to deal with the feelings in a gradual way that may seem more manageable to them. The nurse should not negate or belittle the client's feelings, which we see being done in options 1, 2, and 3. By doing so, the client may choose to hide their true emotions, become bitter, and perhaps not effectively work through their feelings of grief and loss.
A client with cirrhosis is being treated with bumetanide 1 mg daily for the management of ascites. What would the nurse identify as an effect of this medication? 1. Hyperbilirubinemia 2. Hypercalcemia 3. Hypoaldosteronism 4. Hypokalemia
4. Hypokalemia 4. Correct: Bumetanide is a K+ depleting diuretic. Potassium is lost primarily through the kidneys; therefore, when the urine output increases with the use of a diuretic, more potassium can be lost and the client is at risk for hypokalemia. 1. Incorrect: Hyperbilirubinemia may be present with cirrhosis but is not related to the effects of bumetanide. Don't let the presence of ascites convince you that this question is asking about a liver problem. 2. Incorrect: Although loop diuretics, such as bumetanide, can cause a slight increase in the excretion of calcium, which would lead to hypocalcemia, compensatory mechanisms generally are able to keep the calcium levels within normal range. 3. Incorrect: Bumetanide does not cause hypoaldosteronism. This is an aldosterone problem.
A client is seen in the clinic expressing feelings of hopelessness and despair after losing his wife two months ago. He tells the nurse, "I think I am ready to go meet her. Please don't tell anyone." How should the nurse respond? 1. "I can see that you miss your wife very much." 2. "Tell me about your wife." 3. "I will keep your secret if you promise me you won't do anything until we talk again." 4. "I can't keep a secret like that. Are you planning to harm yourself?"
4. Correct: This elderly client is contemplating suicide. Elderly men are at a high risk for succeeding at suicide because they tend to use lethal methods. The nurse has a responsibility to get the client help. The nurse is using the therapeutic communication technique of seeking clarification and validation. 1. Incorrect: This ignores the problem. The issue is that the client is attempting suicide. The non-therapeutic communication technique of interpreting is telling the client what they think they are experiencing. 2. Incorrect: This question does not address the issues of suicide. Talking about his wife may make the client more depressed. The nurse is using the non-therapeutic communication technique of introducing an unrelated topic. The nurse is changing the direction of the conversation. 3. Incorrect: It is not appropriate to keep this information secret. The client may commit suicide in the meantime. This is a non-therapeutic statement because the client's safety is at risk.
After the nurse administers ear drops to an adult client, it is important for the nurse to implement which action? 1. Leave the client lying with the unaffected ear facing up. 2. Place a cotton ball firmly into the affected ear for 15 minutes. 3. Pull the pinna of the ear down and back. 4. Gently massage the tragus of the ear.
4. Correct: This is a correct nursing measure that will facilitate the flow of medication in the auditory canal. 1. Incorrect: The client can remain on the side for 5 to 10 minutes with the affected ear up to help distribute the medication and prevent the medication from escaping the ear canal. 2. Incorrect: The cotton ball is placed loosely at the opening of the auditory canal for 15 minutes to prevent the medication from escaping the canal when the client changes positions. 3. Incorrect: The pinna is pulled up and back on an adult client when instilling the ear drops to straighten the ear canal.
A psychiatric client tells the day shift nurse, "The night nurses have been stealing from all of us while we are sleeping." What is the nurse's best response? 1. "Can you prove what the nurses are stealing?" 2. "No nurse working here would steal." 3. "You must have misunderstood what you were seeing." 4. "Tell me more about what you saw."
4. Correct: This open ended question allows for exploring the idea the client has. This statement does not accuse anyone or deny the possibility of stealing. This statement allows the nurse to remain nonthreatening and nonjudgmental. 1. Incorrect: This response shows disapproval. This statement could make the client feel uncomfortable and seem like the nurse is taking the side of the other nurses. 2. Incorrect: This response is disagreeing with the client. This is a closed-ended statement that does not allow the client to discuss this topic further. Since the nurse has said no nurse would steal then the client most likely will become defensive. 3. Incorrect: This response is defending. It also makes the client feel that the nurse does not believe them.
Which is an example of a sentinel event? You answered this question Correctly 1. The terminally ill client is referred to hospice and dies 3 months later . 2. A client has a mammogram which reveals small cyst. 3. A client with a laceration to the knee falls when getting up unassisted after being instructed to remain in bed. 4. A client scheduled for knee replacement surgery has an above the knee amputation performed.
4. Correct: Yes! Unexpected occurrence causing death or serious injury.1. Incorrect: The terminally ill are expected to die.2. Incorrect: Sometimes cysts are found during mammogram- expected occurrence.3. Incorrect: Not enough injury for sentinel event.
The nurse, caring for an 8 month old infant, should recognize which major stressor of hospitalization for this infant? 1. Fear of unknown 2. Loss of daily routine 3. Body image disturbance 4. Separation anxiety
4. Correct: Yes, they are afraid of being without the caregiver. Separation anxiety develops after a child gains an understanding of object permanence. The infant may become unsettled after the parent leaves. Although some babies display object permanence and separation anxiety as early as 4 to 5 months of age, most develop more robust separation anxiety at around 8 months. Separation anxiety can be worse if the infant is hungry, tired, or not feeling well. 1. Incorrect: Fear of the unknown is not a concern at this age, but rather between the age of 2-3 years. Separation anxiety is their immediate concern. 2. Incorrect: Keeping family routines and providing quality time with trusted adults is reassuring once the child reaches the age of 2. 3. Incorrect: The preschooler fears mutilation resulting in body image disturbance.
A nurse is providing care to a post-operative parathyroidectomy client. Which complication takes priority? 1. Psychosis 2. Renal calculi 3. Positive Trousseau's sign 4. Laryngospasm
4. Laryngospasm 4. Correct: Yes, airway is most important here. But don't pick the option just because it sounds scary all by itself. Think about the why. When the parathyroids are removed, calcium is affected because these glands help control calcium levels in the blood. Laryngospasm may result from the neuromuscular irritability caused by the hypocalcemia. 1. Incorrect: This is disturbing and important, but AIRWAY is the priority. 2. Incorrect: Renal calculi can cause problems, lead to pain, and possibly cause renal failure, but they are not as important as airway obstruction. 3. Incorrect: A positive Trousseau's sign is seen with hypocalcemia but is not the highest priority. Airway is most important in this question.
The nurse is caring for a client with right-sided paresis due to a stroke. The client is preparing for discharge in a few days. The nurse discovers that the spouse has been feeding the client. What should the nurse do? 1. Tell the spouse to require the client to feed independently. 2. Suggest the spouse hire an aide to feed and bathe the client upon discharge. 3. Advise the spouse to consider an extended care facility for the client. 4. Determine the reason why the spouse is not encouraging self-care by the client.
4. Determine the reason why the spouse is not encouraging self-care by the client. 4. Correct: Because family members are important in promoting client self-care and preventing further illness, it is important to include family members in the teaching plan for the client. In a family support model, the goal is client self-care activities through formal and informal support systems. 1. Incorrect: Simply telling the spouse to require the client to perform self-care activities may result in affirmative verbal response from the spouse without actual follow-through after the nurse leaves. 2. Incorrect: Hiring others to perform care activities that the client can do independently does not contribute to the self-care model. 3. Incorrect: No indications that client needs an extended care facility.
After the nurse administers ear drops to an adult client, it is important for the nurse to implement which action? 1. Leave the client lying with the unaffected ear facing up. 2. Place a cotton ball firmly into the affected ear for 15 minutes. 3. Pull the pinna of the ear down and back. 4. Gently massage the tragus of the ear.
4. Gently massage the tragus of the ear. 4. Correct: This is a correct nursing measure that will facilitate the flow of medication in the auditory canal.1. Incorrect: The client can remain on the side for 5 to 10 minutes with the affected ear up to help distribute the medication and prevent the medication from escaping the ear canal.2. Incorrect: The cotton ball is placed loosely at the opening of the auditory canal for 15 minutes to prevent the medication from escaping the canal when the client changes positions.3. Incorrect: The pinna is pulled up and back on an adult client when instilling the ear drops to straighten the ear canal.
A client with persistent vomiting reports weakness and leg cramps. Which acid base imbalance would the nurse anticipate? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
4. Metabolic alkalosis 4. Correct: Symptoms of metabolic alkalosis are often due to associated potassium loss and may include irritability, weakness, and cramping. Excessive vomiting eliminates gastric acid and potassium, leading to metabolic alkalosis. 1. Incorrect: Not respiratory related. It is a metabolic acid-base imbalance. 2. Incorrect: Not respiratory related. It is a metabolic acid-base imbalance. 3. Incorrect: Not acidosis. There is loss of gastric acid and potassium with persistent vomiting, leading to metabolic alkalosis.
The nurse is teaching a group of clients who have osteoarthritis how to protect joints. What should the nurse include? Select all that apply 1. Use small joints and muscles. 2. Turn doorknobs clockwise. 3. Sit in a chair that has a low, straight back. 4. Push off with the palms of hands when getting out of bed. 5. Use hairbrush with extended handle.
4. Push off with the palms of hands when getting out of bed. 5. Use hairbrush with extended handle. 4. & 5. Correct: Pushing off with the palms of the hands is using a larger joint and muscles. Using the fingers will cause more joint injury. Use long handled devices such as a hairbrush with an extended handle to decrease stress on joints (in this case the wrist). 1. Incorrect: Larger joints and muscles can take more stress and weight than smaller ones. Using small joints again and again puts more stress on them and may lead to deformity. Try to spread the strain and weight over several joints. This helps you use each part of your body to its best advantage. 2. Incorrect: Do not turn a doorknob clockwise. Turn it counterclockwise to avoid twisting the arm and promoting ulnar deviation. 3. Incorrect: Sit in a chair that has a high, straight back. This will provide more support for the back.
The nurse enters a client's room and finds the client masturbating. Which action by the nurse would be most appropriate for the nurse to take? 1. Ask the client to stop 2. Remain in the room until client has finished. 3. Document the activity in the client's chart. 4. Quietly leave the room
4. Quietly leave the room 4. Correct: Leaving the client's room allows the client to have privacy. The client has the right to express self sexually in private. 1. Incorrect: The client has a right to express sexuality through masturbation, which is a normal way of finding sexual release.2. Incorrect: Ignoring the behavior and continuing presence in the room will embarrass the client. 3. Incorrect: The nurse can chart the client's sexual activity in the chart. However, when the nurse enters the client's room and finds the client masturbating, the nurse first needs to leave the client's room quietly.
Which action by an unlicensed nursing assistant would require the nurse to intervene? 1. Collecting I & O totals for unit clients at the end of shift. 2. Elevating the head of the bed 30°- 40° for the client post thoracotomy 3. Ambulating a client who is 2 days post vaginal hysterectomy 4. Turning off continuous tube feeding to reposition a client, then turning the feeding back on
4. Turning off continuous tube feeding to reposition a client, then turning the feeding back on 4. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. The nurse should do this when repositioning is needed. Prior to turning feeding back on, tube placement needs to be verified. 1. Incorrect: Obtaining the urinary output of a client at the end of the shift is appropriate for the nursing assistant and should be documented and reported to the RN. 2. Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. 3. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. This is an appropriate and safe action for the unlicensed nursing assistant to do.
Which client diagnosis would require the nurse to initiate droplet precaution? 1. Methicillin-resistant Staphylococcus aureus (MRSA) 2. Varicella 3. Vancomycin-resistant enterococci (VRE) 4. Whooping cough
4. Whooping cough 4. Correct: Droplet isolation precautions are used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples: pneumonia, influenza, whooping cough, bacterial meningitis). Healthcare workers should wear a surgical mask while in the room. Mask must be discarded in trash after leaving the room. Clean hands (hand washing or use hand sanitizer) when they enter the room and when they leave the room. 1. Incorrect: Contact isolation precautions are used for infections, diseases, or germs that are spread by touching the client or items in the room {examples: MRSA, VRE, diarrheal illnesses, open wounds, Respiratory syncytial virus (RSV)}. Healthcare workers should wear a gown and gloves while in the client's room. Remove the gown and gloves before leaving the room. Clean hands (hand washing or use hand sanitizer) when entering and leaving the room. Visitors must check with the nurse before taking anything into or out of the room. 2. Incorrect: Airborne isolation precautions are used for diseases or very small germs that are spread through the air from one person to another (examples: Tuberculosis (TB), measles, varicella). Healthcare workers should ensure client is placed in an appropriate negative air pressure room (a room where the air is gently sucked outside the building) with the door shut. Wear a fit-tested NIOSH-approved N-95 or higher level respirator while in the room. Clean hands (hand washing or use hand sanitizer) when they enter the room and when they leave the room. Ensure the client wears a surgical mask when leaving the room. Instruct visitors to wear a mask while in the room. 3. Incorrect: Contact isolation precautions are used for infections, diseases, or germs that are spread by touching the client or items in the room (examples: MRSA, VRE, diarrheal illnesses, open wounds, RSV). Healthcare workers should wear a gown and gloves while in the client's room. Remove the gown and gloves before leaving the room. Clean hands (hand washing or use hand sanitizer) when entering and leaving the room. Visitors must check with the nurse before taking anything into or out of the room.
Which foods should the nurse encourage a client to avoid when prescribed a diet limiting purine rich foods? 1. Peanut butter 2. Potatoes 3. Apples 4. Venison 5. Scallops
4., & 5. Correct: Purines are found in many foods and produced naturally by the body. Meats such as liver, bacon, veal, and venison are high in purine and should be avoided. Seafood such as sardines, mussels, codfish, scallops, trout, and haddock are high in purine and should be avoided. 1. Incorrect: Peanut butter is low in purine and allowed on a diet limiting purine rich foods. 2. Incorrect: Potatoes are allowed on low purine diet. 3. Incorrect: All fruit and fruit juices are low in purine. So apples can be eaten on a diet limiting purine rich foods.
Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Check client's bony prominences for redness. 2. Monitor client need for suctioning hourly. 3. Explain how to collect 24 hour urine to client. 4. Take a tympanic temperature on client every two hours. 5. Perform postural drainage and chest physiotherapy on client. 6. Report client's pulse oximetry reading every hour.
4., & 6. Correct: The UAP can take vital signs (including tympanic temperatures) and pulse oximetry readings but cannot interpret these findings. This statement is telling the UAP to report the reading, which can be done by the UAP. 1. Incorrect: The nurse cannot assign assessment or evaluation to the UAP. 2. Incorrect: The UAP cannot monitor, assess, or evaluate. This requires the skills of a nurse. 3. Incorrect: The nurse cannot assign teaching to the UAP. 5. Incorrect: Postural drainage and chest physiotherapy is not a routine and frequent task. Monitoring is required during this procedure as well. This would require the care of a nurse. Unlicensed assistive personnel (UAP) are unlicensed health care providers trained to function in a supportive role by providing client care activities as assigned by the nurse. The term includes, but is not limited to nurse aides, orderlies, assistants, attendants, or technicians. UAPs function under the nurse practice act of each state. The UAP can perform daily care of a client or group of clients that is frequently recurring and are performed according to an established sequence of steps. The activity should involve little or no modification from one client care situation to another. The activity may be performed with a predictable outcome without inherently involving ongoing assessment, interpretation, or decision making which cannot be logically separated from the procedure itself. The activity should not endanger the client's life or well-being. The UAP must have been properly trained and validated as competent by the RN. Agency policies and procedures must also permit the task, and the nurse must provide appropriate supervision.
The nurse is caring for a client while an antibiotic is being infused. The client reports burning at the intravenous (IV) site and the nurse notes that there is no blood return after lowering the IV bag. Which nursing intervention should the nurse implement? 1. Apply ice compresses. 2. Slow the infusion. 3. Inspect the IV site again in 15 minutes. 4. Stop the infusion
4..Stop the infusion 4. Correct: The infusion should be stopped. The IV fluid will move into subcutaneous tissue and can cause damage to the tissue. 1. Incorrect: No, infiltration will result in swelling around the IV site. A warm compress will help to dilate vessels and absorb fluid. Ice will cause too much vasoconstriction and could damage tissue. 2. Incorrect: No, stop the infusion. The infusion will continue to enter the subcutaneous tissue otherwise. 3. Incorrect: After evaluating the IV site, stop the infusion. The IV is no longer in the vein. Don't wait another 15 minutes to re-assess. That is delaying treatment.
A client is to receive an antibiotic in 50 mL of D5 W over 30 minutes using an infusion pump. The nurse will set the infusion pump to deliver how many mL per hour? Round off to the nearest whole number.
50 mL: 30 min. = x mL: 60 min. Multiply means together and extremes together.30 x = 3,000 30x = 3,00030 30 x= 100
A caretaker has numerous questions about normal growth and development of a 10 month-old infant. Which characteristic should be of most concern to the nurse? Able to stand up briefly in play pen Head circumference greater than chest 50% increase of birth weight Crying when the parents leave
50% increase of birth weight Correct! Birth weight should double by 6 months of age, triple at 1 year, and quadruple by 18 months. The other characteristics are normal for the age of this infant. A tip for answering this question is to recognize that the question being asked is about what would be abnormal for a 10 month-old.
The nurse is caring for a client on the pediatric unit. The primary healthcare provider prescribes phenytoin 30 mg by mouth every 8 hours for a client weighting 18 kg. The recommended dosage is 5 mg/kg/day. What does the nurse determine is the safe dosage for the child in mg/day? Round your answer to the nearest whole number.
5mg x 18 kg = 90 mg/day
Vancomycin should be infused over
60 minutes 100 min if infusing over 1 gm When the medication is given too fast the client may develop red man syndrome
blood pressure target for clients with diabetes
<140/90
The hospital is under a severe weather warning. The nurse is prioritizing clients for discharge to make beds available for possible emergency admissions. Which of the following adult clients would be most appropriate to discharge? (Select all that apply.) A client who is ambulatory with the support of crutches. A client who is dependent on a mechanical ventilator. A client who can manage their self-care. A client who requires the administration of enoxaparin. A client who requires a complex dressing change.
A client who is ambulatory with the support of crutches. Correct! A client who can manage their self-care. Correct! A client who requires the administration of enoxaparin. Correct Response In preparing for a weather emergency, it may be necessary to discharge clients to ensure hospital beds are available for emergency admissions. Ambulatory clients who can manage their self-care should be discharged first. Those requiring minimal care can also be considered for discharge. Clients with complex dressing changes, or who require mechanical ventilation cannot be considered for discharge. Clients or family members can be taught how to self-administer subcutaneous medications such as the anticoagulant enoxaparin (Lovenox) at home.
A client of Hispanic heritage refuses emergency unit treatment until a curandero is called. What should the nurse understand about the practices of a curandero? A curandero offers spiritual advising The client believes in witchcraft Herbal preparations will be used A curandero uses holistic healing practices
A curandero uses holistic healing practices Correct Response A curandero is a folk healer (or shaman) who uses a holistic approach that includes herbs, aromas and rituals, to treat the ills of the body, mind and spirit. Many times, the curandero works with traditional Western health care providers to restore health.
brachytherapy radiation
A permanent or temporary implantation of small, sealed containers (seeds) of radioactive material directly into the tumor or in a cavity of the tumor. Radiation source is within the client who emits radiation and is a hazard to those around for a period of time.
In a patient with pneumonia what lung sounds can you expect?
A pneumonia cough is generally a productive cough, often with yellow or green mucus. The breathing sounds are also different from asthma - Instead of wheezing, a doctor will hear rales and rhonchi with their stethoscope. Bilateral crackles also Crackling or bubbling noises (rales) made by movement of fluid in the tiny air sacs of the lung. ... "E" to "A" changes in the lungs (egophony). Your doctor may have you say the letter "E" while he listens to your chest. Pneumonia may cause the "E" to sound like the letter "A" when heard through a stethoscope.
Hypospadias repair
A surgical correction of a urethral meatus found abnormally on the undersurface of the penis is __________. A) Hypospadias repair B) Epispadias repair C) Wilms procedure D) Nephrectomy
Lisonopril
ACE inhibitors Prevent pathological enlargement of the left blocks crucial step in the renin-angiotensin-converting enzyme system s/e:angioedema, dry cough
UAP scope of practice
ADLs Hygiene Linen Change Routine, Stable Vitals Documenting Input/Output Positioning
To evaluate the effectiveness of IV methylprednisolone (Solu-Medrol) given to a patient with a T4 spinal cord injury, which information is most important for the nurse to obtain? a. Leg strength and sensation b. Skin temperature and color c. Blood pressure and apical heart rate d. Respiratory effort and O2 saturation
ANS: A The purpose of methylprednisolone administration is to help preserve motor function and sensation. Therefore the nurse will assess this patient for lower extremity function. The other data also will be collected by the nurse, but they do not reflect the effectiveness of the methylprednisolone.
When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Avoidance of cool room temperature e. Administration of H2 receptor blockers
ANS: A, C, D, E The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine.
Legal respomsibilities with regard to informed consent
Act as a witness that the client signed the consent form voluntarily Document in the medical record the date and tiem the signature was obtained Verify that the cleint is competent to provide informed consent Make sure the client is competent to sign
nurse's leagal responsability regarding informed consent:
Acting as awitness that the clkient signed the informed consent for voluntarily Document in the medical records when the consent was signes/date and time Verify that the client is competent to provide informed consent
A client is newly admitted with severe injuries from a motorcycle accident. The client's vital signs are BP 120/50, rate 110, respiratory rate of 28 and oxygen saturation 90%. Which of these actions should be done as an initial nursing intervention? Administer the ordered oxygen therapy Begin the ordered pain control therapy Institute the ordered cardiac monitoring Initiate continuous blood pressure monitoring
Administer the ordered oxygen therapy Correct! This client demonstrates early findings of shock with hypoxia, rapid heart rate and respirations. Oxygen therapy is the most important initial intervention by the nurse. The other interventions are secondary to oxygen therapy.
The nurse recognizes that client identification in accordance with agency policy must occur immediately prior to which of the following actions? (Select all that apply.)
Administration of oral acetaminophen Correct! Discontinuation of an intravenous normal saline infusion Correct Response Insertion of an indwelling urinary catheter Correct! Collection of a point of care blood glucose test Correct! Submit As part of safe nursing care, the nurse must collect client identification with at least two approved identifiers according to agency policy immediately prior to medication administration, implementation of health care provider prescriptions, collection of laboratory samples, discontinuation of intravenous infusions and many additional situations. It would not be required to confirm the client's identification immediately prior to placing the call light activation device within reach.
isosorbide discharge instructions
Adverse Reactions/Side Effects CNS: dizziness, headache. CV: hypotension, tachycardia, paradoxic bradycardia, syncope.GI: nausea, vomiting.Misc: flushing, tolerance. Patient/Family Teaching ● Instruct patient to take medication as directed, even if feeling better. Take missed doses as soon as remembered; doses of isosorbide dinitrate should be taken at least 2 hr apart (6 hr with extended-release preparations); daily doses of isosorbide mononitrate should be taken 7 hr apart. Do not double doses. Do not discontinue abruptly. ● Caution patient to make position changes slowly to minimize orthostatic hypotension. ● May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. ● Instruct patient to take last dose of day (when taking 2- 4 doses/day) no later than 7 pm to prevent the development of tolerance. ● Advise patient to avoid concurrent use of alcohol with this medication.Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking other Rx, OTC, or herbal products. ● Inform patient that headache is a common side effect that should decrease with continuing therapy. Aspirin or acetaminophen may be ordered to treat headache. Notify health care professional if headache is persistent or severe. Do not alter dose to avoid headache. ● Advise patient to notify health care professional if dry mouth or blurred vision occurs
The nurse observes low set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum on a newborn infant. What would be a priority focus when the nurse talks to the parents?
Alcohol use during pregnancy Correct! The identification of this cluster of facial characteristics is often linked to fetal alcohol syndrome (FAS). Facial abnormalities including small head (microcephaly); small maxilla (upper jaw); short, up-turned nose; smooth philtrum (groove in upper lip); smooth and thin upper lip; and narrow, small, and unusual-appearing eyes with prominent epicanthal folds. The palpebral fissure separates the upper and lower eyelids.
The emergency department nurse admits a client who is experiencing diarrhea, abdominal cramps, fever and headache. This is the third client admitted today with the same symptoms. All three clients stated they attended the same local air show yesterday. Which of the following actions should be the priority? Alert the nursing supervisor and discuss the need to contact public health authorities regarding the similarity of the cases Suggest placing all clients in the same room until a cause for their symptoms can be determined Ask the client for permission to talk with the family members regarding their symptoms Determine what foods the clients ate while attending the air show
Alert the nursing supervisor and discuss the need to contact public health authorities regarding the similarity of the cases Correct Response The nurse should be alert to illness patterns that could indicate an infectious disease outbreak. Although three clients in one hospital does not necessarily signal an outbreak, the nurse may not be aware of clients seeking care in other health care settings. The nurse should contact the nursing supervisor about the similarity of the cases and discuss the need to contact public health authorities. Placing the clients in the same room may be appropriate, but it is not the priority. Although family members may have important information to share about the client's symptoms, the focus of the care is the client - family members do not need to be assessed at this time. While the symptoms seem to be food-related, other factors could also be the cause of the symptoms.
A client diagnosed with schizophrenia insists that the nurse explain the use and side effects of the medications prescribed for the client. What should the nurse understand before responding to the client? The psychiatrist will need to grant permission to discuss the client's medications. A decision to reinforce or not reinforce information about medications should be made by the nurse alone. It is too dangerous for clients who are diagnosed with schizophrenia to know about their medications. All clients have a right to be informed about their prescribed medications
All clients have a right to be informed about their prescribed medications Correct! Clients have the right to be informed about the use and side effects of their medications, regardless of their diagnosis. Clients have the right to refuse treatment, including taking prescribed medications, even if the client has a psychiatric diagnosis such as schizophrenia.
A licensed practical nurse (LPN) is planning client assignments prior to the beginning of a shift. Which tasks would be appropriate for the LPN to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Change dressing on a new postoperative client. 2. Ambulate a 3 day postoperative client. 3. Provide insulin to a diabetic client before breakfast. 4. Collect urine for a 24-hour urine collection. 5. Monitor client expressing suicidal thoughts hourly.
Ambulate a 3 day postoperative client Collect urine for a 24-hour urine collection. 2.& 4. Correct: It is appropriate for the UAP to attend to a stable client who requires frequent ambulation. The UAP has been trained to safely ambulate clients. It is appropriate for the UAP to collect a 24-hour urine specimen. The UAP is skilled at this task.1. Incorrect: A new postoperative client who requires dressing changes should be cared for by a nurse. It is appropriate for the LPN to perform dressing changes and to monitor the client's status; however, it remains the responsibility of the RN to perform ongoing assessments of the client.3. Incorrect: Insulin is a high alert medication that must be administered by a nurse. The UAP is not trained to monitor for signs of hypoglycemia.5. Incorrect: A client who is under suicide precautions should be closely monitored by an experienced psychiatric nurse. Follow the 5 rights of assignment: Right task, right person, right circumstance, right direction, right supervision.
A nurse is reinforcing information about actions to prevent hypercalcemia to a client diagnosed with metastatic bone disease. Which topic is important for the nurse to discuss with the client? Parenteral fluids Ambulation Diuretics Hemodialysis
Ambulation Correct Response Ambulation promotes mineralization of bones and can reduce serum calcium levels. During reinforcement of client teaching, it is preferred that the interventions that are most client-focused and least invasive be emphasized first. Volume expansion, hemodialysis and diuretics can also all decrease serum calcium levels. If you are unsure of the correct response, you should note that three of the options involve medical, and not nursing, interventions. Ambulation is the only client-centered and nursing response.
Glasgow Coma Scale (GCS) score
An evaluation tool used to determine LOC, which evaluates and assigns point values (scores) for eye opening, verbal response, and motor response, which are then totaled; effective in helping predict patient outcomes
A client diagnosed with hypothyroidism with myxedema is prescribed levothyroxine, which is to be taken in increasing dosages. Which finding, if present, indicates that the drug dosage is too high? 1. Dry skin and sensitivity to cold 2. Anorexia and fatigue 3. Weight gain and constipation 4. Angina and palpitations
Angina and palpitations 4. Correct: Angina and palpitations. When a nurse administers a thyroid replacement medication, there is an expected therapeutic response. The most desirable response is an increase in energy, improved affect, improved gastric motility, weight loss and less sensitivity to cold. If the dose is too high, the client may experience an increased HR, angina, palpitations, and a headache. In fact, the client is at risk of having a heart attack!1. Incorrect: Dry skin and sensitivity to cold are s/s of hypothyroidism. The question is asking about too much thyroid.2. Incorrect: Anorexia and fatigue are s/s of hypothyroidism.3. Incorrect: Weight gain and constipation are s/s of hypothyroidism.
A client was admitted with a diagnosis of Type II diabetes. The primary healthcare provider initiated the Insulin Sliding Scale Protocol for Type II Diabetic Clients. The prescription regimen was to begin at the high dose regimen with regular insulin AC & HS. How much insulin should the nurse administer at 2100 hours? Exhibit Date/Time Glucose Level Insulin Dose Regimen Insulin Dose 1/19 @ 0730 368 mg/dL High dose regimen 16 units regular insulin 1/19 @ 1130 256 mg/dL High dose regimen 12 units regular insulin 1/19 @ 1700 164 mg/dL High dose regimen 4 units regular insulin 1/19 @ 2100 248 mg/dL
Answer: 10 Rationale: Prescription: The prescription regimen was to begin at the high dose regimen with regular insulin AC & HS using the Insulin Sliding Scale Protocol for Type II Diabetic Clients. The protocol states to advance to the next higher dose regimen if glucose level is greater than 250 two (2) times in 24 hours and all readings are greater than 100. All glucose readings were greater than 100, and the readings were greater than 250 three times. So, the client should move to the next highest dose regimen which indicates that 10 units of regular insulin should be given at 2100 hours for a glucose of 248.
A nurse is caring for a hospitalized 12 year-old client diagnosed with hemophilia A. Which intervention should the nurse plan on implementing as a priority? Protective isolation Stool checks for blood Intake and output Bleeding precautions
Bleeding precautions The risk associated with hemophilia A is hemorrhage because the blood cannot clot properly to stop bleeding. Therefore, the client should be on bleeding precautions. The stool checks would be secondary because prevention is a priority and bleeding precautions are preventive.
The client has been prescribed a topical anticholinergic medication for the treatment of glaucoma. Which report by the client indicates a common side effect? 1. Constriction of the iris sphincter 2. Blurred vision 3. Pain 4. Confusion
Blurred vision is a common side effect of the medication due to the dilatation of the iris sphincter.
what can hinder fracture healing
Bone healing depends on nutrition, adequate circulation, and age peripheral arterial disease those dignose with osteoporosis
Post-op tonsillectomy care
Anticipate ear pain and administer acetaminophen Pt might develop bad breath Call the doctor if experince frequent and increaseing swallowing ,clearing of the troath,vomiting bright red blood,might have low grade fever,haliotosis, Trach kit should be in hand butvused only in emergencies.
Lorazepam (Ativan)
Benzodiazepine anxiolytic,antixiety long half life, not for elderly can cause:drowsziness,dizziness, ataxia, and confusion
A client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together with the baby at home. The client is exhibiting which emotional reaction to her pregnancy? Anticipation of the birth Ambivalence about pregnancy Acceptance of the pregnancy Focus on fetal development
Anticipation of the birth Correct! Directing activities toward preparation for the newborn's needs and personal adjustment are indicators of an appropriate emotional response in the third trimester. The nurse would expect ambivalence in the first trimester. Normal second trimester emotions include accepting the pregnancy and focusing on fetal development.
Amytriptyline (Elavil)
Antidepressant/also treats neuropathic pain CLASS- TCA PREDOMINANT SE- sedation, dry mouth, blurred vision, urinary retention, delatued mictruition, dizziness, fainting
Levetiracetam (Keppra)
Approved for: -Focal -Generalized tonic-clonic -Juvenile myoclonic epilepsy Side effects: -Somnolence, dizziness, anxiety, psychiatric manifestations Anticonvulsant Antiepileptic
A client is newly admitted with acute diarrhea and is wearing an adult incontinence pad. What action should the nurse take before visitors arrive and enter the client's room? Ask each visitor to dress in a gown and wear gloves before entering the client's room Call the health care provider to request an order for a private room Verify that each visitor is wearing a mask if less than 3 feet (0.9 meters) from the client Remind all visitors to wash their hands before entering, and when exiting, the room
Ask each visitor to dress in a gown and wear gloves before entering the client's room Correct Respons According to the Centers for Disease Control and Prevention, diarrhea in an incontinent patient requires contact precautions. The nurse can implement precautions for a known or suspected infection; the nurse must then obtain an order (usually within 24 hours) from the health care provider (HCP.) Contact precautions also include standard precautions, such as placing the client in a private room or cohorting; an order is not required for this. Washing hands is very important, but not enough to protect against potential enteric pathogens. Droplet precautions, not contact precautions, involve wearing a mask when within 3 feet (0.9 meters) of the client.
A 75 year-old client scheduled for surgery with a general anesthetic refuses to remove dentures prior to leaving the surgical unit for the operating room. Which approach by the nurse is the most appropriate intervention? Explain to the client that the dentures must come out as they may get lost or broken in the operating room Notify the surgeon of the client's refusal to remove the dentures Ask the client if there are second thoughts about the surgical procedure Ask the client if it would be preferred to remove the dentures in the operating room receiving area Submit(1 attempt remaining)
Ask the client if it would be preferred to remove the dentures in the operating room receiving area Correct! Prior to surgery, clients may experience a variety of fears. This choice allows the client control over the situation and fosters the client's sense of self-esteem and self-concept. The client may simply be concerned about physical appearance during the trip through the halls of the hospital to the surgical suite.
A nurse on a psychiatric unit overhears an unlicensed assistive personnel (UAP) tell a client who is very restless and continually pacing, "I am going to put you in restraints if you do not go to your room and sit down." The nurse should inform the UAP that this comment could lead to which legal action being taken against the UAP? 1. Assault 2. Battery 3. False imprisonment 4. Invasion of privacy
Assault 1. Correct: Assault is an act that results in a person's genuine fear and apprehension that he or she will be touched without consent. 2. Incorrect: Battery is the unconsented touching of another person. These charges can result when a treatment is administered to a client against his or her wishes and outside of an emergency situation. Harm or injury need not have occurred for these charges to be legitimate. 3. Incorrect: For confining a client against his or her wishes, and outside of an emergency situation, the nurse may be charged with false imprisonment. Examples include locking a person in a room; taking a client's clothes for purposes of detainment against his or her will; and retaining in mechanical restraints a competent voluntary client who demands to be released.4. Incorrect: This is a charge that may result when a client is searched without probable cause. You need a healthcare provider's prescription and written rationale showing probable cause for this intervention.
Some examples of tasks and aspects of care that can be delegated legally to nonprofessional, unlicensed assistive nursing personnel, provided they are competent in these areas, under the direct supervision of the nurse include:
Assisting the client with their activities of daily living such as ambulation, dressing, grooming, bathing and hygiene Measuring and recording fluid intake and output Measuring and recording vital signs, height and weight The provision of nonpharmacological comfort and pain relief interventions such as establishing and maintaining an environment conducive to comfort and providing the client with a soothing and therapeutic back rub Observation and reporting changes in and the current status of the patient's condition and reactions to care The transport of clients and specimens and other errands and tasks such as stocking supplies Assistance with transfers, range of motion, feeding, ambulation, and other tasks such as making beds and assisting with bowel and bladder functions
The client has received fentanyl, atropine, cefazolin and benzocaine for an endoscopic procedure. The nurse is monitoring the client and notes that the heart rate has increased from the pre-procedure baseline. Which medication is most likely responsible for the increased heart rate? Fentanyl Atropine Cefazolin Benzocaine
Atropine Correct! Atropine is an anticholinergic drug that is used to dry secretions during the procedure. However, it can also increase heart rate and dilate the pupils and is the most likely cause for the increased heart rate. Fentanyl is an opioid analgesic and short-term central nervous system (CNS) depressant and tends to slow breathing and lower heart rate and blood pressure. Benzocaine is a topical anesthetic and cefazolin is an antibiotic; neither should affect the heart rate.
Anticholinergics
Atropine GI - Slows motility, spasm Eyes - Dilates pupils *DO NOT GIVE TO GLAUCOME PTS* Heart - Increase HR Resp - bronchodilator (Atrovent), and dry secretions
Ipratropium/Albuterol
Atrovent short-acting inhaled anticholinergic used in combination with short-acting beta-agonist (eg; albuterol )to promote bronchodilator and reduce bronchospasms
A young hispanic client is experincing a spontaneous abortion.What is the best use of an interpreter in this situation?
Attempt to use a female interpreter to avoid gender sensitivity, Make good eye contact with the client(rather the interpreter)when speaking. Teach about one intervention at a time and in order it will occur.
During the physical inspection of a client, the nurse notes a pulsating mass in the client's periumbilical area. Which action should the nurse take next? Palpate the area. Auscultate the area. Percuss the area. Measure the length of the mass.
Auscultate the area. Correct! A pulsating mass at the periumbilical area is indicative of an abdominal aortic aneurysm (AAA). Auscultation of the abdomen should be done next to check for a bruit, which will further confirm the possible presence of an AAA. The other actions are contraindicated because causing pressure to the area through palpation or percussion may cause the aneurysm to leak or rupture. Measuring the area would not provide any useful data.
Malignant hyperthermia
Autosomal-dominant trait characterized by often fatal hyperthermia in affected people exposed to certain anesthetic agents. Inheried muscle abnormality succiniylcholine (Anectine) a depolarizing muscle relaxant used to induced general anesthesia. In MH clients , the triggering agent leads to excessive rerlease of calcium from muscles,causing sutained muscle contraction and ridigity(usually the jaw and upper body[early signs]increase oxygen demand and metabolism and a dangerously high temperature(later sign)
bilateral lung crakles indicate?
Bilateral crackles refers to the presence of crackles in both lungs. ... Crackles are caused by the "popping open" of small airways and alveoli collapsed by fluid, exudate, or lack of aeration during expiration
Alendronate (Fosamax) indications
Bone health/osteoporosis It can treat or prevent osteoporosis. It can also treat Paget's disease of the bone You should not take Fosamax if you have problems with your esophagus or low levels of calcium in your blood. Do not take Fosamax if you cannot sit upright or stand for at least 30 minutes after taking the medicine. can cause serious problems in the stomach or esophagus. Stop using this medicine and call your doctor at once if you have chest pain, new or worsening heartburn, or pain when swallowing.
Montelukast (Singulair)
Bronchodilatory/leukotriene receptor antagonist used to prevent asthma attacks but it is not recommended for rescue drug in asthma.
A community health clinic nurse is interviewing a client who is experiencing lightheadedness. The client reports a history of arthritis and is taking naproxen sodium for the pain. The client is pale, the blood pressure is 88/40, pulse is 114, respiratory rate is 22 and temperature is 98.2° F (36.7 C°). What additional information should the nurse solicit from the client? (Select all that apply.) Tingling or numbness in the extremities Bruising Color of bowel movements Frequency and amount of naproxen used Photophobia Help|Terms & Trademarks © 2020 NCSBN. All rights reserved.
Bruising Correct! Color of bowel movements Correct! Frequency and amount of naproxen used Correct! Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen can cause gastrointestinal (GI) irritation and bleeding. The client's vital signs and pale skin color indicate possible hypovolemia (tachycardia and hypotension) secondary to blood loss. The nurse should inquire about other findings that may indicate bleeding, e.g., black tarry stools and bruising. The nurse should also determine the amount of naproxen the client has been taking. Tingling, numbness or photophobia are not side effects seen with naproxen use or overuse.
calcium monitor during preclampsia
Calcium in preeclampsia Calcium supplementation compared with placebo Calcium supplementation is more effective at reducing the risk of pre-eclampsia compared with placebo, especially in women with low dietary calcium or who are at a high risk of developing pre-eclampsia (high-quality evidence).
Rapid fluid effeusions:
Can cause hypervolemia as excess fluid accumulates within the extracellular space, specially with clients with heart faliure and kidney disease. Infussion should be stopped and the person should be checked for pulmonary edema(eg.;dyspnea, lung crackles) and fluid overload ( peripheral edema, JVD)If sigsn are present you should call HCP as fluid overload can cause respiratory and cardiovascular compromise.
Information about case management and the role of the case management nurse is presented during an orientation session for new nurses. Which statement correctly describes an important fact about case management?
Case management is a collaborative process designed to meet complex client needs. Correct! Case management is a collaborative process of organizing and coordinating resources and services within and across multiple settings. The focus is on cost-savings as well as quality and continuity of care. Case management nurses work closely with physicians, nurses, social workers to meet the complex health needs of the client. Case management is "client-centric" and all members of the team, including the client, work together to achieve desired outcomes. Cases that involve high-risk diagnoses (such as HIV/AIDS, cancer or people with cognitive deficits) or high-volume cases (such as total hip or total knee replacements) are often selected for case management.
medications given for open fractures
Cefazolin(ancef) Cylobenzaprine(flexeril) Tetanus or diphteria toxoid Ketorolac(Toradol) Opioids
Common HAIs include:
Central line-associated bloodstream infection (CLABSI) Catheter-associated urinary tract infection (CAUTI) Ventilator-associated pneumonia (VAP) Surgical site infections example: A client is admitted to the hospital for cellulitis, a community-associated infection that occurred while the client was at home. A few days after admission, the client is diagnosed with a bloodstream infection related to the peripherally-inserted central catheter (PICC) that was placed for IV antibiotic administration, a health care-associated infection. The most common HAI is caused by a "staff" infection - one that is transmitted to a client from a health care worker or "staff member."
What is the most important action for the nurse to take prior to a client having a liver biopsy? 1. Make certain the consent has been signed. 2. Obtain vital signs. 3. Check clotting study results. 4. Position client supine with right arm above head.
Check clotting study results. Correct: This is a priority question. All actions should be done by the nurse, however, the nurse better check the clotting study results. The client could hemorrhage if the clotting factors are too messed up. 1. Incorrect: Yes, the consent must be signed, but what is more life saving? Checking the clotting factor results. 2. Incorrect: Yes, the nurse will need to obtain pre-procedure vital signs. However, the procedure may not be done if the clotting study results are bad. 4. Incorrect: Yes, the client will need to be positioned so that the primary healthcare provider has access to the liver. But again, this is not the priority.
Following a surgical procedure, a pneumatic compression device is applied to the adult client. The client reports that the device is hot and the client is sweating and itching. Which of the following steps should the nurse take? (Select all that apply.) Check for appropriate fit Confirm pressure setting of 45 mm Hg Explain that the health care provider ordered the device and it cannot be removed Collaborate with health care provider for anti-embolism stockings to be worn under the sleeves of the device Inform the client that removing the device will likely result in the formation of deep vein thrombosis
Check for appropriate fit Correct! Confirm pressure setting of 45 mm Hg Correct! Collaborate with health care provider for anti-embolism stockings to be worn under the sleeves of the device Correct! In any situation in which a client has discomfort associated with a medical device, the nurse should ensure it is applied correctly and functioning safely. The usual safe and effective pressure range is 35 to 55 mm Hg. Explanations to the clients should support their informed decision-making capabilities and should not be phrased to intimidate or remove client autonomy. Applying anti-embolism stockings under the disposable sleeves of the device may help with the sweating and itching.
A client with spinal cord injury at the C-5 level reports having a "pounding" headache. The blood pressure is 180/120 mm Hg. A nurse should take which action first? Assist the client into a sitting position Ask the registered nurse (RN) to assess the client Evaluate the client for nuchal rigidity Check the urinary catheter tubing for kinking
Check the urinary catheter tubing for kinking Correct Response This client is exhibiting findings of autonomic dysreflexia (or autonomic hyperreflexia), which is a medical emergency that occurs in clients with spinal cord injury above the C-6. level in response to noxious stimuli. A distended bladder or bowel is the most common cause of autonomic dysreflexia. Prompt relief of this by draining the bladder, in the case of bladder distention from kinked catheter tubing, will relieve findings. A sitting position will not resolve the problem. Nuchal rigidity (neck stiffness) is associated with meningitis or a cerebral bleed, not autonomic dysreflexia.
A client with spinal cord injury at the C-5 level reports having a "pounding" headache. The blood pressure is 180/120 mm Hg. A nurse should take which action first? Assist the client into a sitting position Ask the registered nurse (RN) to assess the client Evaluate the client for nuchal rigidity Check the urinary catheter tubing for kinking
Check the urinary catheter tubing for kinking Correct Response this client is exhibiting findings of autonomic dysreflexia (or autonomic hyperreflexia), which is a medical emergency that occurs in clients with spinal cord injury above the C-6. level in response to noxious stimuli. A distended bladder or bowel is the most common cause of autonomic dysreflexia. Prompt relief of this by draining the bladder, in the case of bladder distention from kinked catheter tubing, will relieve findings. A sitting position will not resolve the problem. Nuchal rigidity (neck stiffness) is associated with meningitis or a cerebral bleed, not autonomic dysreflexia.
A hospice nurse arrives to make a scheduled visit with a client in a long-term care facility. The nurse is approached by the facility staff who want the client sent to a hospital due to an exacerbation of symptoms. What is the first action the hospice nurse should implement? Explain that the client can be kept comfortable in the long-term care facility Check with the client to see if he wants to go to the hospital Call a hospice care team meeting to discuss the staff's request Discuss the concept of comfort care measures with the staff
Check with the client to see if he wants to go to the hospital Correct! A client on hospice care is allowed to go to the hospital, especially when the client needs urgent care. The hospice nurse will assess the situation and ask the client if they want to be transported to the hospital. If the client decides to stay in the long-term care facility, the hospice nurse can reinforce comfort care measures with the staff. If the client is hospitalized, a hospice team meeting may be needed to review the client's status and plan of care.
There are three categories of restraints:
Chemical: These include medications such as anxiolytics, sedatives, opioids and paralytics. Physical: These include mechanical devices or equipment that limit the client from moving or from moving an extremity. A chair with an attached tray that prevents the client from getting up is considered a restraint. Raising all bed rails can be considered a form of restraint; however, one raised side rail that the client uses to move in and out of bed would not be considered a restraint. Seclusion: A locked room or area away from other clients that the client cannot leave. This is primarily used with clients in behavioral health settings who are at risk for violent behavior and only after all other interventions have failed. Using a physical restraint or seclusion requires continuous monitoring by the nurse and IDT. Some facilities use video and audio equipment or sitters (specially-trained UAPs) to monitor the client in seclusion. A physical restraint or safety device requires a provider order that specifies the: Reason for the restraint Type of restraint or safety device to be used Time limit for its use If the restraint is still needed after the time limit has expired, the nurse is responsible for contacting the provider to obtain a new order. Most facilities have strict policies in place that stipulate that the more restrictive the device or restraint is, the shorter the time period it can be ordered for. For example, the nurse might need to obtain a new order every four hours for a client who requires physical restraints to all four extremities. Similar policies apply if the client is a child. If a client can easily remove the device, it does not qualify as a physical restraint. A provider order for restraints can never be written in advance for "what if" situations or "as needed" (i.e., PRN). Always attempt to use the least restrictive form of restraint and/or safety device. Never apply or use a restraint (chemical, physical or seclusion) to punish a client.
Which client assignment would be appropriate for the nurse to accept from the charge nurse? 1. Client admitted one hour ago with a diagnosis of leukemia. 2. Client who has developed Addison's disease. 3. Client who has gastroenteritis. 4. Client post transsphenoidal hypophysectomy.
Client who has gastroenteritis. 3. Correct: Gastroenteritis involves an irritated and inflamed stomach and intestines, typically caused by a viral or bacterial infection. Of the four clients, this one would be the most stable client. 1. Incorrect: The newly admitted client hospitalized with leukemia is not going to be the most stable client. This client is likely to have a low white count and be susceptible to infection, anemia, and bleeding. 2. Incorrect: The client with Addison's disease is at risk for fluid volume deficit/shock due to a lack of aldosterone. 4. Incorrect: What are we worried about with a client post transsphenoidal hypophysectomy? Diabetes Insipidus. Not enough ADH = FVD/Shock.
The nurse is caring for a group of clients when a fire alarm sounds in the hospital cafeteria. What should the nurse do next? Find the fire extinguisher. Remove oxygen devices. Begin evacuating the clients. Close all doors in the area.
Close all doors in the area. The nurse should act immediately to protect the clients under their care. This begins with closing all doors to prevent the fire from spreading. It is not necessary to evacuate the clients because they are not in immediate danger. The fire extinguisher is not needed since there is no active fire in this area. Removing oxygen devices is not required.
An older adult client with a history of alcoholism is 12 hours post-op. The client calls a nurse and says "Get me out of this boat - the sharks are going to eat me." Which action should the nurse take? Ask when the client last drank alcohol Place the client on telemetry monitoring Check the capillary blood glucose and capillary refill time Collect data about the client's respiratory rate and pulse oximetry
Collect data about the client's respiratory rate and pulse oximetry Correct Response A sudden change in mental status (for example, hallucinations) in any post-op client should trigger a nursing intervention directed toward correcting an abnormal oxygenation status. However, the nurse first needs to collect data about the problem before any intervention. Pu oximetry and respiratory rate and effort would be an appropriate initial assessment. An alcohol-dependent person may have hallucinations if alcohol ingestion is suddenly stopped, but this assessment is not as important as pulse oximetry. Hallucinations are not commonly associated with an abnormal serum glucose level and this client gives no evidence for needing cardiac monitoring.
intussusception
Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools. enema---resolution=bowel movements Palpable sausge mass in URPQ Screaming and draw knee to chest stool mix with blood and muscus
A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law? Clinical specialty certification by an accredited organization Sworn statement that health care provider orders were followed Above-average performance reviews prepared by nurse manager Complete and accurate documentation of assessments and interventions
Complete and accurate documentation of assessments and interventions Correct! The medical record is a legal document. Documentation should include all steps of the nursing process; it must be complete, accurate, concise and in chronological order. Inaccurate or incomplete documentation will raise red flags and may indicate the nurse failed to meet the standards of care. The attorney will review the medical record with the nurse before giving a deposition (sworn pretrial testimony). Above-average performance reviews could be considered supporting information. Certification is an "extra" based on the nurse's initiative; it is, however, unrelated to accurate charting.
A newly admitted client reports gaining 5 pounds (2.27 kg) the past week even though he has hasn't been very hungry. The nurse observes swelling of the feet and ankles. What is the most likely explanation for the weight gain? Hyperthyroidism Malnutrition Congestive heart failure Acromegaly
Congestive heart failure Correct! The unexplained rapid weight gain is probably due to fluid retention. Clients who gain as little as two pounds (0.9 kg) in a week may require hospitalization due to worsening heart failure. The lack of appetite (or a feeling of being full) and edema are also signs of worsening heart failure. Hypothyroidism, and not hyperthyroidism, can lead to low body temperature, which causes fluid retention or bloating. Low protein levels in the blood caused by malnutrition can cause edema. However, there's not enough information given in the question to know if this client is malnourished or not. Acromegaly is characterized by overgrowth of body tissues, not edema, and is caused by excessive secretion of growth hormone.
A client recovering from hip replacement surgery is taking acetaminophen with codeine every three hours for pain. For which side effect should the nurse monitor the client?
Constipation Correct! Codeine is an opioid analgesic and antitussive (cough suppressant). For analgesic use, codeine is formulated alone and in combination with non-opioid analgesics (either aspirin or acetaminophen). Because codeine and non-opioid analgesics relieve pain by different mechanisms, the combination can produce greater pain relief than either agent alone. Opioids such as codeine slow down the function of the central nervous system. This can affect involuntary movements in the body, such as peristalsis. As the movement of food through the intestinal tract is slowed down, the walls of the intestine absorb more fluid. With less fluid in the intestines, stool becomes hard and constipation develops. The other side effects are not usually seen with codeine.
If a patient has not had bm in 3 days
Constipation in the elderly can be caused by a number of circumstances including: Long-term use of painkillers Decreased appetite and fluid intake Reduced mobility
A nurse is preparing to admionsiter 2 continous IV medications concurrently via 20-gauge IV.What is the nurse's priority action?
Consult a medication guide for compability. Rationale: The priority when administering 2 IV meds concurrently is to determine drug compability. Incompatible drugs given through the same IV line will deteriorate or form a precipitate..This could be done by checking the color change, a clouding of the solution, or the presence of particles.If 2 or more drugs are not compatible, the nurse might consider inserting a second IV or consulting the pharmacist and the health care provider to determine the safest and most beneficial plan for the client.
A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM). The newborn weighs 6 lbs (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What action should the nurse take? 1. Administer the drug intravenously (IV) since a large volume is required. 2. Choose three injection sites and give the medication as prescribed. 3. Consult with the pharmacy for a different medication concentration. 4. Read the available drug information to determine how to administer the medication.
Consult with the pharmacy for a different medication concentration. 3. Correct: The nurse must consult with the pharmacy to receive further instructions. The dose is greater than the allowed volume to be given IM, which warrants clarification by the pharmacy.1. Incorrect: Since the drug is prescribed IM, the route should not be changed to IV administration because this violates the prescription as written.2. Incorrect: The dose is greater than the allowed volume to be given IM, which warrants clarification by the pharmacy. You want to avoid having to give three injections.4. Incorrect: The concern is not drug information or administration; it is the concentration, which can only be provided by the pharmacy.
The hospice nurse cared for a client who is recently deceased. Which of the following nursing interventions would be included in follow-up care after death? Attend the client's funeral or visitation service Make sure the arrangements are what the client wanted Help family members dispose of the client's belongings Contact the client's family one to two months following the client's death
Contact the client's family one to two months following the client's death Correct Response Bereavement services are an essential part of hospice care that includes anticipating grief reactions and providing ongoing support for the family. Bereavement services continue for 13 months after the client's death; 13 months is significant because it includes the first anniversary of the client's death. One to two months following the client's death, after friends have returned to their "normal" routines, the nurse should contact the family. Attending a funeral service is an appropriate gesture, but it is not part of follow-up care. Funeral arrangements and disposing of the client's belongings are not the responsibility of the hospice nurse.
The licensed practical nurse (LPN) is assisting with the discharge of a client following inpatient treatment for pulmonary tuberculosis. What information would be important for the LPN to reinforce? Avoid contact with children, pregnant women or immunosuppressed people Continue medication use as prescribed until symptoms are relieved Continue medication use as prescribed Take medication with food or antacid for epigastic upset
Continue medication use as prescribed Correct! Clients should understand that they must continue any therapy as prescribed. Early cessation of treatment may lead to the development of medication resistant bacteria. The other options are incorrect statements. There is no need to avoid children, pregnant women or immunocompromised individuals and medication should be taken on an empty stomach.
right sided heart failure
Cor pulmonale causes swelling in extremities 1. Jungular Vein Distention 2. Ascending Dependent Edema 3. Weight Gain 4. Hepatomegaly (Liver Enlargement)
A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? 1. Try to calm the patient and make the environment soothing. 2. Assess for a full bladder. 3. Notify the healthcare provider. 4. Prepare the patient for diagnostic radiography.
Correct Answer: 2 Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher, and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing environment is fine, though not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.
Methylprednisolone
Corticosteroid, Systemic,antiinflamtory improvres respiratory symptoms and overall lung function in clients experincing exacerbation of COPD
The nurse is caring for a client who has had a right upper lobectomy. When caring for this client, the nurse understands that pain management will promote which focus of the care plan? Incisional healing and position Coughing and deep breathing Relaxation and sleep Range of motion exercises and sensation
Coughing and deep breathing Correct Response The priority for this client is effective exchange airway gas exchange and the expelling of mucous. Without effective pain management, this client will be reluctant to move or cough and/or deep breathe. And if clients, in this case do not cough and deep breathe, they may develop atelectasis or even pneumonia.
antocoagulants
Coumadin (warfarin) Prescribed in treatment and prevention of thomboembolic disorders.
The nurse is obtaining a pulse rate for a client with a dysrhythmia. Which of the following actions should the nurse take?
Count the apical rate for 60 seconds.
medications contraindicated when a patient has hepatitis
Cyclobenzaprine for muscle spasms
Cyclophosphamide
Cyclophosphamide's pharmacology classification is an alkylating agent. This medication is prescribed for the treatment of nephrotic syndrome to suppress the body's immune system. The prescription of cyclophosphamide is appropriate for this client.
Kussmaul respirations
Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure. Regular but rapid , deep respirations and is aasociated with conditions that cause metabolic acidosis (eg; renal faliure, diabetic ketoacidosis, shock)
iron deficency anemia,what education to reinforve upon discharge
DISCHARGE INSTRUCTIONS: Call 911 or have someone call 911 for any of the following: You lose consciousness. You have severe chest pain. Seek care immediately if: You have dark or bloody bowel movements. Contact your healthcare provider if: Your symptoms are worse, even after treatment. You have questions or concerns about your condition or care. Iron or folic acid supplements help increase your red blood cell and hemoglobin levels. Vitamin B12 injections may help boost your red blood cell level and decrease your symptoms. Ask your healthcare provider how to inject B12.
A young child is receiving treatment for lead poisoning. Which of the following is the most serious effect of long-term exposure to lead? Impaired kidney function Damage to the central nervous system Anemia and fatigue Lead colic and constipation
Damage to the central nervous system Correct! Lead toxicity can affect every organ system but it is especially dangerous for the brain. Lead can even alter the structure of the blood vessels in the brain and can lead to bleeding and brain swelling. In children, lead exposure is associated with lower IQ scores, learning disabilities, hyperactive behavior, and impaired hearing; higher levels of exposure can cause seizures and death. Neurological effects may persist into adulthood, despite treatment. Anemia (and fatigue), damage to the kidneys and abdominal pain (also called lead colic) are potentially reversible with treatment.
A nurse is gathering data from a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. After confirmation of pregnancy is made by other tests, which date should the nurse determine as the estimated date of delivery (EDD)? February 11 December 23 January 15 April 8
December 23 Correct! The use of Naegele's rule to calculate the EDD will give an approximate date. This rule is: add seven days and subtract three months from the first day of the last regular menstrual period to calculate the estimated date of delivery.
The nurse hears a scream coming from a client's room. When entering the room, the nurse finds the client lying on the floor beside the bed. Which of the following actions should the nurse take? (Select all that apply).
Determine the client's level of consciousness. Correct! Take the client's vital signs. Correct! Notify the client's provider about the incident. Correct! Observe the client for abnormal leg rotation. Correct Response Fall prevention is a national patient safety goal and is monitored closely in all health care settings. It is important for the nurse to assess and evaluate the client to determine if the client experienced a loss of consciousness or a change in vital signs that contributed to the fall. It is important to determine if there are visible injuries and note any areas of pain or abnormal leg rotation. The nurse will notify the provider and complete an incident report. Risk management will receive notification through the completion of an incident report; the nurse should not notify the legal department by themselves. Physical restraints are not indicated and may, in fact, make the client more prone for future falls.
Tasks for newly hired UAP
Directions to the UAP should be tasks with especific and explicit requirements ( vs total client responsabilities) with specific and explicit requirements those that require assessment ,data interpretation or nursing judgement. UAP can : offer a drink apply restrains Assign a new UAP tasks that do not require speciallized knowledge or skills UAP can gather data but should not be asked to perform assessment or data interpretation
The nurse is caring for a client receiving an intravenous infusion of normal saline that is prescribed at 150 milliliters per hour. Using a tubing that has a drop factor of 15, how many drops per minute should the nurse deliver? Round answer to the nearest whole number.
Divide 150 by 60 minutes to equal 2.5. Multiplying 2.5 by the drip factor of 15 equals 37.5. Since partial drops cannot be counted, always round to nearest whole number, which is 38.
clients taking long term corticosteroid replacement
Do not discontinue abruptly report signs of infection Stay attuned for signs of stress that will need for the dose to be increased hyperglycemia s/s osteoporosis cataracts gastric irritation
principles of time,distance and shielding when treating patients with radiation treatement
Do not spend more than 30 minutes with the patient in the room Place a sign on the door Tell the family to stay away 6 ft away Use a lead apron Wear radiation film badge, while in the room to monitor radiation exposure
Pavlik harness care
Dress the child in a shirt and knee socks under the straps. Light massage the skin under the straps daily. Place the diaper under the straps
Preventing DVT discharge instructions:
Drink plenty of fluids ,limit caffeine and alcohol,avoid dehydration elevate feet dorsiflex feet often resume walking and swuimming change positions often stop smoking Avoid wearing restrictive clothes
A client who has been diagnosed with Raynaud's disease and hypertension is prescribed nifedipine. For which side effect should the nurse monitor the client? Increased pain in fingers Decreased urine output Facial flushing Cyanosis of the lips
Facial flushing Correct Response Nifedipine is a calcium channel blocker (CCB) used in the treatment of Raynaud's disease and hypertension by producing vasodilation. As a result of this vasodilating effect, facial flushing can occur. Cyanosis of the lips and decreased urinary output are not expected findings with nifedipine. Raynaud's disease causes vasoconstriction, resulting in pain in the fingers that should decrease when nifedipine is taken.
A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure?
Elevate head of bed to fowler's position. Measure distal NG tube from nose tip to earlobe to xiphoid process. Lubricate 2-3 inches of distal NG tube. Insert NG tube into unobstructed naris. Advance NG tube upward and backward until resistance is met. Rotate catheter and advance into nasopharynx. Have client swallow ice as NG tube advances into stomach. Secure NG tube.
A licensed practical nurse (LPN) is caring for a client diagnosed with multiple myeloma who is undergoing radiation therapy. Which side effect should be reported to the registered nurse (RN) immediately? Excessive vomiting Mouth ulcers Elevated temperature Erythema around the radiation site
Elevated temperature Correct Response Elevated temperature is the first finding of infection. Radiation suppresses the body's production of white blood cells, which increases the risk for infection. Remember that because multiple myeloma is generalized in the body, the radiation therapy would be as well. Therefore, you can eliminate all the options dealing with specific locations and select the more generalized symptom (temperature elevation).
A client has been on antibiotics for 72 hours to treat cystitis. Which findings reported by the client require priority attention by the nurse? Smelly urine Nausea and anorexia Burning on urination Elevated temperature
Elevated temperature Correct! Submit Elevated temperature after 72 hours on an antibiotic indicates that the antibiotic has not been effective in eradicating the offending organism. The health care provider should be informed immediately so that an appropriate medication can be prescribed and complications, such as pyelonephritis, are prevented. The smelly urine and burning are expected with cystitis and during initial treatment. Gastrointestinal findings may be related to the antibiotics as a side effect and should also be reported. However, they are a lower priority and may resolve if the antibiotic is changed.
A nurse is caring for a client with schizophrenia who has been treated with quetiapine for one month. Today the client is increasingly agitated and reports having muscle stiffness. Which of these additional findings should be reported to the health care provider? Decreased pulse and blood pressure Mental confusion and general weakness Elevated temperature and sweating Muscle spasms and seizures
Elevated temperature and sweating Correct Response Neuroleptic malignant syndrome (NMS) is a rare disorder that can occur as a side effect of antipsychotic medications. It is characterized by muscular rigidity, tachycardia, hyperthermia, sweating, altered consciousness, autonomic dysfunction, and increased creatine phosphokinase (CPK). This is a life-threatening complication that can occur anytime during therapy with antipsychotic medications.
The nurse hears a health care provider (HCP) loudly criticizing one of the unlicensed assistive persons (UAP) within the earshot of others. The UAP does not react or respond to the HCP's complaints. What is the best action by the nurse?
Encourage the UAP to directly confront the HCP about the unprofessional behavior. The QSEN competency Teamwork and Collaboration requires the nurse to function effectively within nursing, working with inter-professional teams, and fostering open communication and mutual respect. The nurse should first approach the HCP to stop the behavior and then attempt to discuss communication styles that diminish the risks associated with authority gradients among team members. Notifying the chief of the medical staff might be necessary in the future if the HCP continues to act unprofessionally toward the staff. Directly confronting the HCP would most likely cause the HCP to become defensive and should be avoided. Completing an incident report is not necessary at this time.
The client states to the nurse: "I am ready to stop all of these treatments. I just want to go home and enjoy my family for the little bit of time I have left." Which action is most appropriate? Call in a referral to a social worker and explain that the request will need to be discussed in more detail at a later time Encourage the client to discuss this decision with the health care provider and family Tell the family members that the client's preference is to go home to die No action is needed at this time unless the client repeats the statement to another caregiver
Encourage the client to discuss this decision with the health care provider and family Correct Response The client has the right to stop treatment and should be supported in clearly communicating this decision with the health care provider and family. The nurse needs to act as an advocate for the client. It is factually incorrect to wait until the request is repeated; clients should not need to express their wishes repeatedly before caregivers listen to them. The nurse should not be the one to share sensitive information with the family; the client controls that information. Social services may get involved but time is of the essence for those who are terminally ill.
A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first to assure that the client's request is respected? 1. Ensure a do-not-resuscitate prescription has been provided. 2. Report client wishes during the end-of-shift report. 3. Have the client sign an advanced directive. 4. Ask the client who holds the durable power of attorney for h
Ensure a do-not-resuscitate prescription has been provided. 1. Correct: The nurse should check the medical record for a DNR order. By law, a person who does not have a do-not-resuscitate (DNR) prescription, must be provided CPR in the event of a cardiac/respiratory arrest. This action will ensure the client's end-of-life wishes have been communicated and will honor the client's wishes. 2. Incorrect: It is appropriate to report the client's end-of-life wishes to other care givers, but not before ensuring a DNR order is in place. 3. Incorrect: If the client has advance directives, a copy should be placed in the medical record. However, a DNR prescription must also be in place to ensure the client is not resuscitated. 4. Incorrect: The client's request can be initiated by notifying the primary healthcare provider. It would be helpful for the client to have a durable power of attorney. 1. Identify key words in the stem that set a priority, such as first, initially, best, priority, safest, most. These words modify what is being asked. This question requires you to put a value on each option and then place them in rank order. If you are having difficulty ranking the options, eliminate the option that you believe is most wrong among the options. 2. A strategy you can draw on to help answer priority questions is to refer to basic guiding theories that are part of the foundation of nursing. Maslow's Hierarchy of Needs, The Nursing Process, Kubler-Ross's Theory of Death and Dying, Teaching/Learning Theory, Therapeutic Communication.
A primary healthcare provider has prescribed restraints for a violent adult client. Which measures would the nurse provide as proper interventions for this client?
Ensure that circulation to extremities is not compromised. Assist client with needs related to nutrition and elimination. Provide help with personal hygiene. Renew restraint prescription in 4 hours if needed. Rationale: interventions for safety when a violent client requires restraints. When applying restraints you do not want the restraint so tight that extremity circulation is diminished. The client must still be provided with proper nutrition, hydration, and allowed to go to the restroom. If the client is restrained, the client will need help with basic care and comfort measures. Prescriptions for restraints used on an adult client must be renewed every 4 hours if needed. restraints should be observed every 15 minutes. Safety of the client is extremely important. Physical needs, such as food and toileting, should also be addressed.
Which of the following interventions should the nurse include in the plan of care for a client who recently experienced a fall at home? (Select all that apply.) Ensure the room lighting is adequate and remove clutter in the room. Avoid using chairs with armrests to reduce the risk of injury. Apply nonslip strips to the bottom surface of the shower. Insert an indwelling urinary catheter to reduce incontinence episodes. Provide soft flooring by placing throw rugs throughout the home. Monitor blood pressure when lying down, sitting and standing.
Ensure the room lighting is adequate and remove clutter in the room. Correct! Apply nonslip strips to the bottom surface of the shower. Correct! Monitor blood pressure when lying down, sitting and standing. Correct! The nurse should ensure that the client's home environment is safe (i.e., has appropriate lighting, is free of clutter and unnecessary furniture and throw rugs). There is no indication for an indwelling catheter for this client, and unnecessary urinary catheterization is a risk factor for catheter-associated urinary tract infections (CAUTIs). Chairs with armrests can reduce the risk of falls, since the armrests provide support and help prevent client from sliding off the chair. Monitoring blood pressure for orthostatic hypotension can reduce the risks of falls. Nonslip strips and grab bars can improve safety in the bathroom and reduce the risk of falls.
Radiation side effects and treatments
Loss of taste, esophagitis, diarrhea, malabsorption Xerostomia (dry mouth, so moisten food) Mucositis (inflammation of mucosal lining of oropharynx and esophagus); avoid fresh, raw, uncooked foods. Offer carbonated beverages, frude ades, cold and soft food
A Cambodian client witnessed a murder three days prior to admission to an inpatient psychiatric unit. The client now reports that a "wind has entered my chest and I know I am dying." Which nursing intervention is a priority? Establish a therapeutic relationship Challenge the delusion with reality statment Encourage the client to suppress the traumatic memories Discourage visits from the client's family until the medication takes effect
Establish a therapeutic relationship Correct Response Khyâl is a panic attack among Cambodians that can occur with acute stress disorder (ASD) following a traumatic event. Symptoms include the belief that a wind enters the body in the diaphragm causing shortness of breath, tinnitus, dizziness, neck soreness and feelings of impending death. Establishing a therapeutic relationship is necessary to understand the cultural aspects of the client's symptoms and is a priority in ASD. Challenging delusions assumes psychosis rather than examining cultural indications of ASD. Voluntary memory suppression is not practical nor therapeutic in ASD. Family visits can assist the client via cultural understanding of symptoms and event interpretations.
A nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first take what action? Establish that the client is unresponsive Call for help by activating the emergency button in the room Find out if anyone saw the client fall Direct someone to bring the crash cart and defibrillator
Establish that the client is unresponsive Correct! The first step in basic life support (BLS) is to establish unresponsiveness. Calling for help and checking for a pulse are actions that should follow establishing unresponsiveness. Getting a history of the fall should follow after the clinical situation has been resolved and stabilized. You will note that the correct response is the only data collection answer. The other options are actions or interventions.
Establishing
Establishing priorities helps the nurse deliver safe and quality client care. When caring for an assigned group of clients, the nurse must be able to effectively plan, organize and prioritize nursing interventions to meet client needs. Prioritization requires the nurse to apply their knowledge of pharmacology, pathophysiology and decision-making strategies such as: Basic Life Support (BLS) guidelines Primary survey steps in emergencies (Airway-Breathing-Circulation or ABC) Maslow's Hierarchy of Needs (e.g., physiological and safety needs should be met before psychosocial needs) Steps of the nursing process (e.g., assessment/data collection should come before planning and implementation) Acute vs. chronic problems (e.g., sudden onset or rapid worsening of shortness of breath or pain) New onset, unexpected clinical manifestations that can indicate a complication vs. expected signs and symptoms of the medical problem (e.g., low blood pressure and tachycardia in a client with a urinary tract infection (UTI) can indicate that the client has developed urosepsis, a medical emergency, while dysuria, flank pain and/or urinary frequency are commonly seen with a UTI)
oxytocin for induction of labor
Evaluate fluid intake Notify if >5 contractions in 10 minutes Obtain BP reading with each Oxytocin dose HR,BP,resp q30 min or with each dose
Valsartan, Losartan
Examples of angiotensin receptor blockers,ARBs
The parent of a 7-year-old child calls the clinic nurse because their child was sent home from school due to a rash. The child was diagnosed with fifth disease (erythema infectiosum) the day before and is otherwise in good health. What would be the appropriate action by the nurse?
Explain that the rash is no longer contagious and does not require isolation. Correct Response Fifth disease is a viral illness with an uncertain period of communicability (perhaps one week prior to and one week after the onset). Children are not contagious after the appearance of the rash, which gives a "slapped cheek" appearance. Isolation of children with fifth disease is not necessary except in cases of hospitalized children who are immunosuppressed or having aplastic crises. The parents may need written confirmation of this from the health care provider to give to the school. Treatment is symptomatic and supportive. Antibiotics are not indicated for this viral infection.
Burning building
Explosions or blasts can cause unique patterns of injury. Most injuries involve multiple penetrating injuries and blunt trauma. A bomb event has the additional potential for chemical and/or radiological contamination. Treatment Overview Lung injuries: High flow oxygen sufficient to prevent hypoxemia using a non-rebreather mask, CPAP or ET tube Prompt decompression for clinical evidence of pneumothorax or hemothorax Abdominal injuries: Clinical signs can be subtle at first Monitor client for potential internal injuries such as worsening abdominal pain, abdominal distention, sign and symptoms of shock Ensure tissue perfusion but avoid volume overload Burns: Follow ABC treatment algorithm Remove nonadherent clothing Cover burns with dry dressing or clean sheet Prepare for IV insertion and fluid resuscitation Ear injuries may include tinnitus (ringing in the ears) or deafness Monitor injured areas for the five Ps: pain, paresthesia, paralysis, pulse and pallor Clients with injuries resulting in non-intact skin or mucous membrane exposure should receive hepatitis B immunization (within seven days) and tetanus toxoid vaccine ABCDE A = Alertness & Airway B = Breathing C = Circulation D = Disability E = Exposure
The nurse is caring for a 4 year-old child. Which behavior should be of the greatest concern to the nurse when caring for a preschool age child? Explores the playroom Plays imaginatively Identifies with a family member Expresses shame
Expresses shame Correct Response Erikson describes the stage of the preschool child as being the time when there is normally an increase in initiative. The child should have resolved the sense of shame and doubt as a toddler. The key words in this question are "preschool aged child" and "most concern to the nurse," which implies you should look for an answer that would be abnormal for a child this age.
The nurse is reinforcing information about clozapine. What information about side effects should the nurse emphasize?
Extreme salivation Correct Response Clozapine (Clozaril) is prescribed for the management of severely ill schizophrenics who fail to respond to standard drug treatment for schizophrenia. There is a significant risk of agranulocytosis and seizure. Many clients who take clozapine experience extreme salivation and other autonomic nervous system findings.
Fall-related documentation
Fall-related documentation in the client's medical record should only consist of objective information, such as a description of client's condition immediately prior to and after the fall, vital signs, provider notifications, any orders received, nursing care rendered, signs and symptoms of possible injuries and notification of client's family or power of attorney for health care (POAH).
In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last.
First, apply clean gloves. Second, remove soiled dressings. Third, discard soiled dressings and clean gloves in red bag. Fourth, don sterile gloves. Fifth, clean surgical wound with moistened sterile 4x4's. Sixth, clean around Penrose drain using circular pattern inside to outside. Seventh, place dry, sterile 4x4's over surgical wound and Penrose drain. Eighth, apply abdominal dressing pad.
Prior to entering an isolation room, what order should the nurse apply personal protective equipment?
First, perform hand hygiene Second, apply gown. Tying at neck and waist Third, put mask on, covering mouth and nose Fourth, place goggles snugly around face and eyes Fifth, apply clean gloves
Place the steps in order that the nurse should take to administer a subcutaneous injection
First perform hand hygiene. Then apply gloves and locate injection site using anatomical landmarks. Start at the center of the site and rotate outward in a circular direction to cleanse the site. Remove the needle cap by pulling the cap straight off. Next, hold the syringe and pinch the skin with nondominant hand. Inject the needle quickly then administer the medication slowly. Finally, dispose of the syringe in the sharps container. Before placing the steps in order, visualize performing the procedure. Maintain standard precautions. Hand hygiene prevents spread of microorganisms. Gloves help prevent exposure to contaminants. Selecting the appropriate site prevents injury. Cleansing the areas is necessary because pathogens on the skin can be forced into the tissues by the needle. Moving from center outward prevents contamination. Pulling the cap straight off helps lessen the risk of an accidental needle stick. Pinching is advised for thinner clients and when a longer needle is used. Inserting the needle quickly causes less pain. Rapid injection of solution creates pressure in the tissues resulting in discomfort, so inject medication slowly. Proper disposal of the needle prevent injury.
The LPN is verifying that a new LPN understands the principle of least restrictive intervention on a psychiatric unit. In what order should the new LPN correctly place interventions from least to most restrictive? Place in correct order from least restrictive to most restrictive.
First, verbally tell the client to stop the unacceptable behavior and escort client to another part of the day room. This is the least restrictive. Second, walk the client out to the courtyard. This removes the client from the situation while still allowing some freedom. Third, take the client to the quiet room for a time out. This removes the client from the situation but also sets restrictions on where and with whom they can interact. Fourth, place client in the isolation room with staff observation. This is more restrictive than the quiet room, but doesn't require restraints. Fifth, restrain client's arms with wrist restraints. This is a two point restraint which is much more restrictive than the isolation room. Lastly, use four point soft cloth restraints. This is the most restrictive. 1. Stay away from restraints, wheelchairs, and invasive drugs as long as possible when choosing an answer. The NCLEX lady does not like nurses who tie people down or nurses who run to the medication cart for every little thing. 2. Always go with the least invasive first.
diet for patients with end stage renal disease
Foods low in potassium: asparagus, green beans, corn, cucumber, okra, onions, green peas, green peppers apples, grapes, grapefruit, peaches, pears, pineapples cottage cheese chicken, turkey, tuna, shrimp, eggs rice, bread pasta made with white flour
Side effects of diuretics
Frequent urination, rash, hypotension, fluid and electrolyte imbalances, dizziness
For apatient with ADHF/acute decompensated heart faliure,marginal blood pressure,crackles in the lungs,low oxugen saturation,JVD and peripheral edema should receive?
Furosemide
Thiazolidinediones (TZDs)
Glitazones; rosiglitazone/Avandia pioglitazone/Actos used to treat type 2 diabetes theses drugs can worsen heart faliure by causing fluid retention, and increase bladder cancer Can also increase the risk for myocardial infarction
The nurse is providing care for an infant who has had a pyloromyotomy. Which of these approaches for the first postop feeding is most appropriate? Formula or breast milk as tolerated Regular diet appropriate for age Bland diet appropriate for age Glucose and electrolyte solution
Glucose and electrolyte solution Correct Response A pyloromyotomy is a surgical procedure to correct pyloric stenosis. Postoperatively, the infant is NPO for about 3 to 12 hours. The initial feedings are clear liquids provided in small quantities to provide calories and electrolytes. Later, if tolerating the clear liquids, the infant can be given watered-down formula or breast milk and eventually switched over to regular breast milk or formula.
Cullen and Grey turner sign
Grey Turner sign refers to ecchymosis of the flanks and may occur in conjunction with Cullen sign, especially in patients with retroperitoneal hemorrhage. When Cullen or Grey Turner signs result from acute pancreatitis, they signal severe disease, with a mortality estimate as high as 37%.
Guillien Barre Syndrome, with paralysis and paresthesia
Guillain-Barré syndrome is a rare but serious autoimmune disorder in which the immune system attacks healthy nerve cells in your peripheral nervous system (PNS). This leads to weakness, numbness, and tingling, and can eventually cause paralysis Monitor respiratory rate frequently
The client has been hospitalized 48 hours for multiple injuries sustained in a motor vehicle accident. An elevated blood alcohol level was present at the time of the accident. Which finding(s) should be a priority in the plan of care? Hallucinations Loss of appetite and nausea Diaphoresis Fine tremors
Hallucinations Correct Response The symptoms of alcohol withdrawal usually begin about 5-10 hours following the last drink and peak around 24-72 hours. The severity of symptoms experienced during detoxification varies with each client. Individuals who have been abusing alcohol for many years are at risk of developing delirium tremens (DTs). Symptoms of DTs include hallucinations, extreme confusion, extreme agitation, and tachycardia; DTs is a medical emergency. Loss of appetite, nausea, diaphoresis and fine tremors are symptomatic of the earlier stages of withdrawal.
A client is receiving general anesthesia in the same day surgery unit,what is the most critical question to ask during preoperative assessment and health Hx?
Has any family member ever had a bad reaction to general anesthesia.? Rationale: Malignant hypethermia HM is a rare,life threatening inherited muscular abnormality that is triggered by especific drugs used to induced general anesthesia.Therefore is critical for the perioperative nurse to screen fo MH susceptibilty by asking if any of the client's blood relatives have ever experienced an adverse reaction to general anesthesia,including unexplained death.
nitroglycerin patient education
Headace is a side effect Keep in a darl cool space do not open often renew after 6 months , 2 yrars for spray
The nurse is reinforcing information about the use of sublingual nitroglycerin. What information about side effects should the nurse emphasize? Headache Anorexia Dry mouth Depression
Headache Correct Response The most common side effect is headache, which is related to the generalized vasodilatation.
A polydrug user has been in recovery for eight months. Recently, the client has begun to skip breakfast, has not been eating regular dinners, and has been seen frequenting bars to "see old buddies." What should these client behaviors indicate to the nurse? Adjusting to recovery Feeling hopeless Headed for relapse In need of increased socialization
Headed for relapse Correct! It takes 9 to 15 months to adjust to a lifestyle free of chemical use. Thus, it is important for clients to acknowledge that relapse is a possibility and then to identify early warning signs and actions to take to prevent a relapse. When answering this question, determine if the client's behavior of seeing old buddies in bars indicates recovery or a potential for relapse. Although socialization with others is important in recovery, this could be better accomplished by attending a 12-step program meeting, and not by going to a bar.
The client is admitted with a diagnosis of ulcerative colitis. Which laboratory values should the nurse be sure to check? (Select all that apply.) Hematocrit and hemoglobin Blood urea nitrogen (BUN) T3 and T4 count Erythrocyte sedimentation rate (ESR) White blood cell count (WBC) Albumin
Hematocrit and hemoglobin Correct Response Erythrocyte sedimentation rate (ESR) Correct! White blood cell count (WBC) Correct Response Albumin Correct! Submit Decreased hematocrit and hemoglobin may reveal the client has anemia as a result of the bloody diarrhea characteristic of this inflammatory bowel disease A low protein albumin level would indicate that the client is experiencing a nutritional deficit due to malabsorption. Increased numbers of white blood cells and an elevated erythrocyte sedimentation rate (ESR) indicate active inflammation. Blood urea nitrogen is related to kidney function and T3 and T4 are related to thyroid function; these lab values do not provide information related to the diagnosis.
parent teaching for digoxin for children
Hold digoxin if:HR is < 90-110 /min for infants and young children or<70 /min for an older child Administer oral liquid in the side and back of the mouth Do not mix drug with food or liquids as the child 's refusal to ingest these would result in inacurate medication dose intake. If a dose is missed do not double or increase the dosage.Mantain the same schedule. If >2 dose are missed notify the HCP If the child vomits after the frst dose do not double, Nausea ,vomiting and slow pulse can indicate toxicity notify HCP. Give water or brush teeth afteradministration to remove the sweetened liquid.
The nurse is making rounds, checking oxygen equipment and assessing clients receiving oxygen therapy. Which of the following situations require intervention by the nurse? (Select all that apply.) Humidified oxygen delivery system contains water from condensation in the tubing Valves and flaps in the nonrebreather mask will not open Oxygen tubing that will allow ambulation to the bathroom is 25 feet (7.6 meters) in length Humidifier is documented as having been changed 12 hours ago The reservoir bag on a nonrebreather mask is inflated Nasal cannula tubing is documented as having been changed eight days ago
Humidified oxygen delivery system contains water from condensation in the tubing Correct! Valves and flaps in the nonrebreather mask will not open Correct! Nasal cannula tubing is documented as having been changed eight days ago Correct Response Clients receiving humidified oxygen need equipment monitored for condensation in the tubing so that water does not empty into the client mask. Frequent emptying of the tubing away from the client is necessary. Valves and flaps in nonrebreather masks must be patent and able to open during expiration and close during inhalation to maintain FiO2. A mask with valves that do not open must be replaced. In a nonrebreather mask, the reservoir bag should be inflated; if it deflates the client will breathe in exhaled carbon dioxide. Nasal cannula tubing must be changed at least every seven days and humidifiers changed every 24 hours. Oxygen tubing extensions that allow clients to ambulate to bathroom should not exceed 50 feet.
after having gone thyroidectomy
Hypocalcemia can be a life-threatening consequence of thyroidectomy if the parathyroid glands are inadvertently removed during the surgery, as the four parathyroid glands are located immediately posterior to the thyroid gland. Hypocalcemia following removal of the parathyroid glands may begin any time during the first 24-72 hours, and monitoring of serial calcium levels is recommended for the first 72 hours. The earliest symptoms of hypocalcemia are typically circumoral paresthesias and paresthesias with a "pins-and-needles" sensation in the fingers and toes. The development of carpal spasms upon inflation of the blood pressure cuff is a classic sign of hypocalcemia and is known as Trousseau sign. Chvostek sign is the other classic sign of hypocalcemia and is elicited by tapping the facial nerve in the preauricular area causing spasm of the facial muscles.
To place a client in a one-on-one observation
If a client who cannot answer yes or no to the possibility of feel suicidal should be consider a yes, so for the patients safety measures should be taken to ensure the safety of the client and others.The client needs constant supervison and should never be left alone.
Which medication prescription should the nurse question for a client diagnosed with nephrotic syndrome?
Ibuprofen The prescription of ibuprofen, a NSAID, would be questioned. Ibuprofen is a nonsteroidal ant-inflammatory medication. NSAIDs can cause acute interstitial nephritis and acute tubular nephritis. The client with nephrotic syndrome currently has damage to the micro blood vessels in the kidneys.
A client diagnosed with cancer is being discharged home to live with an adult child. What action should the nurse take to participate in the continuity of care? 1. Identify community services available for the client and family. 2. Discuss hospice care for the client. 3. Advise family that client would benefit more from nursing home placement. 4. Make arrangements for around the clock home health aides.
Identify community services available for the client and family. 1. Correct: The nurse promotes continuity of care at discharge by providing a smooth transition from one level of care to another. The nurse should include in the discharge plan appropriate community support services available to the client and family so that they can obtain support as needed. 2. Incorrect: This may be premature at this point. Hospice care may be provided when a person has a life threatening illness, which measures life in months rather than years. The PN can participate in the client referral process. 3. Incorrect: It is not appropriate for the nurse to impose personal opinions about what is best for the client. 4. Incorrect: This may be premature at this point. Further assessment is needed and can be provided as the cancer progresses.
A home health nurse is making an initial visit to a new client. What action should the nurse take first to meet the client's health needs?
Identify the client's learning needs. With a focus on health promotion, the nurse should first identify any learning needs. This also represents the first step in the nursing process. Once the client's learning needs are identified, the nurse will be able to develop or assist with developing a plan of care that meets the client's individual needs. Then the nurse should perform a home safety check, identify community resources for the client and, if needed, assist with meal planning.
The client needs assistance to insert bilateral in-the-ear hearing aids. What action should the nurse take before inserting the hearing aids?
Identify the hearing aid that goes in the right ear and left ear Since hearing aids are customized for each ear, the nurse should make sure the correct hearing aid is inserted in the correct ear (a red dot indicates the right ear.) The volume should be turned down when inserting the devices and adjusted after they are in the ear. Hearing aids should only be cleaned with a soft cloth; water or alcohol can damage the device. The battery door should never be used as a handle.
It's mealtime at the long term care facility. The nurse observes an unlicensed assistive person (UAP) returning an uneaten food tray to the food cart, where other trays are waiting to be served. What is the priority action of the nurse? Reinforce infection control information after all trays are passed Observe the UAP during the next meal to see if the action is repeated Immediately reinforce information about infection control Report the incident to the director of nursing
Immediately reinforce information about infection control Correct Response Returning a food tray (that had previously been delivered to a client) to the cart will cross-contaminate the other undelivered, "clean" trays, even if the contents of the tray are uneaten. The priority action is to immediately reinforce information regarding infection control. Waiting until all the trays have been delivered or for another meal increases the risk of cross-contamination and illness. There's no need to involve the director of nursing unless the behavior continues unchanged.
isometric exercises
Involves muscle contraction w/o shortening (ie, no movement or a min. shortening of muscle fibers). Ex - contracting quadriceps/gluteal muscles.
The client is diagnosed with Addison's disease. What should the nurse understand about the diet of a person with this diagnosis?
Increase sodium and drink at least 1.5 liters of water each day Correct Response In Addison's disease, the adrenal glands do not make enough of the hormone cortisol (and sometimes aldosterone). This results in sodium wasting and potassium retention. The findings are typically dehydration, hypotension, hyponatremia, hyperkalemia and acidosis. Mineralocorticoids are usually the preferred treatment. Also, fluids and dietary sodium intake should be increased; potassium intake should be restricted. Don't confuse this with Cushing's disease in which sodium intake is restricted. Eating just enough calories to maintain a healthy weight is too generic a statement for Addison's disease.
Glitazones/thiazolidinediones
Increased insulin sensitivity in peripheral tissue. Binds to PPAR-gamma nuclear transcription factor pioglitazone and rosiglitazone Use: Type 2 diabetes Side effects: weight gain, edema. Heaptotoxicity, HF, increased risk of fractures Can worsen heart faliure by increase fluid retention increase risk of bladder cancer
In the post-anesthesia care unit (PACU) a nurse provides care to a teenage client after an emergency appendectomy. Which finding is an indication that the client may be in an early stage of shock? Decreasing blood pressure Abnormal breath sounds Increasing pulse rate Cyanosis of the lips
Increasing pulse rate Correct! An early finding in shock is an increasing pulse rate. The blood pressure does not decrease in shock until later, as the compensatory mechanisms begin to fail.
A nurse assigned to a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis on the plan of care is a priority at this time? Risk for fluid volume alteration related to change in peristalsis Ineffective breathing patterns related to central nervous system depression Decreased gastrointestinal mobility related to narcotic effects Altered nutrition related to inability to control nausea and vomiting
Ineffective breathing patterns related to central nervous system depression Correct! Respiratory depression is a life-threatening risk in narcotic overdoses.
A client is experiencing a panic attack. What priority action should the nurse take?
Instruct client to deep breathe with the nurse. The most important action for the nurse to take is to slow down the client's breathing so that they do not end up in respiratory alkalosis from hyperventilation. They cannot concentrate on anything but the panic they feel. teach them this when they are not having a panic attack. Also teach ways to stop the anxiety from escallating. Approach the client in a nonthreatening manner. Give them space. Do not add to the anxiety by getting in their space.
Basal insulin Glargine/Lantus
Insulin glargine (Lantus) is a long-acting, human insulin analogue that has been specifically designed to overcome the deficiencies of traditionally available 'intermediate-acting' insulins that are currently used for basal insulin supplementation.
water seal chamber
Intermittent bubbling in the water seal chamber when the client coughs, sneezes, or exhales is considered normal.
Isotretinoin (Accutane) should be avoided during pregnancy why
It can cause sever birth defects Retinoids should not be prescribed to females in childbearing age without a formal agreement iPLEDGE and a comittment two use 2 forms of contraceptives
The nurse is caring for a 3 year-old child who is hospitalized for a cardiac procedure. Which of the following nursing actions will help reduce anxiety in the child? Keep the daily routine close to the usual home routine Ask the parents to leave at night to allow for better sleep Have the child explain why he is in the hospital Discuss the expected outcomes of the hospitalization
Keep the daily routine close to the usual home routine Correct! Hospitalization for a child induces stress responses and anxiety. The early childhood developmental stage is most comforted by daily routines that more closely mimic the home routine. During the middle and adolescent stages of development, children benefit from sharing their feelings about being hospitalized and procedures they will undergo. Parents should be encouraged to stay overnight since this helps reduce anxiety in the 3 year-old.
What nursing actions should the nurse initiate in a client who experiences sundowning? Select all that apply 1. Limit naps. 2. Encourage TV watching in the evening. 3. Create a calm, quiet environment. 4. Open window blinds during the day. 5. Leave the lights on at night. 6. Maintain a routine.
Limit naps. Create a calm, quiet environment. Open window blinds during the day Maintain a routine. 1., 3., 4., & 6. Correct: Sundowning occurs when the client becomes more confused and agitated in the late afternoon or evening. Behaviors commonly seen include agitation, aggressiveness, wandering, resistance to redirection, and increased verbal activity such as yelling. Limit naps because too much daytime napping may interfere with sleeping at night. A calm environment may promote relaxation. Light therapy may reduce agitation and confusion during the day, so open the blinds. Caregivers should remain calm and avoid confrontation. Routine helps the client feel secure. Sundowning is a symptom of Alzheimer's disease and other forms of dementia. It's also known as "late-day confusion." If someone has dementia, their confusion and agitation may get worse in the late afternoon and evening. Symptoms may be less pronounced earlier in the day. Daytime napping and inactivity can make it harder for the client to fall asleep at bedtime. To promote a good night's sleep, help them stay active during the day. Take the client for a walk or clear some space to dance. This might help improve sleep quality. You want the client to stay calm in the evening. So encourage simple activities that aren't too challenging or frightening. Frustration and stress can add to confusion and irritability. Those clients who have mid-stage or advanced dementia find it difficult to watch television or read a book. Consider playing soft music to create a calm and quiet environment. Some studies suggest light therapy can reduce agitation and confusion in clients with dementia. Turn on the lights in the daytime and open the window blinds. Routine is very important for these clients. A routine makes people feel secure. Dementia can make it hard to develop and remember new routines. The client might react to unfamiliar places and things with feelings of stress, confusion, and anger. These feelings can play a large role in sundowning. Stick to the same schedule every day to help the client feel more calm and collected.
side effects of lithium
Lithium toxicity occurs in dehydration, hyponatremia, decreased renal function and drug to drug interactions:(nonsteroidal anti-inflammatory drugs and hydrochlorothiazide) weight gain tremor, GI disturbance fatigue, arrythmias, seizures goiter/ HYPOTHYROIDISM leukocytosis coma polyuria/dipsia alopecia metallic taste Acute viral gastroenteritis /stomach flu, diarrhea, vomiting, abdominal pain.
What factors are a risk for falls
Liying pulse of 80/min, standing pulse 110/min Osteoarhritis of knees Carvidopa/Levodopa Use cane to ambulate Positive orthostatic vital signs(eg; ris ein pulse of >20 min) indicate increase rsik of syncope and falls, Presence of IV therapy wet floors rooms congested with furniture, and improper toilet seat or bed height are factors gait abnormalities due to use of patrkinson medications Sinemet can also cause headaches, involuntary movements, and orthostatic hypotension age > 65-75
UAP care of client with cast or traction
Maintain body position and alignment Apply ice as directed by RN Assist pt with PROM, ROM Notify RN for pt c/o pain, loss of sensation in affected extremity reapply pneumatic compression device after bath Remind to use incentive spirometer after nurse or respiratory therapist has taught Notify nurse of client reporting pain,tingling, or decreased sensation in the affected extremitiy Mantain proper use of pneumatic compression devices Remind to frequently use the overhead trapeze
When caring for clients receiving internal radiation or brachytherapy, the nurse should implement the following precautions:
Mark the client's room with appropriate signage. Place the client in a private room. Place a wristband on the client, indicating that the client is receiving internal radiation therapy. Make sure long-handled forceps and a lead container are in the client's room in case of implant dislodgement. Apply shoe covers and protective gloves before entering the client's room. Minimize the time spent at the client's bedside, to the extent possible without compromising client care. While providing care, maintain the greatest distance possible from the client, without adversely affecting client safety. Wear a film badge (such as a dosimeterA radiation dosimeter or badge is a device that measures dose uptake of external ionizing radiation. When used as a personal dosimeter, it is worn by the person being monitored. It produces a record of the radiation dose the person received.) while caring for the client to monitor exposure; have it checked per agency policy. For protection, remember the three elements of radiation safety: Time Distance Shielding
Oxytocin side effects
Maternal Side Effects: Cardiovascular: dysrhythmias, chest pain, hypertension Neurological: seizures Respiratory: dyspnea Gastrointestinal: nausea/vomiting Genitourinary: Severe uterine cramping, uterine rupture Fetal Side Effects: Cardiovascular: bradycardia, ectopic rhythms Neurological: intracranial hemorrhage Respiratory: hypoxia, asphyxia
A nurse is assisting in the exam of a pregnant client in her third trimester. The ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely associated with what condition? Sexually transmitted infection Chromosomal abnormalities Exposure to teratogens Maternal hypertension
Maternal hypertension Correct! Submit Pregnancy-induced hypertension (also known as gestational hypertension or pre-eclampsia) is a common cause of late pregnancy fetal growth restriction. Vasoconstriction reduces placental exchange of oxygen and nutrients, resulting in poor fetal growth.
The nurse must be able to recognize when an incident report should be completed. An incident report should be filled out whenever an unexpected event occurs. Examples include:
Medication administration errors (even if the error did not reach the client) Any time a client makes a complaint Medical device malfunction Any time a client, staff member or visitor is injured or involved in a situation with the potential for injury When a client leaves the health care facility against medical advice (AMA) Loss or theft of a client's or visitor's property Medication administration errors are the most common type of incidents. When the nurse realizes that an error occurred, such as medication given to an incorrect client, the administration of incorrect medication, or medication administered at the incorrect time or incorrect dose, the first response should be to monitor the client closely for any adverse effects and report the error to the prescriber. Next, the nurse must complete an incident (or occurrence) report.
The nurse is preparing to administer regular insulin subcutaneously to a client at 0800. What information from the client's electronic health record should the nurse review in order to safely administer the medication? (Select all that apply.)
Medication administration record (MAR). Correct! Name and date of birth. Correct! 0700 blood glucose. Correct! The nurse must review the appropriate information in order to safely administer medications. The use of two client identifiers is to ensure the identity of the correct client. The nurse must review the medication administration record (MAR) to verify the correct medication, dose, and time. The nurse should review the client's most recent blood sugar value before administering the insulin to prevent hypoglycemia.
What OTC medications with thrombocytopenia can take
Medications. Your doctor will talk with you about over-the-counter medications or supplements you take and whether you need to stop using any that might inhibit platelet function. Examples include aspirin, ibuprofen (Advil, Motrin IB, others) and ginkgo biloba
The hospice nurse makes a home visit to admit a new client diagnosed with terminal lung cancer. The client is experiencing pain that is not well controlled. The client and partner reveal the client needs more assistance with activities of daily living than the partner is physically able to provide. What actions are indicated for this home situation? Meet with the hospice team to revise the client's plan of care Suggest that the couple sell their house and consider long-term care Arrange a transfer to the hospital to treat the client's pain Coach the spouse on how to care for the client
Meet with the hospice team to revise the client's plan of care Correct! Hospice care focuses on providing care and supporting the needs of the client. Typically a family member serves as the primary caregiver, but in this case, the hospice team will need to meet and revise the client's plan of care since the spouse is unable to provide the needed care. In the meantime, the nurse could arrange for scheduled visits by a home health aide to help with activities of daily living. Even with coaching, the client's partner may be unable to meet all the client's needs. There are many options for pain control and these can usually be managed at home. It is inappropriate for the nurse to suggest that the couple should sell their home.
Meloxicam
Mobic NSAID
The 54 year old client is scheduled for a coronary angiography. The client's medical history includes angina, type 2 diabetes mellitus and mild renal insufficiency. Which of the following orders does the nurse anticipate? Restrict oral fluid intake post-procedure Monitor serum creatinine levels pre- and post-procedure Ibuprofen (Motrin) 800 mg by mouth PRN for pain post-procedure Metformin (Glucophage) 500 mg by mouth pre-procedure
Monitor serum creatinine levels pre- and post-procedure Correct! Coronary angiography requires the use of a contrast dye. Persons with diabetes and/or impaired kidney function are at high risk for developing contrast media-induced nephrotoxicity (CIN). Adequate hydration helps maintain renal blood flow and reduces the time the contrast media is in contact with the renal tubules and, therefore, will help prevent CIN. Serum creatinine levels are used to monitor for the development of CIN. Nephrotoxic drugs, such as ibuprofen, should not be used for procedures requiring contrast media. The oral hypoglycemic drug metformin increases the risk of lactic acidosis if CIN were to occur; it should be held the day of the procedure until kidney function returns to baseline (as determined by serum creatinine).
The nurse is caring for a client with bilateral wrist restraints. Which intervention(s) should the nurse include in the client's plan of care? (Select all that apply.)
Monitor the client's emotional response to the restraints. Correct Response Routinely assess if the client is ready for restraint discontinuation. Correct! Remove restraints every two hours to allow for movement of involved extremity. Correct! Ongoing assessment of clients who require restraints is essential. Restraints should be removed every two hours to allow the nurse to assess the neurovascular status of the restrained extremity, skin integrity under and around the restraint, the client's response to the restraint and the client's emotional state. A new restraint order must be obtained every 24 hours. Assessment of the client with restraints should be documented in the client's medical record at least every 2 to 4 hours. Nurses should frequently assess clients to determine readiness for restraint discontinuation. Restraints should remain in place when client has visitors to ensure client and visitor safety.
A neonate is having difficulty maintaining a temperature above 98 F (36.6 C) and is placed in an infant warming system (IWS). Which of the following actions will ensure the safety of the neonate? Avoid touching the neonate with cold hands Wrap the neonate snugly in a cotton blanket Monitor the neonate's temperature continuously Warm all medications and liquids before administration
Monitor the neonate's temperature continuously Correct! When using a warming device, the neonate's temperature should be continuously monitored using a probe that's securely attached to the skin. Monitoring the neonate's temperature is the priority safety concern because skin burns, permanent brain damage or even death can result due to improper use or monitoring of equipment. No clothing or swaddling is needed in the IWS; usually babies are dressed only in a diaper (although bubble wrap blankets or plastic wrap blankets can be used to minimize heat loss in high risk newborns.) For healthy term newborns, nurses should warm their hands and stethoscopes prior to contact with the baby.
A client who lives in a long-term care (LTC) facility (nursing home) is placed on contact precautions when drainage from a wound tests positive for methicillin-resistant Staphylococcus aureus (MRSA). What interventions should the nurse include in the care of the client? (Select all that apply.) Plan to transfer the client to the hospital. Move the client to an available private room. Educate the client on good personal and hand hygiene. Monitor staff compliance with using required personal protective equipment (PPE).
Move the client to an available private room. Correct! Educate the client on good personal and hand hygiene. Correct! Monitor staff compliance with using required personal protective equipment (PPE). Correct!'' Collaborate with the facility infection preventionist on treatment for the wound. Correct! Recommendations are very straightforward for the placement of clients with MRSA colonization and infection in a hospital—a private room is preferred. Recommendations for placement in an LTC facility are not as clear cut. Some guidance on the use of contact precautions in an LTC facility is given in the CDC/HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007. Make decisions regarding client placement on a case-by-case basis, balancing infection risks to other clients in the facility, the presence of risk factors that increase the likelihood of transmission and the potential adverse psychological impact on the infected or colonized client. When single-client rooms are available, assign priority for these rooms to clients with known or suspected multi-drug resistant organism (MDRO) colonization or infection. Give highest priority to those clients who have conditions that may facilitate transmission, such as uncontained secretions or excretions and lack of compliance with personal and hand hygiene due to cognitive deficits. An LTC infection preventionist should collaborate on the care plan of all clients with wounds in the facility and monitor any infections they might have. It is not necessary to transfer the client to a hospital or limiting the client's visitors at this time. On the contrary, limiting visitors would constitute interference with the client's rights and dignity.
Ibuprofen side effects
N/V, diarrhea, constipation; headache, dizziness; fluid retention; GI bleeding; hives; rash
client teaching for ECT
NPO for 6-8 hr prior anesthesia (methotexia, propofol) and muscle rleaxants is administered so the pt feels no pain Driving is not permited during treatement Temporary memory loss and confussion is common
Tinitus is a side effect of
NSAIDs like naproxen or aminoglycosides like gentamycin, neomycin,tobramycin
Ketorolac (Toradol),Indomethacin, ibuprofen,naproxen
NSAIDs, are nephrotoxic Should never be given in combination with other NSAIDs
A client is receiving erythromycin 500 mg IV every six hours to treat pneumonia. Which of these findings is the most common side effect of the medication? Severe headache Nausea Insomnia Blurred vision
Nausea Correct! Erythromycin is a macrolide anti-infective. Nausea is a common side effect of erythromycin, regardless of the route of administration. You should note that the other options listed are not "common" side effects of most medications.
The client is undergoing radiation therapy for Hodgkin's disease. The nurse should recognize that which finding is most likely associated with the radiation treatment? Night sweats Face and neck edema High fever Nausea
Nausea Correct! Submit Because the client with Hodgkin's disease is usually healthy when therapy begins, the nausea is especially troubling. Hodgkin's disease is cancer of the lymphatic system. The content of this question is "radiation therapy," not Hodgkin's disease. All options, except one, are associated with this disease and not the radiation therapy.
The nurse observes two unlicensed assistive personnel (UAPs) transferring a client using a mechanical lift. Which observations would require the nurse to intervene immediately? (Select all that apply.)
No support is provided for the client's head. Correct! The client is lowered as quickly as possible to the chair. Correct! The safe use of a mechanical lift includes ensuring the equipment and sling are fully functional, and confirming the appropriate weight limit prior to use. The client should be raised just enough to clear their bottom off of the bed. The client should be lowered slowly to the chair. The nursing staff will need to provide support for the client's head during the lift.
Lactate levels
Normal: 4.5-19.8 mg/dl Indicated in shock, heart failure, lung disease, and intense exercise
An 80 year-old client is hospitalized for a chronic condition. The client informs family members that a living will has been prepared and the client wants no life-prolonging measures performed. The client's condition deteriorates and the client becomes unresponsive. Which of the following nursing actions is most appropriate? Notify the attending physician Consult the charge nurse and prepare to transfer the client to an intensive care unit Call the rapid response team Contact the family member indicated in the admission forms
Notify the attending physician Correct Response The first action would be to notify the attending physician for further orders. Then the family member(s) can be contacted about his condition. When a client has an advanced directive, it is not appropriate to perform CPR on him.
A client treated for depression tells the nurse at the mental health clinic, "I have recently purchased a handgun because I am thinking about ending my life." The first nursing action should be to take which approach? Suggest voluntary inpatient psychiatric care Respect the client's confidential disclosure Notify the primary health care provider immediately Phone the family to warn them of the risk
Notify the primary health care provider immediately Correct! The health care provider must be contacted immediately as the client is a danger to self and others. Immediate hospitalization, either voluntary or involuntary, is indicated because this client has a suicide plan involving a gun. The key words in this question are "first nursing action." Remember, when the content of the question is life-threatening or potentially life-threatening, notifying the health care provider is the only correct response.
care of blind client due diabetic rethinopathy
Offer the client an elbow to hold. and walk a half step=ahead for guidance. Say goodbye when leaving the room to help orient the client. Use a clock-face pattern to explain food pattern arrangement on the client's meal tray Announce you're self upon entry or exit Describe the location of items, using a clock face orientation Instruct the use of a cane with the dominant hand and to sweep areas in front from side to side Orient the client to the room and maintain this orientation for safety.
typical predator or child abuse
Often have Hx of growing in an enviromnet of domestic violence Abusers have Hx of substance abuse Teen parents are particularly more vulnerable of abusing their children Unrealistic expectations for the child's performance, behavior or accomplishments,over critical Confuse punishment for discipline, exhibit a stern and authoritative approach to discipline Cope with ongoing stress and crisis such poverty, violence, illness,lack of social support and isolation. Low self-esteem, sense of incompetence and unworthiness. as a parent. Hx of substance abuse, alcohol and drugs before and during the abuse occurrence. Experience punitive treatment or abuse as a child him/her self. Young parental age. Resent or reject the child. Low tolerance for frustration and poor impulse control. Attempt to conceal the child's injury or evasive when questioned about their injury; show little concern about the child's injury.
The client is diagnosed with post-traumatic stress disorder (PTSD). What are the some of the more common treatment options for PTSD? (Select all that apply.) Opioid analgesics Selective serotonin reuptake inhibitors (SSRIs) Eye movement desensitization and reprocessing (EMDR) Cognitive behavioral therapies
Opioid analgesics Selective serotonin reuptake inhibitors (SSRIs) Correct! Eye movement desensitization and reprocessing (EMDR) Correct Response Cognitive behavioral therapies Correct Response The only two FDA approved medications for the treatment of PTSD are the SSRIs sertraline (Zoloft) and paroxetine (Paxil). There are other medications that are helpful for specific PTSD symptoms, but narcotics should not be used since they don't relieve psychogenic pain and there's a risk of dependence. Most people who experience PTSD undergo some type of psychotherapy, most commonly cognitive-behavioral therapy and/or group psychotherapy, EMDR and hypnotherapy.
fifth disease (erythema infectiosum)
PATHOGEN: Human parvovirus B19 PORTAL OF ENTRY: Respiratory tract SYMPTOMS: Mild disease witha macular "slapped-cheek" facial rash METHOD OF TRANSMISSION: Aerosol Diagnosis: Usu. diagnosed by clinical signs and symptoms and may be confirmed by serological tests or PCR TREATMENT: none is a childhood disease caused by the human parvovirus. This common community-acquired disease does not usually require treatment, but respiratory isolation is recommended for 7 days following the onset of symptoms. The initial stage of the disease presents as red cheeks that appear to be "slapped" or "slapped cheeks" with circumoral pallor
A client received a leg cast that was applied following fracturing the left femur. What observation would be a priority for the nurse to report to the primary healthcare provider? 1. Reports of a feeling of warmness under the cast after application. 2. Pain not relieved by elevation, cold packs, and pain medication. 3. Reports of itching under the cast not relieved by cool air. 4. Slight swelling of the toes of the affected extremit
Pain not relieved by elevation, cold packs, and pain medication. 2. Correct: Pain that is disproportionate to the injury, becomes severe, and/or is not relieved by elevation, cold packs, and pain medication could indicate a complication such as compartment syndrome. Failure to detect this could lead to neurovascular damage and possible amputation. 1. Incorrect: Due to the drying process of the cast material, it is normal for the cast to feel warm. The primary healthcare provider would not need to be notified. The warm feeling should subside. 3. Incorrect: A common complaint is itching under the cast. The cast material may cause irritation to the skin. Cool air under the cast may help to relieve this. The primary healthcare provider would not need to be notified at this time. 4. Incorrect: Some swelling is expected initially due to the damage of the tissue around the fracture which may result in dependent swelling of the toes. This compromised circulation should be relieved by elevation. The primary healthcare provider would not need to be notified at this time.
The hospice nurse is visiting a client diagnosed with end-stage lung cancer and metastases to the bone. What should the nurse keep in mind when planning for effective pain management? High doses of opioid analgesics will be required. The client will most likely become addicted. Pain therapy is based on the client's report of pain. Relief of pain will be achieved quickly.
Pain therapy is based on the client's report of pain. Correct! Every person's pain experience is unique and should be treated based on the individual's goals for pain management. Therefore, the amount of medication needed is dependent on the client's needs and reports of pain relief. The nurse should not assume that high doses of analgesics will be needed to alleviate the client's pain. Immediate or quick pain relief might be difficult to achieve, especially in light of the client's type of cancer and bone metastases. Addiction is a psychological condition and not a concern for this client. However, the client may develop a physical dependence and tolerance to pain medications that may require an increase in dosage to manage pain effectively. Correct!
The nurse is admitting a client who does not speak English. Which of the following interventions should the nurse include when caring for the client? (Select all that apply.)
Pay attention to any effort by the client to communicate. Correct Response Plan on taking twice as long as usual to complete nursing interventions. Make a note of the client's preferred language in their medical record. Correct! Use a trained medical interpreter provided through the facility's interpreter services. Correct! Providing culturally competent care requires the nurse to advocate for clients who do not speak English or whose English proficiency is limited. Advocating for those clients can be accomplished by noting the client's preferred language in their medical record and using an agency interpreter or interpreter services. The nurse should only use a trained medical interpreter, especially for sensitive tasks such as obtaining informed consent. Using an interpreter will require more time than usual, and therefore the nurse should plan to take extra time when caring for the client. Not all interactions with the client will require a qualified interpreter. Show respect for the client by paying close attention to the client's attempts to communicate with the health care team. It is recommended to speak in a low, moderate voice and avoid excessive hand gestures, because they can give the impression that the nurse is angry and yelling at the client. The nurse should avoid using children as interpreters.
The nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears somewhat blue. What would be the appropriate initial intervention? Call for the emergency response team Perform abdominal thrusts Ask the toddler to cough Begin resuscitation
Perform abdominal thrusts Correct! Because the victim is a toddler, and still conscious but choking, the most effective way to clear the airway of food is to perform abdominal thrusts using the Heimlich maneuver. After the first few abdominal thrusts, if the airway has not cleared, the emergency response team should be called as interventions to clear the airway are continued. Asking the toddler to cough would not be appropriate, as he has a complete airway obstruction.
The client is diagnosed with Clostridium difficile (C. difficile.) The nurse, who does not apply personal protective equipment (PPE), enters the room to administer a medication. The client requests assistance to sit up in bed before taking the medication. What is the next action by the nurse? Perform hand hygiene with soap and water Assist the client to move up in bed Leave the room to apply PPE Reposition the client and then apply alcohol-based hand rub
Perform hand hygiene with soap and water Correct Response C. difficile is an anaerobic gram-positive bacterium that produces spores resistant to heat, drying and many antiseptic solutions. The spores are transmitted from client to client via improperly sanitized hands. Meticulous hand hygiene, using soap and water, and strict adherence to isolation protocols will help prevent the transmission of C. difficile. In this scenario, the nurse needs to first wash his or her hands with soap and water and then apply PPE (gown and gloves) before providing any care. Alcohol-based hand rubs are ineffective against C. difficile.
A nurse is caring for a post-surgical client at risk for the development of deep vein thrombosis (DVT). Which action is preventative and should be reinforced by the nurse? Take prescribed antiplatelet agents Massage the legs several times daily Perform range of motion exercises and walk Place pillows under the knees
Perform range of motion exercises and walk Correct Response Mobility reduces the risk of DVT in the post-surgical client and in any adults at risk. Clients should perform ROM exercises of the legs while in bed, and they should get out of bed to stand, sit in a chair or walk in the hallway several times a day. It is contraindicated to place pillows under the knees because pillows will press against the veins and cause an increase in venous stasis. Antiplatelet agents are not the drug of choice for DVT prevention. Leg massage should be avoided as it can dislodge a thrombus causing pulmonary embolism, which is a very serious complication of DVT.
Teratogenic medications
Phenytoin: Neural tube defects, orofacial clefts, microcephaly, nail or digit hypoplasia Lithium: Ebstein anomaly, nephrogenic diabetes insipidus, hypothyroidism. Valproate: neural tube defects Isotretinoin: Microcephaly, thymic hypoplasia, small ears, hydrocephalus. Methotrexate: Limb and craniofacial abnormalities, neural tube defects, abortion ACE inhibitors: Renal dysgenesis, oligohydramnios Warfarin: Nasal hypoplasia,strippeled epiphysis
Which one of these statements is true about the effects of immobility in children? Physical effects are similar to those found in adults Subsequent complications are higher in children The progression of language and fine motor development is delayed Children are more susceptible to the effects of immobility than adults
Physical effects are similar to those found in adults Correct! Care of an immobile child includes efforts to prevent complications such as muscle atrophy, contractures, skin breakdown, decreased metabolism and bone demineralization. Secondary alterations also occur in the cardiovascular, respiratory and renal systems. Similar effects and alterations occur in immobile clients of all ages.
The nurse is using sterile forceps to move sterile gauze to a sterile container so that cleansing solution may be applied. Which action by the nurse would compromise the sterile field? 1. Touching the dry forceps to the center of the field. 2. Placing the forceps in the outer 1-inch margin of the field. 3. Moving the forceps above the level of the table. 4. Holding the forceps at table level within sight.
Placing the forceps in the outer 1-inch margin of the field. 2. Correct: The outer 1-inch perimeter of the field is considered non-sterile. This action would compromise the sterile field. 1. Incorrect: The forceps may be placed in the center of the sterile field. This is an appropriate action and does not compromise the sterile field. 3. Incorrect: Holding the forceps above the level of the table does not compromise the sterile field. This is a correct action. 4. Incorrect: The nurse should always maintain sight of equipment within the sterile field. This is the way to be sure that the sterile field is not compromised.
Clopidogrel (Plavix)
Platelet aggregation inhibitor Given PO with or without aspirin Give with food! Labs to watch - AST, ALT, CBC, Hct/Hgb, PT Adverse Effects: - Prolonged bleeding time; bleeding; bruising - Diarrhea Monitor for signs of bleeding Monitor for rash as can cause Stevens Johnson syndrome
The nurse is preparing a client for a colonoscopy and notes that the consent form has not been signed. Which of the following statements by the nurse are appropriate to make to the client? (Select all that apply.)
Please tell me your full name and date of birth." Correct! "Do you have any questions about the colonoscopy?" Correct Response "Describe what the health care provider told you about a colonoscopy." Correct!
A 90 year-old is readmitted to the hospital, less than 2 weeks after being discharged, for the same health concern. What factors contribute to hospital readmissions among older adults? (Select all that apply.) Poor communication among providers Client health status Excellent primary care Family preferences Reconciliation of medications
Poor communication among providers Correct! Client health status Correct! Family preferences Correct! Avoidable hospitalization, especially among older adults living in skilled nursing facilities, usually results from multiple system failures. The reasons most often cited include inadequate primary care (including inadequate discharge planning and lack of reconciliation of medications), poor care coordination, poor skilled nursing facility quality of care, poor communication among providers and even family preferences. Not all illnesses can be anticipated and clients with more complex health issues are readmitted more often, regardless of quality or coordination of care.
Before a Magnetic resonance cholangiopancreatography(to determine the cuse of cholecystitis,cholelitiasis and biliary obstruction)
Pregnacy contrast allergy metal or electrical implants NPO status
A nurse is reinforcing teaching in a parenting class for first time parents in an attempt to decrease child abuse in the community. What type of prevention is the nurse utilizing? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Case management
Primary prevention is aimed at reducing the incidence of mental disorders within the population. Primary prevention targets individuals and the environment. Emphasis: assisting individuals to increase their ability to cope effectively with stress and targeting and diminishing harmful forces (stressors) within the environment. Reinforcing teaching about parenting skills and child development to prospective new parents is primary prevention. 2. Incorrect: Secondary prevention services are aimed at reducing the prevalence of psychiatric illness by shortening the course or duration of the illness. 3. Incorrect: Tertiary prevention services are aimed at reducing the residual effects of severe or chronic mental illness. 4. Incorrect: Case management occurs at the secondary level of prevention and is a way to organize client care so that specific outcomes are achieved within an allotted time frame.
Administer Acetaminophen suppository for Children less than 3-year-old and for children older than 3 years old
Provide age appropriate explanation or distraction to reduce stress.Toddlers and infantcan benefit from distraction with a toy,preeschoolers and older childrem can be instructed to take deep breaths or count during the procedure 1. Apply clean gloves and postion the client appropriately based on age and size ( eg; infant supine with knees and feet raised, older childrem side-lying with knees bent) 2. Lubricate the tip of the suppository with water -soluble jelly. Petroleum-based products can reduce absorption. 3. Insert the suppository past the internal sphincter using the fifth finger (pinky)if the child is under 3 years of age. Use of the index might cause injury to the colon or sphincters in children yhounger than 3 years.the suppository should remain in contact with th rectal mucosa(and not be buried inside the stool) to ensure systemic absorption. Hold the buttocks for severla minutes , or until the urge to defecate has [assed, top prevent expulsion. 6. If a bowel movement occurs within 10-30 minutes,observe for the presence of the suppository The suppository must be inserted past the external and internal sphincters for proper placement. If not inserted far enough, it may be expelled before achieving a therpeutic effect. 4. Angle suppository and guide it along the rectal wall.
performing procedures to children with autism spectrum disorders
Provide brief, concrete, and developmental appropriate communication or demonstrations. Explain each step during the procedure Children with respond well to pictures, as they tend to visually oriented Encourage parents or care givers to remain close to provide comfort and reassurance Reduce stimulation by reducing the number of staff during the procedure Introduce staff or equioment slowly , preferably with care givers near by Physical touch and eye contact may activate a stress respinse in children with ASD
The nurse has been caring for a client who was seriously injured in a bus accident. Several people were killed in the accident, including the client's son. The client's spouse has had several episodes of yelling at the staff and is now threatening legal action due to "inadequate care." What intervention should the nurse implement? (Select all that apply.) Notify the health care provider about the situation Active hospital security to respond to the incident Provide information about grief support groups Request a change in client assignment Allow the spouse to express their feelings
Provide information about grief support groups Correct! Allow the spouse to express their feelings Correct! Parents of children who die are at greater risk for traumatic stress. Anger and frustration are common reactions when a person is experiencing grief. The nurse should allow the spouse to verbalize their feelings because this can help with the grief process. The nurse can provide both the client and spouse with referrals to grief support groups. Notifying the health care provider is not needed at this time. Presently, the spouse is not posing a danger to the client, staff or other visitors so security is not needed. Changing the patient assignment would not facilitate a therapeutic nurse-client relationship that's needed in this situation.
An elderly client, with dentures, is concerned about performing oral care. Which nursing intervention would increase the likelihood of oral care being completed? 1. Provide a soaking container for the artificial teeth. 2. Provide privacy for the client after setting up the equipment needed. 3. Offer moistened foam swabs to the client. 4. Encourage the family to provide oral care for the client.
Provide privacy for the client after setting up the equipment needed. 2. Correct: Personal hygiene, particularly tooth care with dentures, can be uncomfortable for some clients. The nurse can provide privacy, while still making sure that the client has the needed items. The curtain in the room may need to be pulled, or a privacy sign applied to the door of the room. 1. Incorrect: Soaking container alone will not assist the client to meet the oral hygiene needs. 3. Incorrect: Moistened swabs may make the mouth feel less dry; however, those alone cannot accomplish the oral hygiene needs of the client. 4. Incorrect: If the client is uncomfortable with the nurse providing care, it is likely that the client would be uncomfortable with the family performing oral care.
Which action shall the nurse take to preserve the client's right to autonomy?
Providing the client with requested information to make an informed decision. Correct Response Autonomy can be defined as the personal freedom and the right of competent people to make choices. Autonomy, the principle of respect for a person, is sometimes called the primary moral principle. This concept holds that humans have incalculable worth or moral dignity not possessed by other objects or creatures. If an autonomous person's actions do not infringe on the autonomous actions of others, that person should be free to decide whatever they wish. This freedom should be applied even if the decision creates risk to their health and even if the decision seems unwise to others. Concepts of freedom and informed consent are grounded in the principle of autonomy.
A client was prescribed thioridazine five days ago and presents at the clinic with a shuffling gait, tremors of the fingers, drooling, and muscle rigidity. Which adverse reaction to this medication is suspected? 1. Akinesia 2. Neuroleptic malignant syndrome 3. Pseudoparkinsonism 4. Oculogyric crisis
Pseudoparkinsonism Pseudoparkinsonism may appear 1 to 5 days following initiation of antipsychotic medications and occurs most often in women, the elderly, and dehydrated clients. Symptoms include tremor, shuffling gait, drooling, and rigidity. 1. Incorrect: Akinesia is defined as muscle weakness. This is not an adverse reaction of thioridazine. 2. Incorrect: Neuroleptic malignant syndrome (NMS) is a rare, but fatal complication of neuroleptic drugs. Routine assessments should include temperature and observation for NMS symptoms (Hyperpyrexia up to 107 degrees F or 41.67 degrees C, tachycardia, tachypnea, fluctuations in BP, diaphoresis, and coma). 4. Incorrect: Oculogyric crisis is uncontrolled rolling back of the eyes and may appear as part of dystonia (Involuntary muscular movements of face, arms, legs, and neck).
Aspirin is contraindicated in
Pts under 18 years with chickenpox or flu-like symptoms may cause Reye's Syndrome thyroid storm In patinet's with evidence of bleeding
soft limb restraint:
Purpose: Wrist or ankle restraint to prevent range of motion of extremities Safety Concerns: Check wrist or ankle for any signs of circulatory, integumentary, or neurologic compromise
soft limb restraint
Purpose: Wrist or ankle restraint to prevent range of motion of extremities.Use for the prevention of falls or attempted removal of devices. 2 fingers should fit under the secured restrains. Safety Concerns: Check wrist or ankle for any signs of circulatory, integumentary, or neurologic compromise
The nurse is caring for a client who has a vancomycin-resistant enterococci (VRE) urinary tract infection (UTI). Which of the following infection control precautions should the nurse implement?
Put on a surgical mask when obtaining a urine specimen for culture and sensitivity (C & S) Wear a protective gown when changing the client's bed linens.
A client is admitted with the diagnosis of infective endocarditis (IE). History of which finding is most important for the nurse to report to the registered nurse (RN)? Clubbing of the nails Fever for the past 24 hours Rash that appears suddenly Tiredness and drowsiness
Rash that appears suddenly Correct Response A sudden rash indicates a hypersensitive response and can be the forerunner of more serious responses such as laryngeal edema. It can possibly be due to a severe reaction to a new treatment such as antibiotics that are the main treatment for infective endocarditis. You should note that drowsiness, fever, and tachypnea should all be reported to the RN, but because of its potentially grave consequences, a sudden rash is the most important finding to report to the RN. Clubbing of the nails does not occur suddenly, so is not a priority.
A client presents to the after-hours clinic with reports of pain that occurs with walking but generally subsides with rest. The nurse notes coolness and decreased pulses in lower extremities bilaterally. What condition would the nurse recognize these symptoms being most indicative of? 1. Chronic Arterial Insufficiency 2. Chronic Venous Insufficiency 3. Chronic Unstable Angina 4. Chronic Coronary Artery Disease
Rationale 1. Correct: These symptoms are indicative of arterial insufficiency as there is pain with walking that is relieved by rest. This pain is known as intermittent claudication. In addition, the pulses are decreased or may be absent with arterial insufficiency, and the extremities are cool to touch. Other s/s include: paleness of extremity when elevated or possible redness when lowered, loss of hair on affected extremity, and thick nails. 2. Incorrect: Venous insufficiency is not characterized by pain with walking. Pulses are generally normal and color is generally normal with the exception of the brown pigmentation that may be noted (especially around the ankles). 3. Incorrect: The description in the stem is evident of peripheral arterial insufficiency and is not descriptive of decreased coronary artery perfusion. No reports of chest pain were noted. 4. Incorrect: The description is evident of peripheral arterial insufficiency and is not descriptive of decreased coronary artery perfusion. The symptoms listed in the stem are indicative of a peripheral artery problem.
The nurse has been assigned to a client with a Steinman pin insertion 48 hours ago. Which pin site care interventions would the nurse implement? Select All That Apply 1. Perform pin care daily. 2. Rinse pins with water. 3. Clean with chlorhexidine. 4. Dry the area with clean gauze. 5. Monitor pin site every 10 hours.
Rationale 1., & 3. Correct: Pin care is prescribed 48 to 72 hours after insertion. The pin care is initiated once a day. Chlorhexidine is prescribed to clean the pin insertion site. 2. Incorrect: The pins are rinsed with sterile saline and not water. 4. Incorrect: The area around the pin site is dried with sterile gauze. The use of clean gauze is not appropriate. 5. Incorrect: The pin site is assessed. Every 10 hours is not often enough to monitor for infection.
The nurse is caring for a client following a cholecystectomy. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms? Select All That Apply 1. Drink between meals. 2. Reduce intake of carbohydrates. . Eat small, frequent meals daily. 4. Sit semi-recumbent for meals. 5. Remain upright for one hour after eating. 6. Lie down on left side after eating.
Rationale 1., 2, 3, 4., & 6. Correct: Clients are instructed to eliminate all fluids during meals. In some cases, clients may also need to eliminate fluids for one hour before and immediately after meals in order to control symptoms and slow the progress of food through the digestive tract. The symptoms described indicate the client is experiencing dumping syndrome, an adverse response following gastric or bariatric surgery. Clients may also experience tachycardia, nausea or cramping with the intake of food due to surgical restructuring of the gastrointestinal tract. Because this will be a lifetime issue, the nurse must teach the client to adjust eating habits and patterns. Reduction of carbohydrates will help decrease the problem since carbohydrates speed through the digestive track too quickly. Eating smaller, more frequent meals in a semi-recumbent position will further slow food through the digestive tract and eliminate most of the uncomfortable symptoms. After eating, the client should lie down on the left side to keep food in the stomach longer.
Which assessment findings would indicate to the nurse that a client may have a fracture? Select All That Apply 1. Swelling 2. Deformity 3. Crepitus 4. Discoloration 5. Tenting of skin
Rationale 1., 2., 3. & 4. Correct: Swelling, deformity, crepitus, and discoloration are signs of a fracture. The swelling is caused by fluids and blood that move into the soft tissues. The leaking of blood from the soft tissue or from the bone will result in a discoloration or bruising at the injury site. The most accurate sign of a broken bone is deformity of the bone. An example would be when a bone is bending in an inappropriate direction. 5. Incorrect: Tenting of the skin is not a sign of a fracture. Tenting is the slow return of skin after the skin has been pinched. If tenting is present, this indicates that the client is possibly dehydrated.
The nurse is implementing cast care instructions for a client with a plaster cast applied 2 hours ago. Which cast care instruction would be included? Select All That Apply 1. Rest cast on a soft pillow. 2. Keep the cast uncovered until air dried. 3. Mark the cast if there is breakthrough bleeding. 4. Place ice packs on side of the cast for first 24 hours. 5. Use the palms of hands when moving the cast for first 6 hours.
Rationale 1., 2., 3., & 4. Correct: Until the cast has dried completely, the cast care instructions are to prevent indentations on the cast, reduce swelling, and evaluate any breakthrough bleeding. 5. Incorrect: To prevent indentations in the plaster cast, the cast should be moved with the palms of hands for first 24 to 72 hours.
A client's skeletal traction has been accidently released. What signs/symptoms does the nurse expect to see? Select All That Apply 1. Pain 2. Foot drop 3. Muscle spasm 4. Bone displacement 5. Itching under the straps
Rationale 1., 3., & 4. Correct: The purpose of traction is to stabilize and realign bone fractures and reduce pain. If the skeletal traction is interrupted by losing the traction on the bone, the result may include pain, muscle spasm, and bone displacement. 2. Incorrect: Foot drop is the weakness or paralysis of the muscles that lift the front part of the foot. Causes of foot drop may include; nerve injury, muscle or nerve disorders, brain and spinal cord disorders, and immobility. 5. Incorrect: The client would not experience any itching under any straps or cords due to the accidental release of the skeletal traction.
A client was diagnosed with a fractured ulna 8 hours ago. Which assessment data may indicate a compartment syndrome? Select All That Apply 1. The pain is located at the elbow area. 2. The prescribed opioid does not relieve the pain. 3. When forearm is elevated, the swelling in the forearm is reduced. 4. The pain in the forearm is described as a 9 on a 10 scale and throbbing. 5. When placing a cold compress on the forearm, the pain level is reduced.
Rationale 2. & 4. Correct: Compartment syndrome occurs when swelling occurs within the compartment. This results in increased pressure on the capillaries, nerves, and muscles in the compartment. The pain is very intense. The client is expressing pain at a 9 on a 10 scale and throbbing. The pain is also unrelieved by opioid administration. 1. Incorrect: The location of pain at the elbow area does not indicate the presence of compartment syndrome. The pain related to compartment syndrome would not occur in the elbow. The swelling and bleeding will occur in the compartment of the forearm due to the swelling or bleeding. 3. Incorrect: The swelling will not be reduced by elevating the forearm as result of the constant increased pressure in the compartment. 5. Incorrect: Applying a cold compress on the forearm that decreases the swelling is not a symptom of compartment syndrome. The increased pressure in the compartment results in a decrease of the blood flow to the muscles and nerves.
Which interventions would the nurse implement for a client with a right total hip arthroplasty performed 6 hours ago? Select All That Apply1. Remove the abductor pillow.2. Place a pillow under both knees.3. Position the feet with the toes pointed upward.4. Assess client's popliteal, dorsalis pedis, and posterior tibial pulses.5. Report to the healthcare provider the 15g/dL (9.31mmol/L) Hemoglobin.
Rationale 3. & 4. Correct: These are correct interventions. The feet should be placed in a neutral rotation position with the toes pointed to the ceiling. This positioning of the feet prevents the hips from rotating inwardly or outwardly. If the hips are not positioned appropriately, there is a postoperative risk for dislocation of the hip. The postoperative neurovascular assessment of the right leg includes evaluating the client's popliteal, dorsalis pedis, and posterior tibial pulses. The nurse should evaluate the peripheral pulses distal to the hip. The primary healthcare provider should be notified of any alterations in the peripheral pulses. 1. Incorrect: The abduction pillow is not removed within 6 hours of a total hip arthroplasty. This is an inappropriate intervention. The abduction pillow is attached to the legs to prevent adduction of the hips to decrease the risk of a dislocation of the surgical hip. 2. Incorrect: The nurse should not place a pillow under either knee. The pillows would decrease the circulation to the lower extremities and increase the risk factor for deep vein thrombosis (DVT). Also, an abduction pillow is attached to the lower extremities. 5. Incorrect: The normal hemoglobin range for a male client is 14-15 g/dL (8.7-11.2 mmol/L). The client's hemoglobin level is 15g/dL (9.31mmol/L). Since the client's hemoglobin level is within normal range, the nurse will not notify the primary healthcare provider.
The client has been instructed on crutch safety. The nurse identifies that further teaching is needed when the client makes which statement? Choose One 1. "The crutches are adjusted according to my height." 2. "I will support my weight on the hand grips when not walking." 3. "I plan to place my affected leg on the step first when ascending stairs." 4. "I will position the crutches 1 -2 inches below the axilla when walking with crutches."
Rationale 3. Correct: This statement is incorrect and further client teaching is needed. When going up stairs, the client should lead with the unaffected leg. The unaffected leg will provide the support required to then move the affected leg to the step. 1. Incorrect: The crutches should be adjusted according to the client's height and arm length. The top of the crutches should be approximately 1 to 2 inches under the axilla. The hips should be even with the hand grips. Also, the crutch length should be measured from the client's axilla to approximately 6 inches in front of the toe. This is a true statement. 2. Incorrect: If the weight is supported by placing the top of the crutches against the axilla, then brachial nerve damage will occur. To prevent the damage to the brachial nerve the hands rest on the hand grips when resting. This is a correct statement by the client. 4. Incorrect: To prevent damage to the brachial nerve, the client should position the crutches 1 to 2 inches below the axilla when walking with crutches. With the shoulders relaxed the client should be able to also position 2 finger widths between the axilla and the crutch pads.
The nurse is reinforcing stump care discharge instructions to the client with a right below-the-knee amputation (BKA). The client responds, "What is the purpose of the compression sock on my stump?" Which statement by the nurse is appropriate? Choose One1. "The compression sock on the stump will increase your balance when crutch walking."2. "Phantom limb pain will decrease by applying the compression sock tightly around the stump."3. "A compression sock is applied to shape the stump smaller and rounder on the bottom."4. "The application of a compression sock will decrease the risk of the incidence of deep vein thrombosis (DVT)."
Rationale 3. Correct: Wrapping the stump with an ace bandage will assist in configuring the stump into a cone shape. The cone shape is smaller and rounded on the bottom. The cone shaped stump will result in the stump fitting easier into the prosthesis. 1. Incorrect: The compression sock will not increase the client's balance when crutch walking. The compression sock will assist in shaping the stump. 2. Incorrect: This is an incorrect statement. The nurse's interventions to decrease phantom pain would include diversional activity and administering the prescribed analgesic. 4. Incorrect: Applying a compression sock to the right stump is not an appropriate intervention to decrease the risk of a DVT. The risk for a DVT after surgery is increased in the left leg. Interventions to decrease a DVT are to move the extremities frequently and increasing fluid intake.
A nurse is caring for a client with fat embolus syndrome (FES). Which data would support the nurse's assessment that the FES has resolved? Choose One 1. Respirations - 24. 2. Oxygen saturation - 94%. 3. Arterial blood gas - pH 7.34. 4. No infiltrates noted on chest x-ray.
Rationale 4. Correct: A fat embolism is caused by droplets of bone marrow fat that is released into the venous system. The droplets may lodge in the lungs. An x-ray of the lungs with the bone marrow fat will have a "snowstorm" appearance. A chest x-ray that does not identify any filtrates and does not have a "snowstorm" appearance is indicative the fat embolus is decreasing in size or completely resolved. 1. Incorrect: A respiratory rate of 24 is not within the normal range of respirations for an adult. If FES has resolved, you would expect the respiratory rate to be normal. 2. Incorrect: Oxygen saturation is the percentage of hemoglobin saturated with oxygen. A oxygen saturation value of 94% is not within the normal range of 95% to 100%. If FES has resolved, you would expect the oxygen saturation percentage to be normal. 3 Incorrect: The normal pH arterial blood gas range is 7.35-7.45. The client's pH level of 7.34 is not within the normal pH range. It is acidotic. The body regulates the pH level by changing the body's CO2, bicarbonate, oxygen levels. This lab value is not reflective of the resolution of a FES. If you missed this question, review page 125 of your student book.
A client is admitted to the emergency room with an open fracture of the left tibia which has been temporarily splinted. Which nursing intervention would the nurse implement? Choose One1. Physically reduce the fracture. 2. Externally rotate the left leg. 3. Position the bed into a high Fowler's position. 4. Cover the fractured site with a sterile dressing.
Rationale 4. Correct: An open fracture is when the bone has broken the skin and underlying soft tissue, and the bone is protruding from the wound. The nurse should cover the fracture site with a sterile dressing to prevent contamination of deeper tissues. 1. Incorrect: The leg was splinted as a temporary emergency intervention. Upon arrival in the emergency room, the fracture should not be reduced by the nurse. Once the skin has been broken at the fracture site, the wound is a portal of entry for contaminants. A surgical procedure is performed to clean the wound and the bone. 2. Incorrect: If the nurse externally rotates the left leg, there is an increased risk of additional trauma to the tissues from the movement of the fracture bone. Also, there is a risk of the bone slipping into the wound from the external rotation. 3. Incorrect: Placing the client in high Fowlers position is not an appropriate intervention. The fractured site and/or limb should be elevated.
The primary healthcare provider prescribes 12,000 units of Heparin every 12 hours. The pharmacy dispensed a vial of heparin containing 40,000 units per mL. How many mL will the nurse administer? Round answer using one decimal point.
Rationale Strategies 40,000 units: 1 mL = 12,000 units: x mL 40,000x = 12,000 X = 0.3
The nurse is caring for a client receiving digoxin. What information should be reinforced by the nurse to the client about this medication? 1. Check your pulse daily before taking the medication. 2. Report a marked decline in pulse rate. 3. Consume foods high in potassium to maintain adequate serum potassium levels. 4. Report pulse rate of 64 or more. 5. Report symptoms of nausea, loss of appetite, or visual disturbances.
Rationale Strategies 1., 2., 3., & 5. Correct: The client should be told to take his pulse daily to assure pulse rate is above 60. Any marked decline in pulse rate should be reported as it could indicate heart block or toxicity. Digoxin works best when potassium levels are adequate. Symptoms of toxicity include anorexia, nausea, bradycardia, visual disturbances.4. Incorrect: Only when the pulse rate is below 60 should the client be concerned about not taking the medication as prescribed.
what labs should you check for a patient with DIC
Some routine tests that may be performed include: CBC (complete blood count) - includes a platelet count; in DIC, platelets are often low. Blood smears from individuals with DIC often show decreased number of platelets and presence of large platelets and fragmented red cells (schistocytes).Apr 14, 2016
A 2-month-old is admitted with a fever of undetermined origin. The infant received acetaminophen two hours ago and is now sleeping. The parents are refusing to allow the unlicensed assistive person (UAP) to attempt to measure the baby's temperature because the infant is asleep. What action by the nurse is indicated in this situation? Recognize that the parents have a right to refuse treatment Insist that the temperature must be taken now Ask the parents to step outside of the room to discuss the situation Send a different UAP to measure the client's temperature
Recognize that the parents have a right to refuse treatment Correct! A client or the client's advocate has the right to accept or refuse routine assessments, especially when it will not alter the outcome. The nurse can make other assessments (for example, count respirations, observe color of skin) and document these findings along with information that the client is sleeping. The client's temperature can be re-evaluated later, when the client is awake.
Which of the following defines the Quality and Safety Education for Nurses (QSEN) competency of Patient-Centered Care?
Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs. Correct Response The definition of the Quality and Safety Education for Nurses (QSEN) competency of Patient-Centered Care is: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs. The other answers pertain to the competencies of Teamwork and Collaboration, Evidence-Based Practice (EBP) and Quality Improvement.
A newborn who is delivered at home and without a birth attendant is admitted to the hospital for observation. The initial temperature is 95 F (35 C) axillary. The nurse should recognize that cold stress may lead to what complication? Hyperglycemia Reduced partial pressure of oxygen in arterial blood (PaO2) Metabolic alkalosis Lowered basal metabolic rate
Reduced partial pressure of oxygen in arterial blood (PaO2) Correct Response Hypothermia and cold stress cause a variety of physiologic stresses including increased oxygen consumption, metabolic acidosis, hypoglycemia, tachypnea and decreased cardiac output. The baby delivered in such circumstances needs careful monitoring. In this situation, the newborn must be warmed immediately to increase its temperature to at least 97 F (36 C). Normal core body temperature for newborns is 97.7 F to 99.3 F (36.5 C to 37.3 C).
The nurse is assisting clients with trigeminal neuralgia (tic douloureux) and their nutrition needs. During home care of these clients, which approach should be taken by the nurse?
Reinforce the need for small meals containing high-calorie and soft-textured foods Correct Response If a client is losing weight because of poor appetite due to the facial pain, the nurse can reinforce the need for foods that are high in calories and nutrients. The goal is to provide more nourishment with less chewing. Reinforce that frequent, small meals be eaten instead of three large meals. To minimize jaw movements when eating, the nurse could suggest pureed or liquid forms of nutrition. To help answer this question, you can ask yourself: Which function of the body would be associated with food and nerves? You might think: "eating and chewing." You could then ask: Is this condition painful? If yes, you will notice that only one option focuses on soft food (that would require less chewing). Incorrect
A nurse is caring for elderly residents who live in a long-term care setting. Which activity would most effectively meet the growth and developmental needs for the elderly? Regularly scheduled social activities Reminiscence groups Aerobic exercise classes Transportation for shopping trips
Reminiscence groups Correct Response According to Erikson's theory, older adults need to find and accept the meaningfulness of their lives, or they may become depressed, angry and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and working through loss. Erikson identifies this developmental challenge of the elderly as "ego integrity versus despair."
Steps in removing a nasogastric tube
Removal 1. Adhere to Standard Precautions. 2. Explain procedure to patient. 3. Place a towel across the patient's chest and inform him/her that the tube is to be withdrawn. 4. Rotate tubing and inject approximately 10 mL of saline before clamping tubing. 5. Remove the tape from the patient's nose. 6. Instruct the patient to take a deep breath and hold it. 7. Slowly but evenly withdraw tubing and cover it with a towel as it emerges. (As the tube reaches the nasopharynx, you can pull quickly.) 8. Provide the patient with materials for oral care and lubricant for nasal dryness. 9. Monitor the patient for signs of gastrointestinal difficulties or changes. AFTER CARE: 1. Cleanse reusable equipment, rinse, dry and cover with clean towel. 2. Document in patient's record: a. Procedure and observations. b. Size and type of tube inserted. c. Time of insertion or removal. d. Patient's response to procedure. e. Instructions given to patient/caregiver. f. Communication with physician.
What would the nurse do first when assisting in decontaminating a client who was recently involved in a chemical exposure event? 1. Rinse the client off with a copious amount of water. 2. Remove clothing from the client. 3. Wash the client thoroughly with soap and water. 4. Flush the skin with an antibacterial agent.
Remove clothing from the client. 2. Correct: Eighty percent of decontamination can be accomplished by removal of clothing. Complete decontamination involves clothing removal, complete flushing of the skin with water, and wrapping the client in a sheet or protective cover. 1. Incorrect: Complete decontamination involves clothing removal, then complete flushing of the skin with water, and wrapping the client in a sheet or protective cover. 3. Incorrect: Soap is not recommended for decontamination. 4. Incorrect: Antibacterial agents are not recommended. 1. Identify key words in the stem that set a priority, such as first, initially, best, priority, safest, most. These words modify what is being asked. This question requires you to put a value on each option and then place them in rank order. If you are having difficulty ranking the options, eliminate the option that you believe is most wrong among the options. 2. Identify clues in the stem. Generally, the stem is short and contains only the information needed to make the question clear. A clue is the use of a word or phrase that leads you to the correct answer. The clue shows a relationship to word or phrase in the correct answer.
What to teach a patient taking Warfarin
Remove scatter rugs Avoid aspirin and other NSAIDs Avoid alcohol Gently brush teeth using a soft toothbrush Do not use alcohol-based mouth wash Avoid contact sports and rollerblading Use electric razor Floss should be avoided unless wax floss is used Wear a medical alert
The nurse notices flames and smoke in the garbage can in a client's room. Which action should the nurse take first?
Remove the client from the area. Correct! The nurse's first action in an active fire should be to remove the client from imminent harm. The other actions should occur after the client is taken to safety.
The nurse is preparing to leave the client's room where personal protective equipment has been necessary. What should the nurse do first? 1. Remove the gown. 2. Remove the protective eyewear. 3. Remove the gloves. 4. Wash hands.
Remove the protective eyewear. 3. Correct: Removing the most contaminated item first is the most effective way to prevent spread of contamination or infection. The gloves should be removed first, followed by hand washing, removal of the protective eyewear, and finally removal of the gown.1. Incorrect: The gown should be removed last in the sequence mentioned above.2. Incorrect: The hands should be washed before removing the protective eyewear.4. Incorrect: The gloves should be removed first, followed by hand washing, removal of the protective eyewear, and finally removal of the gown.
Reflection
Repeating back the feeling,idea or message conveyed You're feeling anxious necasue of your job
The nurse is reviewing discharge orders for a client who has been prescribed daily warfarin for the next six months. Which of these points should be emphasized during the discharge instructions? Report any changes in the color of your stools and urine Eliminate all dark green leafy vegetables from your diet Use a soft toothbrush Use a nonsteroidal antiinflammatory drug for headache pain
Report any changes in the color of your stools and urine Correct Response The client should notify the health care provider for color changes to stool or urine; blood will make the stool dark brown or black and the urine more of a rusty red color. The client should use a soft-bristled toothbrush to avoid irritating the gums. Dark green leafy vegetables contain vitamin K, which plays a major role in blood clotting; the client should restrict, but not eliminate these foods from the diet. Taking NSAIDs with warfarin can greatly increase the risk of bleeding; alternative pain medications should be discussed with the health care provider.
The nurse is assessing the client during a home health visit and the client states: "I had physical therapy yesterday. I thought it was supposed to help but my back hurts so much after each visit." The nurse's responsibilities include which of the following actions? (Select all that apply.) Tell the client to take the prescribed pain medication Report the client's findings to the nursing supervisor for further assessment Report the client's findings to the physical therapist Gather more information about the location, duration and intensity of the pain Offer to help the client make an appointment with the physician about the back pain
Report the client's findings to the nursing supervisor for further assessment Correct Response Report the client's findings to the physical therapist Correct Response Gather more information about the location, duration and intensity of the pain Correct! The needs of the client can be best addressed by further assessment of the client (collecting more information about the findings of pain) and then communicating the client's needs to the interdisciplinary team members. Before any medication is given or any appointments are made, more information about the pain is needed.
The nurse is providing care to a client who has a history of violent episodes against his wife. The client has made a specific threat that he plans to kill his wife when he gets out of the hospital. What should the nurse do first? 1. Report the threat with the treatment team immediately. 2. Call the wife immediately to report her husband's intention. 3. Reinforce client teaching on violence prevention. 4. Tell the client that he shouldn't make threats like that.
Report the threat with the treatment team immediately. 1. Correct: Yes, immediately discuss the threat with the treatment team. The duty to warn is an obligation of healthcare providers. The threat should be discussed with the treatment team, and agency policy for notification of the threatened party should be followed. 2. Incorrect: The team should discuss this first; the next action may be to call the wife. At this point, the client is in the hospital and the wife is not in immediate danger. 3. Incorrect: A threat cannot be ignored. The threatened party has the right to know. The team will decide and take the appropriate action. 4. Incorrect: The client has reported valuable information and follow up is required.
The nurse asks another staff nurse to sign for wasting a partial-dose opioid injection, although the wasting was not witnessed by anyone. This type of request seems to be a pattern of behavior for this nurse. What is the most appropriate action for the second staff nurse to take?
Report this request immediately to the nurse manager. Correct! The incident must be reported to the appropriate supervisor, either the charge nurse or the nurse manager, for both ethical and legal reasons. This is not an incident that a nurse can resolve without referring to an appropriate authority. The second nurse should only sign as a witness to the wasting of a controlled substance if the nurse actually observed the wasting. Signing as a witness without having actually witnessed the wasting action can be considered falsification of records and result in disciplinary action by the nurse's employer and the state board of nursing.
RACE:
Rescue the client; activate the alarm; contain the fire in the client's room; extinguish the fire. This standard process ensures safety for the client first and then the remaining people in the facility next. First, remove the client from the room. Second, activate the fire alarm. Third, close the door to the client's room. Fourth, obtain the fire extinguisher. Fifth, extinguish the fire.
Control measure when caring for patients with C. dificile colitis
Resquest that the client be assigned to a single client room, or with others with same problem Wear a single -use , disposable gown during care Contact precautions Implement contact isolation precautions
Informed consent includes
Risks, benefits, complications, alternatives
Xa Inhibitor: Oral Anticoagulants
Rivaroxaban (Xarelto) Apixaban (Eliquis) Do not require routine coagulation monitoring Administered q.d. or b.i.d not affected by vit K
Rapid acting insulin aspart/NovoLOG
Search Results Featured snippet from the web NovoLog (insulin aspart)is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours. ... NovoLog is used to treat type 2 diabetes in adults. NovoLog is also used to treat type 1 diabetes in adults and children who are at least 2 years old.
The licensed practical nurse (LPN) is reviewing laboratory results for a client diagnosed with acute renal failure. Which result should be reported immediately to the registered nurse (RN) if noted by the LPN? Venous blood pH 7.30 Hemoglobin of 10.3 mg/dL (6.39 mmol/L) Blood urea nitrogen (BUN) 50 mg/dL (17.85 mmol/L) Serum potassium 6 mEq/L (6 mmol/L)
Serum potassium 6 mEq/L (6 mmol/L) Correct Response Although all of these findings are abnormal, the elevated potassium is a life-threatening finding and must be reported immediately. The high BUN indicates increased protein breakdown or renal problems. A low hemoglobin is consistent with chronic renal failure even though this client has acute renal failure. It means the lack of erythropoetin to stimulate the bone marrow to produce red cells. A low pH is consistent with renal failure or any other body malfunction that results in metabolic acidosis.
A health care provider orders digoxin 0.125 mg and furosemide 40 mg by mouth every day. The nurse would recommend the client should eat which of these foods on a daily basis? Four ounces of chicken Slice of watermelon A small plate of spaghetti A whole fresh tomato
Slice of watermelon A slice of watermelon is the highest in potassium and will replace any potassium lost by the diuretic. A tomato has high potassium but not as much as a slice of watermelon. The other foods do not have high levels of potassium.
Varenicline (Chantix)
Smoking cessation - start 1 week before quit date BW - Serious neuropsychiatric events including depression, etc. Warning - Angioedema, hypersensitivty rxns, seizures, increase intoxicating effect of alcohol, and serious skin reactions have occured. - use caution in patients with underlying psychiatric disorders and while driving or operating machinery, traffic accidents have occured. Avoid use in pilot, etc. SE - Nausea , constipation, etc > Take w/ food to reduce nausea Note MedGuide required
A client, diagnosed with schizophrenia, tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for the nurse to initiate with this client? 1. Watching TV with two other clients in the day room. 2. Watching TV alone in a conference room. 3. Spending time in brief one on one interactions with the nurse. 4. Sitting in the day-room away from other clients.
Spending time in brief one on one interactions with the nurse. 3. Correct: The interaction with the nurse can keep the conversation reality based and provide interaction with someone. Clients with schizophrenia may be very withdrawn and need the presence of the nurse. 1. Incorrect: The client is very uncomfortable around the other clients. As the client's condition begins to stabilize, this action could be appropriate. 2. Incorrect: The client needs interaction with others. Time with others allows the client to stay reality based. When alone, there may be more time for delusional thought or auditory hallucinations. 4. Incorrect: The nurse can monitor the thought processes of the client and offer acceptance of the client. Sitting away from other clients is not a recommended therapeutic intervention for this client.
Nurse reinforces teaching to a 15 year old primigravida at 16 week gestation during first prenata visit. What is a priority
Stress importanc of consistent prenatal care Adolecents have an increased risk for complications during pregnancy(preeclampsia,LBW,preterm birth, anemia). The primary goal of initial teaching is to stablish rapport and emphasize consistent prenatal care so that complication can be detected and prevented. The have a self focused-outlook in life and might not consider the consequences of their actions, which can negatively affect their health and the fetus.
When administerinf vaccines to a child with hemophilia
SubQ use smallest needdle gauge hold form for 5 minutes
Prior to the start of the shift, the nurse becomes concerned about how she can safely care for the number of clients assigned to her. After discussing the situation with the nursing supervisor, the nurse remains concerned about the unsafe staffing ratio. What is the correct action the nurse should take? Submit a written statement about the concern to the nursing administration Notify the client's health care providers about the nursing care ratios Decline the assignment and promptly leave the unit Inform the nursing staff that she will not accept the entire assignment
Submit a written statement about the concern to the nursing administration Correct! In order to provide safe and effective care, appropriate staffing and skill mix levels are needed. When there is a concern about staffing, the nurse should contact the nursing administrator or immediate supervisor right away. Then the nurse should submit her concerns in writing and, if possible, address any ongoing concerns about staffing ratios. Nursing administration is responsible for nursing, not the health care provider. Leaving the unit would be considered patient abandonment. Refusing to accept an assignment would be inappropriate and counterproductive.
What is most important for the nurse to have at the client's bedside when a large orogastric tube for rapid gastric lavage is being inserted by the primary healthcare provider? 1. Emesis basin 2. Portable x-ray machine 3. Oxygen 4. Suction equipment
Suction equipment 4. Correct: Insertion of a large orogastric tube designed for rapid lavage often causes gagging and vomiting, so suction equipment should be readily available to reduce the risk of aspiration. Maintaining the client's airway is the priority. 1. Incorrect: You would need an emesis basin because of the chance of vomiting, but suction equipment is the priority due to aspiration. 2. Incorrect: An x-ray is the preferred method to check initial placement, once the tubing is inserted. Suction equipment is the priority when inserting the tube due to risk of aspiration. 3. Incorrect: There are no key words in the question to suggest the client needs oxygen at this time.
During a home visit, the nurse observes the mother of a school-aged child in a long leg synthetic cast using a cloth-covered wooden spoon handle to relieve itching inside the cast. Which response by the nurse is most appropriate? Remind the mother and child that itching is normal No response is needed because the mother's behavior is appropriate Suggest placing an ice pack (protected by plastic) over the area that is itching Instruct them to blow hot air from a hand-held hair dryer into the cast
Suggest placing an ice pack (protected by plastic) over the area that is itching Correct! Because itching is a common and frustrating problem for a person with a cast, it would not be therapeutic to simply remind the mother and child that itching is normal. But using anything to scratch the skin inside the cast is not recommended because this can injure the skin, increasing the risk for infection. Clients may use a hair dryer to help relieve itching, but the temperature must be set to cool or cold. Of the given choices, applying ice (protected by a plastic bag) is the most appropriate. Cool temperatures constrict blood vessels, minimizing itching (just like heat vasodilates and intensifies itching.) Sometimes over-the-counter antihistamines may help relieve itching.
A new LPN/LVN is preparing to give a medication to a nine month old client. After checking a drug reference book, crushing the tablet and mixing it into 3 ounces of applesauce, the new LPN/LVN proceeds to the client's room. What priority action should the supervising LPN take? 1. Tell the new LPN/LVN to recheck the drug reference book before administering the medication. 2. Suggest the new LPN/LVN reconsider client's developmental needs. 3. Check the prescription order and the client dose. 4. Observe the new LPN/LVN administer the medication.
Suggest the new LPN/LVN reconsider client's developmental needs. 2. Correct. Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce new food during an illness. 1. Incorrect. There is nothing in the stem about a problem with the medication dose or route. 3. Incorrect. There is nothing in the stem about a problem with the medication dose or route. 4. Incorrect. This is an appropriate action, however, it is not the priority.
The nurse is assisting with a plan to teach a group of young women who want to become pregnant. What information should be included to increase the chances of having a healthy baby? Select all that apply 1. Take 400 micrograms of folic acid every day. 2. Limit alcohol to 1 glass per day. 3. Avoid smoking. 4. Take the flu vaccine during flu season. 5. Start prenatal care by 3 months of pregnancy
Take 400 micrograms of folic acid every day. . Avoid smoking. Take the flu vaccine during flu season. Correct: Folic acid is a B vitamin. If a woman has enough folic acid in her body at least a month before and during pregnancy, it can help prevent neural tube defects. Smoking can lead to premature birth, cleft lip or cleft palate, and infant death. The flu shot given during pregnancy has been shown to protect mom and baby (up to 6 months old) from flu.
Which task can the LPN/LVN assign to an unlicensed assistive personnel (UAP) when caring for a client who has had a stroke? 1. Assess a client's ability to swallow. 2. Insert a foley catheter. 3. Instruct the client how to use a walker. 4. Take the client's temperature.
Take the client's temperature. 4. Correct: The UAP can obtain routine vital signs, such as a temperature. 1. Incorrect: The UAP cannot assess a client. 2. Incorrect: The UAP cannot insert a foley catheter. This is beyond the UAPs scope of practice. 3. Incorrect: The UAP cannot teach.
The nurse is gathering data on a health history with a client who is 10 weeks pregnant. During the interview, the client states, "I'm not so sure I'm really happy about this pregnancy". Which response by the nurse is most appropriate? 1. Many women feel ambivalent about being pregnant. 2. Tell me more about how you are feeling. 3. Why do you feel this way? 4. It seems there is never a good time to get pregnant.
Tell me more about how you are feeling. 2. Correct: Use of the open ended statement provides the client an opportunity for clarification of her feelings, ideas and perceptions. This also emphasizes the importance of the client's interaction.1. Incorrect: While it is true that ambivalence about pregnancy is normal, the client should be afforded the opportunity to explore the interwoven feelings of wanting and not wanting to be pregnant.3. Incorrect: Asking "why" questions can put the client in a defensive position and is not therapeutic.This can be intimidating for the client.4. Incorrect: This response reflects a personal opinion and may be irrelevant for this client. This is imposing the nurse's ideas on the client. 1. A strategy you can draw on to help answer priority questions is to refer to basic guiding theories that are part of the foundation of nursing. Maslow's Hierarchy of Needs, The Nursing Process, Kubler-Ross's Theory of Death and Dying, Teaching/Learning Theory, Therapeutic Communication. 2. Nurses need to use interviewing techniques to effectively communicate in a nonthreatening way with clients.
Acrocyanosis
Temporary cyanotic condition, usually in newborns resulting in a bluish color around the lips, hands and fingernails, feet and toenails. May last for a few hours and disappear with warming.
Doxycycline
Tetracycline,antibiotic Avoided in pregnancy because it can impair bone mineralization and discolor permanent teeth in the fetus
When assisting a mother with breastfing should you wear gloves?
Yes!
An 18 month-old toddler is on peritoneal dialysis in preparation for a renal transplant in the near future. When a nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The priority nursing action should be based on which understanding? An inactivated form of the vaccine can be given at any time The MMR vaccine should be given now, prior to the renal transplant The risk of vaccine side effects precludes giving the vaccine Live vaccines are withheld in children with chronic renal illness
The MMR vaccine should be given now, prior to the renal transplant Correct Response MMR is a live virus vaccine and should be given at this time. Post-transplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the compromised immune system. You will note that two of the responses address the timing of administering the vaccine; however, both the correct response and the question contain the term "MMR."
The nurse is caring for an 80-year-old client who requires wrist restraints. What client behaviors would support the need to continue to use restraints? (Select all that apply.)
The client is confused and trying to pull out an IV catheter. Correct! The client is resisting care and attempting to hit the staff. Correct! Physical restraints should only be used as a last resort. If restraints are indicated, the least restrictive device available should be used to restrain the client. The restraint should protect the individual, but also allow for freedom of movement. Circumstances that require the use of physical restraints include when clients attempt to remove life-support equipment, when clients interfere with therapy or treatment (e.g., enteral feedings, intravenous infusions, tracheostomy tubes, etc.) and when clients are combative and a risk to others. Restraints are not indicated for the convenience of hospital staff. Examples of physical restraints include hand mitts, arm sleeves, lap belts and limb restraints.
The nurse has administered haloperidol 5 mg orally (PO) as needed (PRN) to a client with a diagnosis of schizophrenia. Which of the following behaviors justify use of this chemical restraint? (Select all that apply.)
The client is expressing paranoid delusions. Correct Response The client is verbalizing a plan to harm another client. Correct! The client is experiencing command hallucinations. Correct! Command hallucinations and paranoid delusions can be frightening or dangerous, potentially causing a client to act aggressively. It is important to intervene before a client acts on a plan to harm another person. An antipsychotic medication, such as haloperidol, will help control and manage symptoms and behaviors associated with schizophrenia. A chemical restraint should be used in an extreme or emergent situation. A client has the right to refuse to participate in activities. Verbal intervention, such as offering to speak with the client 1:1, would be appropriate if the client is upset and crying.
A client with CAD was discharged home with a prescription for NTG to treat anginaWhat statement indicates a need for further explanation? I will wait to call 911 if I don't experience relief after a third tablet
The client should be instruct to take 1 pill or 1 spray, every 5 min, for up to 3 doses, but EMT should be called if pain is unimproved or worsen 5 min after the first tablet Previously the EMT were called after taken the last dose Instruct to take water before administration if he patient has dry mouth never swallow ,if inhaled form is used instruct to not inhale but to spary directly under the tongue instead Headache and flushing is common effects of NTG Have the cleint lie down before taking the pill as it can cause dizziness from possible orthostatic hypotension
Four clients are admitted to an adult medical unit on the same shift. The nurse should implement airborne precautions for which client? The client with ventilator-acquired pneumonia (VAP) The HIV-positive client with cytomegalovirus (CMV) The client with advanced carcinoma of the lung The client with a productive cough who just returned from vacation in India
The client with a productive cough who just returned from vacation in India Correct Response India has the greatest incidence of tuberculosis (TB) in the world and a client who develops a cough after spending time in India should be tested for TB or other contagious respiratory infections. Until the testing is complete, the client should be placed in airborne transmission-based precautions, which require a private, negative-pressure room. Health care workers would have to use a N-95 mask when in the room providing care for the client. The CMV virus is not highly contagious, but it can be transmitted by close, direct contact with infectious body fluids. Contact transmission-based precautions might be indicated. Clients with VAP and lung cancer are not considered contagious and do not require airborne precautions.
The nurse is assigned to care for several clients on the day shift. Which client should the nurse see first after receiving shift report? The client with chronic kidney disease who completed peritoneal dialysis two hours ago The client with pancreatitis who reports pain at a level of eight out of 10 The client with peptic ulcer disease who has been vomiting most of the night The client with asthma who is scheduled for a chest X-ray prior to discharge
The client with peptic ulcer disease who has been vomiting most of the night Correct!
During the management of a client's pain, the nurse should adhere to the code of ethics for nurses. Which of these actions should the nurse consider first when treating the client's pain? Cultural sensitivity is fundamental to client-centered pain management. Clients have the right to have their pain managed promptly. The client's self-report of pain is the most important consideration. Nurses should not judge a client's pain based on the nurse's values.
The client's self-report of pain is the most important consideration. Pain is a complex phenomenon that is perceived differently by each individual. A client's self-reported pain serves as the foundation for the nurse's approach to pain management. The nurse shall keep in mind that pain is subjective and accept the client's report of pain in a nonjudgmental and objective manner. Client-centered and ethical nursing care requires that the nurse recognizes their personally held values and beliefs about the management of pain and that the client's expectations, values and beliefs influence outcomes in the management of their pain.
A client has been placed in physical restraints due to aggressive behavior. Which of the following demonstrates that the nurse has appropriately implemented the restraints? (Select all that apply.)
The client's status is documented every 15 minutes. Correct! The appropriate client advocate or relative has been notified. Correct! The radial and pedal pulses are palpable and strong. Correct! To avoid injury, restraints should never be fastened to a moving part of a bed or stretcher. A physical restraint order is never "as needed." An order must be written by a provider for each restraint episode. Using profanity and cursing is not cause for physical restraints. To justify physical restraints, the client must be an imminent threat to themselves or others. Strong radial and pedal pulses indicate that the restraints are not occluding circulation. Documentation must be done every 15 minutes on the restraint flow sheet, which is part of the client's permanent medical record. It is a legal requirement to notify the client's advocate or a relative if requested by the client.
Hepatitis C (HCV)
The most widespread chronic blood-bourne illness in the US. No Vaccine available The virus is spread by contact with contaminated blood, for example, from sharing needles or from unsterile tattoo equipment. Most people have no symptoms. Those who do develop symptoms may have fatigue, nausea, loss of appetite, and yellowing of the eyes and skin. Hepatitis C is treated with antiviral medications. In some people, newer medicines can eradicate the virus. How it spreads By blood products (unclean needles or unscreened blood). By mother to baby by pregnancy, labor, or nursing.
The nurse, who is caring for a client with complex and unique health needs, describes the nature of the illness in an online social forum for nurses. Neither the client's real name nor any other personal identifiers are used. What, if any, consequence could result from posting this information online? There won't be any consequences because the information was posted on a website for nursing professionals The nurse could be reprimanded for not clearing the information first with hospital administration There won't be any consequences because the client's real name was not used The nurse could be fired for breach of confidentiality
The nurse could be fired for breach of confidentiality Correct! Many health care facilities have adopted a social media policy; it is important to understand that nurses can be fired for posting personal information about clients online, because this is an invasion of privacy. In addition to being a HIPAA violation, the Health Information Technology for Economic and Clinical Health Act (HITECH Act) gives states attorneys the right to pursue violations of patient privacy. Audio icon Want a more detailed rationale? Listen to the Learning Extension's Question Dissection® podcast. Can't listen? Read the full transcript.
While working a 12-hour night shift, the nurse has a "near miss" and catches an error before administering a new medication to the client. Which factors could have contributed to the near miss? (Select all that apply.)
The nurse is assigned more clients than usual due to staffing issues Correct Response The nurse has worked four 12-hour night shifts in a row Correct Response The nurse works in the intensive care unit (ICU) Correct Response The nurse was interrupted when preparing the medication Correct! There are a number of reasons for near misses and making medication errors, including heavy workload and inadequate staffing, distractions, interruptions and inexperience. Fatigue and sleep loss are also factors, especially for nurses working in units with high acuity clients such as the ICU.
When performing moderate sedation at the bedside
The nurse takes the role of anesthesist Nurse monitors the client while the HCP focus in performing the procedure. Never leave the cleint during the procedure If another client is need you should tell the charge nurse to help
betablockers are for
prevention of angina
During a discussion with the nurse manager, a staff nurse confides that she is attracted to a client regularly assigned to her. Which of the following actions should be implemented following this discussion? The nurse reassigns all personal care of the client to the nursing assistant The nurse waits until after discharge to tell the client about her feelings The nurse continues to provide care for the client The nurse transfers the care of the client to another nurse
The nurse transfers the care of the client to another nurse Correct! Nurses must practice in a manner consistent with professional standards and be knowledgeable about professional boundaries. A nurse's challenge is to be aware of feelings and to always act in the best interest of the client, avoiding inappropriate involvement. In this case, the nurse did all the right things - aware of her feelings, she consulted with her supervisor and together they decided it would be best if this client were no longer assigned to this nurse. If the nurse had acted on her feelings, this would have been a boundary violation and she could have been subject to board of nursing disciplinary action. Want a more detailed rationale? Listen to the Learning Extension's Question Dissection® podcast. Can't listen? Read the full transcript.
The nurse is preparing to enter a disaster scene to assist with triaging victims. What assessment priorities should the nurse adhere to? (Select all that apply.)
The nurse will assess clients by considering their airway, breathing, circulation and neurological function. Correct! The nurse will allocate resources to those victims with the strongest probability of survival. Correct Response The goal of disaster triage is to use resources for clients with the strongest probability of survival. Age is not a consideration when allocating treatment resources and the nurse does not need to consult a physician prior to making decisions about allocating resources. Furthermore, a nurse does not need special training to assist in a disaster. However, there are certifications available for nurses who are interested. Finally, the nurse will make decisions based on a client's airway, breathing, circulation and neurological function.
When is a urinary catheter is contraidicated
The use of a urethral catheter is contraindicated in the treatment of urge incontinence. Other problems associated with indwelling urethral catheters include encrustation of the catheter, bladder spasms resulting in urinary leakage, hematuria, and urethritis. More severe complications include formation of bladder stones, development of periurethral abscess, renal damage, and urethral erosion.
A nurse is caring for a group of clients and is considering the risk of infection for each. Place the client conditions in rank order from the highest to least potential for infection.
Thermal burns covering 30% of body surface area (BSA) 2 days ago Total hip prosthetic device placement 3 days ago Laparoscopic exploration of right knee 2 days ago Indwelling foley catheter inserted the previous day The client with the greatest risk of infection would be the client with thermal burns covering 30% of the BSA. Burns are considered contaminated wounds. Normally, skin provides a natural barrier against invasive microorganisms. However, with this major burn injury, the client is predisposed to infection as a result of the loss of skin integrity. Additional factors that will place this client at higher risk for infection include the development of eschar, which bacteria loves to live in, and the fact that thermal injuries alter the body's natural immunity. So, are the clients with the other conditions at risk for infection? Well, they could be, but the risk is not as great. Let's consider why the risk is less. The client with the total hip arthroplasty (replacement of the damaged hip with a prosthetic device implanted) would be the next highest in ranking for risk of infection. This client has a relatively large surgical incision and a prosthetic device that infection, when present, tends to migrate to the area. But, this type surgery is performed using sterile technique in sterile environments to minimize the risk of infection. In addition, any dressing changes should be performed using sterile technique. The next client at risk of infection would be the client with the laparoscopic exploration of the right knee. Again, there is surgical perforation of the skin. However, these are smaller puncture sites that are created under sterile conditions, and when cared for appropriately, do not carry a high risk for infection. Finally, the client who has the indwelling foley catheter is the least at risk for infection. The catheter is a portal of entry into the body, but if inserted using sterile technique and proper catheter care is provided, the risk of infection can be kept to a minimum. The longer the foley catheter remains in place, the risk of infection will increase. When considering which client condition would be at greatest risk for infection, you must consider the pathophysiological alterations that are occurring with each situation. The client with the highest infection risk potential is the client with the thermal burns covering 30% of the total BSA. One of the most potentially serious complications that can occur following a burn injury is a burn wound infection. With the thermal burn injuries, loss of the skin barrier occurs, resulting in a compromised state that allows a direct path of entry for microorganisms. In addition, major thermal burn injuries create a state of immunosuppression that also places the client at a higher risk of developing an infection. Another factor that will place this client at higher risk for infection includes the development of eschar, which is an environment that bacteria loves to live in. The client with the total hip arthroplasty would be the next highest in ranking for risk of infection. This client has a relatively large surgical incision and a prosthetic device that infection, when present, tends to migrate to. Clients who are older, in poor nutritional states, are immunocompromised, or have other illnesses that increase the risk of general infections are more prone to developing an infection after a hip arthroplasty. If an infection develops, it could require that surgery be performed to remove the prosthetic device. However, the total hip arthroplasty is performed using sterile technique in sterile environments to minimize the risk of infection. In addition, any dressing changes should be performed using sterile technique to reduce the risk of infection. The next client at risk of infection would be the client with the laparoscopic exploration of the right knee. Although this involves surgical perforation of the skin, a prosthetic device is not implanted. This surgery is accomplished using smaller puncture sites that are created under sterile conditions, and when cared for appropriately, do not carry a high risk for infection. Finally, the client who has the indwelling foley catheter that was inserted the previous day is the least at risk for infection. The catheter is a portal of entry into the body and should be removed as soon as feasible. Catheters should be inserted using sterile technique and proper catheter care should be provided while the catheter remains in place. By carrying out these practices, the risk of infection can be kept to a minimum. However, the longer the foley catheter remains in place, the risk of infection will increase.
broad opening
These statements encourage the patient to further discuss a given topic Ex: "and after that" "you were saying" "What are you contemplating now"
over heating a baby side effects
They feel warm to the touch. Your baby's skin is red. They have a rapid heartbeat. They have a fever but aren't sweating. Your baby is lethargic or unresponsive. Your baby is vomiting. Your baby seems dizzy or confused.
Communication with patients affected with alzheiner's disease
They might have trouble word finding,understading,focus and frustration. Provide a quiet nondistracting environment use clear and simple explanation
The premature infant is recently diagnosed with respiratory distress syndrome. What is the infant's greatest need at this time? High-protein enteral feedings Protective isolation Holding and cuddling Time to develop surfactant in the lungs
Time to develop surfactant in the lungs Correct! Respiratory distress syndrome is primarily a disease related to inadequate lung development and is most common when infants are born prematurely, before fetal surfactant production has started. Surfactant coats the alveolar lining, reducing alveolar surface tension which prevents the alveoli from collapsing. The infant needs time to develop so that surfactant production can begin. Surfactant replacement therapy can also be used to prevent or treat this problem. Protective isolation is standard practice when caring for premature infants who have underdeveloped immune systems. Nutrition with high protein is important as well. However, neither is as important as the infant's need for time to produce surfactant. Holding and cuddling is more of a psychosocial need that should be secondary to the physiological needs.
implement
To put into action; execute
The client is diagnosed with active tuberculosis (TB) and the case has been reported to the local health department. The nurse understands that the most important reason for notifying the health department is:
To trace and screen recent contacts the client had Active tuberculosis is a reportable disease because people who had contact with the client must be traced, evaluated for the disease and possibly treated prophylactically. Statistics are kept and trends documented, but that is not the primary or most important reason for required reporting.
Benstropine
Treatement for Parkinson disease Antichollinergi medication liek benstropin,trihexyphenidylare common tretatements for tremors However this medications can lead to acute glaucoma (es[ecially in the setting of prostatic hyperplesia)../
An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce radiation exposure to others, which information should the nurse reinforce?
Urine and saliva will be radioactive for 24 hours after ingestion. The client's urine and saliva will be radioactive for 24 hours after ingestion. The nurse should teach or reinforce teaching to double flush the commode after use, use disposable utensils and avoid close contact with children and pregnant women for seven days after therapy. Because the treatment may cause nausea, it is best that the client does not eat two hours before or after iodine administration. It is not necessary to wash laundry separately or in hot water.
The nurse is planning care for a client who is receiving radiation therapy for breast cancer. The client has a nursing diagnosis of risk for impaired skin integrity. Which of the following interventions should the nurse include in the client's plan of care?
Use a mild soap and tepid water to clean the affected area. Correct! Submit Radiation can lead to skin changes or skin reactions in the treatment area. Skin changes are commonly seen between the gluteal folds, perineum, collar line and breast. The goal of skin care is to prevent skin breakdown and infection. Clients should be instructed to avoid wearing tight-fitting bras or belts over the treatment areas. During treatment, clients should avoid exposing their treatment areas to direct sunlight, and should also avoid swimming in saltwater and chlorinated pools. Clients should also avoid exposing their treatment area to extremes in temperature (hot or cold). To keep the affected area clean, use a mild soap and tepid water. Correct!
A client is admitted to the emergency department during an acute asthma attack. Which finding would be most important to monitor and report to the registered nurse (RN)?
Use of accessory respiratory muscles Correct Response In asthma, inflammation of the airways cause the muscles surrounding the airways to become tight and the lining of the air passages swells. Either wheezing or a cough may be the main symptom. Use of accessory muscles of breathing would be most important as an indicator of severe respiratory distress. Note that all of the findings are associated with an acute asthma attack, but accessory muscle use is a priority because it means that air is having difficulty getting into the smaller airways inside the lungs.
Which nursing practice best reduces the chance of communication errors that might otherwise lead to negative client outcomes? Use standardized forms for client handoffs Speak using a professional tone on the telephone Maintain respectful working relationships with all staff Document nursing care at the end of the shift
Use standardized forms for client handoffs Correct Response Standardized forms improve information for communication between caregivers. Most problems/poor outcomes involve some element of poor communication. The options of keeping good working relationships and using a professional tone of voice on the phone is good practice but not as useful for minimizing the chance of errors. Documenting at the end of the shift is incorrect practice and may lead to poor communication, as critical findings may be forgotten and not recorded.
Pavlik harness
Used for childern with hip dysplasia, its a abduction harness that sometimes its worn for 23 hours a day even when you shower - Needs to be adjusted by doctor ever 1-2 weeks - Harness may be wron for 3-5 months - Baby wears knee socks to prevent skin break down
Focusing
Using statements to encourage exploration of a particular topic to : I think we should talk more about the pain you have
A client has had a total gastrectomy for stomach cancer. Which vitamin deficiency should a nurse anticipate and discuss with the client while reinforcing prior teaching? Vitamin A Vitamin C Vitamin K Vitamin B12
Vitamin B12 Clients who have had all or part of their stomachs removed lose intrinsic factor, which is responsible for the absorption of vitamin B12 into the body. This results in B12 deficiency and anemia. A monthly injection (IM or SC) of this vitamin will be needed for the remainder of the client's life. Deficiencies of vitamins C, K and A are not associated with gastrectomy or bariatric surgery. This is a specific question and requires a specific answer; only the correct option designates a specific "B" vitamin, whereas the other options are general.
inflammation of the thyroid gland
thyroiditis
When taking the client's blood pressure (BP), the nurse cannot hear the sounds through the stethoscope. Which action should the nurse take first? Check to see if the artery can be palpated in that arm Retake the BP in the same arm, using an electronic BP monitor Wait two minutes and retake the BP in the same arm Retake the BP again immediately in the same arm
Wait two minutes and retake the BP in the same arm Correct Response It is best to wait two minutes between readings of a BP in the same arm to allow the vessels to recover from being squeezed. The electronic cuff would also require a two-minute wait and it may not provide a reading for a very low pressure. The nurse should have palpated the brachial artery first, before applying the cuff.
Vitamin K antidote for
Warfarin related bleeding
The 4-year-old child is newly diagnosed with hepatitis A. Which instructions should the nurse reinforce with the child's parents?
Wash hands thoroughly with soap and warm water after contact with the child. Correct! The hepatitis A virus spreads through contaminated food or water, as well as unsanitary conditions in childcare facilities or schools. The infection resolves spontaneously and symptom relief is usually the only treatment. The child does not have to be confined to bed and they can safely return to daycare or school one week after symptoms begin. In children under 6-years-old, who represent approximately 1/3 of all cases of hepatitis A, the disease may be asymptomatic and jaundice is rarely evident.
Health care associated urinary tract infection
Wash hands throughly and regularly Perform routine perineal hygene with soap and water at each shift and afyer bowel movements. Keep drainage system off the floor or contaminated surfaces. Keep the catheter bag below the level of the bladder. Ensure each client has a separated,clean container to empty collection bag and measure urine. Use sterile technique when collecting a specimen. Facilitate. Facilitate urine drainage from tube to bag to prevent pooling of urine in the tube otr backflow into the bladder. Avoid prolonged kinking,clamping or obstruction tubing. Encourageoral fluid intake if not contraindicated. Secure the catheter (velcro or tape) Inspect the catheter or and tubing for integrity ,secure the connections,and possible kinks.
A nurse is reinforcing discharge instructions with a client diagnosed with asthma. The client is allergic to house dust mites, which makes the asthma worse. Which instruction would be the most helpful suggestion to help control the asthma? Wash pillow covers every month Change the bed linens every two weeks Wash bed linens in warm water with a cold rinse Wash the bed linens in hot water weekly
Wash the bed linens in hot water weekly Correct! For asthma clients who are allergic to house dust mites, washing the bed linens frequently is an important method of preventing asthma symptoms due to the environment. It is helpful to use mattress and pillow covers that are allergen-impermeable. All bed linens (sheets and blankets) should be washed in hot water weekly at temperatures above 130 F (54 C) to kill the dust mites. The key here is to narrow the options down to the two answers that are the most similar but dissimilar. In this case, it would be the two that both refer to washing bed linens. Then ask yourself which one is more likely to kill mites - cold, warm, or hot water?
A newly admitted client has a skin ulcer that tested positive for MRSA (methicillin-resistant Staphylococcus aureus). What precautions should the nurse take when caring for this client? (Select all that apply.)
Wear a mask while providing routine care to the client. Place the client in a private room. Correct! Place personal protective equipment (PPE) at the door to the room. Correct! Perform hand hygiene after contact with the client and before leaving the room. Correct! Keep the door to the room closed at all times. Incorrect Keep all equipment in the client's room for their sole use. Correct! Contact precautions are recommended in acute care settings for MRSA when there is a risk for transmission or wounds that cannot be contained by dressings. The client should be in a single room. All equipment, such as stethoscopes and blood pressure devices, should be for the client's sole use and kept in the room. Health care workers must perform hand hygiene (wash hands with soap and water) after direct contact with the client and their environment and before leaving the isolation room. Contact precautions require health care workers to wear PPE such as gloves and a gown, which should be readily available. It is not required to keep the door closed at all times.
3 point gait
Weight is distributed on both crutches and then on the *unaffected* leg -- then repeat sequence
A client has been told about their cancer has metastasized, the client begings to cry, what should you respond?
You seemed upset , may I sit with you for a while.
During a panic attack,
a client may experience symptoms of dizziness, shortness of breath, and feelings of suffocation. The nurse should remain with the client and direct any statements toward changing the physiologic response, such as taking deep breaths. During an attack, the client is unable to talk about anxious situations and isn't able to address feelings and frustrations.
for a child with hemoplillia and joint discomfort
acetaminophen
a post operative patient is unresponsive to pain stimuli and is given naloxone.5 min later the patient is aroused and respond to verbally,An hour later the patient returns to initial state, what should you do?
administer oxygen administer second dose of naloxone monitor respiratory response
When adminsiter vaccines to a child with hemophilia
administer via subQ route Use small gauge needle Hold firm pressure on the site for 5 minutes Avoid procedures that can cause bleeding, like intramascular injections,rectal temperature measurement. Avoid aspirin Avoid NSAIDs Can take acetaminiphen
retinal photocoagulation
an intense beam of light from a laser condenses retinal tissue to seal leaking blood vessels, to destroy abnormal tissue or lesions, or to bond the retina to the back of the eye. Used to treat retinal tears and detachment, diabetic retinopathy, wet macular degeneration, glaucoma, and intraocular tumors intense beam of light from a laser condenses retinal tissue to seal leaking blood vessels, to destroy abnormal tissue or lesions, or to bond the retina to the back of the eye
Drugs associated with orthostatic hypotension:
antihypertensive/beta blockers-lol ending and alpha-blocker terazosin Antipsychotic medications, olanzapine, risperidone SSRIs diuretics validators( nitroglycerine, hydralazine) Narcotics, morphine
Standard precautions
are a set of infection control practices used to prevent the transmission of bloodborne and other pathogens from recognized and unrecognized sources. They are the basic level of infection control precautions that are used in the care of all clients.
Sentinel events
are shocking events that occur in health care, such as surgery on the wrong body site, mismatched blood transfusion, a client's suicide while hospitalized or foreign objects left in the client's body after an operation.
Physical Retraints
are used to immobiliozed or limit physical mobility or body movemnet to prevent fallls , injury to selft ir others, or removal of medical devices.
A nurse is assigned to a client with Parkinson's disease who is experiencing hallucinations. Which of these medications may have been a contributing factor?
carbidopa-levodopa (Sinemet) Correct Response It is unclear why, but some clients with Parkinson's disease eventually develop what is known as Parkinson's disease dementia. Common symptoms include hallucinations; delusions; changes in memory, concentration and thinking; trouble interpreting visual information; and irritability. Classic antiparkinson medications, such as carbidopa-levodopa and dopamine agonists, can inadvertently cause serious emotional and behavioral changes.
adverse effects of codeine(opioid) for moderate pain and supress cough
constipation nausea vomiting orthostaic hypotension dizziness
Nihilistic delusion
conviction that a major catastrophe will occur the individual has a false idea that the self, a part of the self, others, or the world is nonexistent False feeling that self, others or the world is nonexistent or coming to an end It does't matter if I take my medicine , I'm already dead
administering medications via entereal tubing(nasogastric, gastrostomy)
crush medications before determine if the medications are in liquid form flush the tubin before and after
Lithium toxicity occurs with:
dehydration decrease renal fucntion diet low in slodium drug interactions(NSAIDs and thiazide diuretics) ataxia tremor
POA
designates a representative to act on a person's behalf in the event thatvthe individual becomes incapacitated There are different POA , including medical and financial.
botilinum toxin A side effect
difficult swallowing and breathing constipation and urinary retention
Rhabdomyolysis
dissolution of striated muscle (caused by trauma, extreme exertion, or drug toxicity; in severe cases renal failure can result) Breakdown of muscle tissue that leads to the release muscle fiber contents into the blood.This substance can be harmful to the kidneys and often cause kidney damage.Report any signs of muscle achesor weakness to the health care provider, this could be early signs of rhabdomyolysis,which can be fatal.
Ace inhibitors decrease
excretion of aldosterone
sertraline
for generalized anxiety disorder SSRIs can cause sexual dysfunction
Pneumococcal pneumonia
form of pneumonia caused by the bacterial species Streptococcus pneumoniae Pneumococcal pneumonia is caused by bacteria that live in the upper respiratory tract, and can be spread through coughing. Common symptoms of pneumococcal pneumonia include high fever, excessive sweating and shaking chills, coughing, difficulty breathing, shortness of breath and chest pain.Apr 26, 2018 Active smoking increases the risk of developing community-acquired pneumonia (CAP) and invasive pneumococcal disease
What to reinforce in a patient that has lymphocytic leukemia who is at rsik for thrombocytopenia(low platelet count )
frequent breathing exerfise without coughing
UAP can change linens
from top to with assistance while client lift themselves using overhead trapeze, mataining immobilization of the injures extremity
Phenytoin(dilantin) side effects
gingival hyperplasia, visit dentist regularly folic acid supplement can reduce side effects
medication that can be given to a patient with atrial fibrilation
heparin and lisonopril
When a patient on lithium therapy for management of bipolar disorder had a low sodium lab
hold the next dose of lithium
clients with actual or suspected rabies exposure should receive rabies postexposure prophylaxis
immediate wound care,agressive scrubbing with povodine-iodine or soap and water Administration of tetanus toxoid vaccine if not current Administer huma rabies immunoglobin , provides passive immunity and is injected into the proximal wound area administration of human rabbies vaccine IM on the day of exposure and again days 3, 7, and 14
fall prevention for clients with memory impairment
increase lighting reduce glare limit shadows Use obvious contrast in colour to define objects from the background. Use solid colours with no pattern to decrease confusion. Avoid black surfaces, which may be misinterpreted as being a black hole declutter keep surfaces level, dry and non-slip Keep important items in consistent, visible, easy-to-reach places. Use a firm mattress. Lower bed height. Use adaptive equipment.
Cephalexin
is a cephalosporin should not be given to a pt who is allergic to penicillin
neonatal heelstick(heel lancing)
is used to collect a blood sample top assess capillary glucose and perform newborn screening for inherited disorders(eg;congenital hypothyroidsm,phenylketonuria)
grapefruit juice interaction
lipitor, viagra, ... calcium chanel blockers
ECT can treat
major depression bipolar disorder schizophrenia
oxytocin side effects on the baby
may cause serious or life-threatening side effects in the newborn baby, including: slow heartbeats or other abnormal heart rate; jaundice (a yellow appearance of the baby's skin); a seizure; eye problems; or problems with breathing, muscle tone, and other signs of health. Common side effects may include: nausea, vomiting; or more intense or more frequent contractions (this is an expected effect of oxytocin). Oxytocin is injected into a muscle, or given as an infusion into a vein. A healthcare provider will give you this injection. Your contractions and other vital signs will be watched closely while you are receiving oxytocin. This will help your doctor determine how long to treat you with this medicine. During labor, your baby's heart rate will also be watched with a fetal heart monitor to evaluate any effects of oxytocin on the baby.
site to perform heel stick
medial or lateral side of the outer aspect of the heel Warm the heel for several minutes Sucrose can be used to provide comfort.
Akathisia
motor restlessness
statin medications side effets
muscle cramps and liver injury
facial edma that develops with severe, long-term hypothyroidism; sometimes used as a synonym for hypothyroidism
myxedema
Vancomycin can cause?
nephrotoxicity Check Creatine
the nurse is caring for an adult client who is in soft restrains. What actions should be included in the care plan
offer fluids,nutrition, toiletting every 2 hr and as needed perform neurovascular checks of extremities every hr release restaints to perform ROM every 2 hr
end-stage renal disease (ESRD)
refers to the late stages of chronic renal failure in which there is irreversible loss of the function of both kidneys any type of kidney disease in which there is little or no remaining kidney function, requiring the patient to undergo dialysis or kidney transplant for survival
phenytoin toxicity
sedation, diplopia, gingival hyperplasia,slurred speech, hirsutism, peripheral neuropathy, nystagmus, megaloblastic anemia, teratogenic potential (cleft palate). Drug interactions via induction of hepatic metabolism. CYP450 INDUCER.
how should you place a pt after modified radical mastectomy who is admitted from postanesthesia unit
semifowlers with affected arm on pillows
commuicating with hearing impaired client
sit infront when talking and use a well lit room ask to repeat back the teaching or incstructions incorporate printed material and visuals
Orlistat (Xenical)(Ali)
take A,D,E and K vitamines take 2 hours > after taking orlistat
The nurse is collecting data from a client with Bell's palsy. Which of the following findings would the nurse expect to observe?
tearing on the affected side
The nurse is reinforcing education to the parents of a child who is schedule to receive hypospadias corrction surgery.What should be reinforced about the procedure will include? -relieve from pain -relieve from bladder obstruction the ability to void while standing -the ability to achieve an erection
the ability to achieve an erection
UAP tasks for incontience
• Assist incontinent patient to commode or bedpan at regular intervals.• Clean patient and provide skin care.• Notify RN about new-onset incontinence in a previously continent patient.
UAP tasks for Corrective lenses and hearing aids
• Clean corrective lenses with ordered solutions.• Help patients with hearing aid placement.• Clean and replace batteries in hearing aids
