Adaptive Exam HARD (boardvitals)

100) Which client will most likely suffer from the stigma of psychiatric illness, as a function of their culture? A- A female client B- A male client C- A Hispanic male client D- A Hispanic female client

C- A HISPANIC MALE CLIENT *Culturally males have a "machismo" and are expected to be strong, filled with pride and protect. The LOSS of machismo, even through illness, leads to cultural stigma.

A nurse is caring for a client who requires rapid transfusion of multiple units of blood. Which of the following will reduce the risk of cardiac arrhythmia? A- Blood warmer B- Cardiac moniotor C- Infusion pump D- Pulse OX

A- BLOOD WARMER Rapid transfusion of refrigerated blood products can cause cardiac arrhytmias, so blood warmer should be used to reduce the client's risk when blood products must be rapidly infused. A blood warmer should be used when transfusing large volumes of blood

104) A school nurse is providing teaching to a guardian whose school-aged child has pediculosis capitis. Which of the following indicates and understanding? A- I should seal nonwashable items in a airtight plastic bags B- My child must be free of nits before returning to school C- I will treat all members of our family D- Bedding, clothing and towels should be soaked in cold water

A- I SHOULD SEAL NON WASHABLE ITEMS IN A AIRTIGHT PLASTIC BAG -For at least 14 days to kill any lice Rationale: B- the child can return to school after the initial TX C- Only members that have lice should be treated D- Use hot water to wash Nonwashable- (helmet, pillow, stuffed animals) Combs, brushes and hair accessories (barrettes) should be soaked for one hour with an over the counter pediculicide to kill lice.

120) RN is caring for a client with cardiovascular insufficiency. Blood flow and contractility of the heart are greatly effected. Which valves close during early diastole? -Aortic Valve -Pulmonary Valve

Cardiac cycle is composed of 5 stages: 1) early diastole: semilunar valves (pulmonary and aortic valve) close while the atrioventricular valves (tricuspid and mitral) open. 2) atrial systole: atrium contracts and blood flows from the atrium to the ventriculus. 3) isovolumic contraction- ventricles begin to contract and all the valves close. 4) ventricular ejection: ventricles are contracting and semilunar valves are open 5) isovolumic relaxation: pressure dec while no blood enter the ventricles, making the semilunar valves close due to the pressure of blood in the aorta.

A pregnant client in the 3rd trimester calls the OB office and reports to the nurse that she has had several headaches for the past 2 days. Which nursing actions is most appropriate? 1. Ask the client is having cold/flu symptoms 2. advice the client to eliminate coffee and other sources of caffeine 3. Instruct the client to take two aspirins and lie down for a hour 4. Request the client come to the office immediately

4: REQUST THAT THE CLIENT COME TO THE OFFICE IMMEDIATLY --- A persistent heachache may be due to pregnancy induced hypertension (PIH)

A RN is caring for four clients. The nurse should identify that which of the following clients is at risk for developing a dysrhythmias? SATA A- A client with metabolic alkalosis B- A client who has a total serum calcium level of 9.5 mg/dL C- A client who has an SaO2 of 96% D- A client who has COPD E- A client who had a stent placement in coronary artery

A- A CLIENT WITH METABOLIC ALKALOSIS Acid- base imbalance, such as metabolic alkalosis @ r/f dyrhythimias= atrial tachycardia D- A CLIENT WITH COPD lung disease at r/f dysrhythmia= tachycardia due to hypoxia E- A CLIENT WHO HAD A STENT PLACEMENT IN A CORONARY ARTERY cardiac disease and underwent a stent places at risk=ventricular tachycardia due to irritation of heart muscle *****Monitor clients for conditions that can precipice dysrhythmias such as hypoxia, fluid/electrolyte imbalances, certain medications, heart disease or caffeine intake*****

Which of the following measures should be implemented during promptly after a clients NG tube has been removed? A- Provide the client with oral hygeine B- Offer the client liquids to drink C- Encourage the client to cough and deep breathe D- Auscultate the clients bowel sounds

A- PROVIDE THE CLIENT WITH ORAL HYGIENE The first action is to provide mouth care. Then, if apporpriate and no longer on oral restrictions, oral liquids should be allowed.

RN is assessing a client with intestinal obstruction. Which lab tests will be recommended? SATA A- Serum amylase B- ABG C- Electrolyte D- WBC E- Intrinsic factor test F- Serum osmolality test G- Pepsin

A- SERUM AMYLASE B- ABG C- ELECTROLYTE D- WBC F- SERUM OSMOLALITY TEST Intestinal obstruction is a condition that arises when there is a failure of the intestinal contents to move through the lumen of the intestines. Can be mechanical or functional.. Tumors and inflammatory bowel conditions= mechanical Neurological impairment paralytic ileus is a= functional Amylase becomes increased when there is a strangulation in the intestines ABG, to detect metabolic alkalosis Electrolyte (K and Na, Ch lost through vomiting) WBC to detect leukocytosis Serum osmolality to determine the occurrence of fluid sequestration in the intestines

When drawing an arterial blood gas from the radial artery, why should a nurse perform the Allen test? A- To determine the patency of the ulnar artery B- To identify any neurological deficits C- To determine if the radial artery is patent D- To document cap refill E- To document an adequate pulse

A- TO DETERMINE PATENCY OF THE ULNAR ARTERY Radial artery and ulnar artery contributre to the blood supply to the hand. Beofre drawing, the RN must establish that the hand has good collateral blood supply from the ulnar artery

Which of the following is addressed by the Patient self-determination Act? A- Whether the client has an advanced directive B- the clients right to confidentially of medical records C- Whether the client is able to pay for health care services D- Clients rights to access all areas of the facility

A- WHETHER THE CLIENT HAS AN ADVANCED DIRECTIVE PSDA (patient self-determinitation act) supports the clients decision to care for himself and to decide who will make decisions for him if he is unable to do so Passed into law in 1990 requires hospitals to provide information about advance health care directives to individuals upon their admission to the healthcare facility.

Multiple clients at a community health care facility. Which of the following is a client experiencing an adventitious crisis? A- Workplace violence B- Youngest child starting school C- Severe physical illness D- Job loss

A- WORKPLAVE VIOLENCE Example of an adventitious crisis. (It is not a part of everyday life) Rationale: B- maturational crisis (naturally occuring event during the life) C- situational crisis, (unexpected events) ex- death, loss D- Situational

A RN is caring for a adolescent who has muscular dystrophy and is taking corticosteroids. Which of the following statements should the nurse include? SATA A- Corticosteroids assist in controlling weight gain B- Corticosteroids help to preserve respiratory functioning C- Corticosteroids slow the progression of muscle weakness D- Corticosteroids increase muscle bulk and power E- Corticosteroid's dec the incident of scoliosis

B- CORTICOSTEROIDS HELP TO PRESEVE RESP FUNCTION Encourage to participate in pulmonanry exercises C- CORTICOSTERIODS SLOW THE PROGRESSION OF MUSCLE WEAKNESS prolonged, 6 months-2 years has been shown to delay progression D- CORTICOSTERIODS INCREASE MUSCLE BULK AND POWER leads to increase in muscle strength E- CORTICOSTERIODS DEC THE INCIDENCE OF SCOLIOSIS Side effects of steroid use: Cushingoid facial appearance (increased facial hair) Changes in skin (thinner, easily torn, weight) Fat deposits in back, mood swings, Elevated BP & BS Weigh gain may be a side effect of steroid therapy Important to review side effects of the meds so parents and children can anticipate changes and monitor for side effects

A RN is caring for a client who is at 17 weeks gestation and has a new diagnosis of molar pregnancy. Which of the following manifestations should the nurse RN expect. A- Severe abdominal tenderness B- Dark brown vaginal discharge C- Elevated blood sugar D- Fundal height measurement less than gestational age

B- DARK BROWN VAGINAL DISCHARGE -A client who has a molar pregnancy has dark red or brown vaginal bleeding because there is no placenta to receive maternal blood. The blood collects in the uterus and eventually manifests as abnormal bleeding. Rationale: A- A client with ectopic preg or abruptio placentae reports severe abdominal tenderness/pain B- Elevated BS is associated with gestational diabetes D- Molar pregnancy present with a LARGER fundal height than anticipated for gestational age. A molar pregnancy, is a benign excessive growth of the trophoblasts during early fetal development. Pregnancy is NONVIABLE

According to the American academy of pediatrics, which of the following development health screening should be performed on the 24-month-old child? SATA A- Weight for length B- BMI C- Head circumference D- Autism screening E- Behavioral assessment

B= BMI C- HEAD CIRCUMFERENCE D- AUTISM SCREENING E- BEHAVIORAL SCREENING Developmental screening is an important part of the comprehensive health appraisal of a child. -Tools that are used to provide reliable and objective markers of developmental functions include the Denver Developmental Screening Test and the Denver II + By 24 month, a child support should have a well-child exam including several components to check the child's developmental health: Weight and BMI, measurement of head circumference, screening for autism and behavioral assessment

A RN is caring for a client, with new prescription for metronidazole (Flagyl) for amoebic dysentery. Which of the following is an adverse SE that client should report: A- Joint pain B- Diarrhea C- Rash D- Excessive sweating

C- RASH Metronidazole can cause negative SE. Notify MD if rash occurs as Stevens Johnson syndrome may occur with this med Other SE: dizziness, headache, aseptic meningitis (IV), encephalopathy (IV), optic neuropathy, abdominal pain, anorexia, nausea, diarrhea, dry mouth, furry tongue, glossitis, unpleasant taste burning and mild dryness of the skin Teach: client to avoid alcoholic beverages for at least 3 days after TX (including vaginal gel= causes a disulfiram (Antabuse) like reaction)

A nurse is caring for a client who has 3 mail-in occult blood tests. Which of the following should the nurse relay to the client? A- No dietary changes are needed B- The bowel test will determine if microorganisms are in the GI tract C- This is a screening for colon cancer D- Client with continue to take warfarin during the test

C- THIS IS A SCREENING FOR COLON CANCER used to identify microscopic amounts of blood in the stool. Screening test for colon cancer. (it is not specific, so colonoscopy is also necessary) Rationale: A- Avoid red meat, poultry and fish (can interfere with test) B- test only determines whether blood is present D- Anticoagulants may interfere with the test

A nurse is reviewing snake bite management with a group of parents. Which of the following information should the nurse include in the teaching? A- Apply ice as soon as possible after the bite occurs B- Attempt to orally suck out the venom C- Wash the bite area with soap and water D- Perform passive ROM to facilitate circulation

C- WASH THE BITE AREA WITH SOAP AND WATER Managment of a snake bite: Clean the area with soap and water, cover with a clean dressing, immbolize the area, keep the child calm, place in a reclined position, remove restrictive clothing, arrange for immediate transport to a medical facility

A nurse is caring for a client who is undergoing peritoneal dialysis. The nurse understands that which of the following is most reliable indication of the efficacy of peritoneal dialysis? A- Dec BP B- Hematemesis C- Weight loss D- Dec urine output

C- WEIGHT LOSS Purpose of peritoneal dialysis is to remove excess fluid and waste that cannot be excreted by the kidneys. The best indicator that TX is successful is weight loss

A nurse is receiving lab data for 4 clients. Which of the following requires immediate intervention? A- a client with acute lymphocytic leukemia who has white blood cell count off 4,000 B- A client with DVT who has PT of 50 (control 12) C- Hypertension and diabetes whose trig is 320 D- Peptic ulcer disease and a GI bleed, hemoglobin of 10 and a hematocrit of 30%

B- A CLIENT WITH DVT WHO HAS PT OF 50 (CONTROL 12) PT is 4x the control. the theraputic level is 1.5-2x the control. The higher level places the client at increased risk of bleeding, a potentially life-threatening problem. This is the PRIORITY

Which of the following is a late sign of hypoxemia? SATA A- Elevated BP B- Confusion C- Tachycardia D- Cardiac dysrhythmias E- Flushed skin

B- CONFUSION -not getting enough oxygen to brain tissue D- CARDIAC DYS -low levels of oxygen in the blood and tissues (hypoxemia) resulting to a switch to anaerobic metabolism (results in acidosis) Rationale: A- late hypoxemia will have LOW BP C- Late hypoxemia- Brady ------Early hypoxemia- Tachy E- Cyanosis, not flushed skin Early signs- tachy, HTN, pale skin, restlessness, signs of resp depression Late signs- confusion, stupor, cyanosis, brady, hypotension and cardiac dysrhythmias

125) Charge nurse is discussing medications used during the care of a client with GI bleeding. Which medication should she include in the teaching? A- Protamine sulfate B- Vasopressin C- Oxytocin D- Vitamin K

B- VASOPRESSIN Man-made form of ADH hormone that works on kidneys and blood vessels to stop GI bleeding as a result of gastric varices **Vasopressin is an analog of antidiuretic hormone used to TX DI and hemorrhagic shock unresponsive to other vasopressors Works in GI bleeding by constricting the arterioles and reducing inflow to the portal vein. Also causes contraction of smooth muscles in the GI tract Rationale: A- Protamine sulfate- antidote used to reduce the anticoagulant effects of heparin C- Oxytocin is used to stimulate uterine contractions (induction of labor) D- Vit K is used to reverse the anticoag effects of warfarin

92) A nurse is assessing a client who has autism spectrum disorder. Which of the following findings should the nurse expect? A- Preoccupation of thoughts B- Associative looseness C- Echolalia D- Magical thinking

C- ECHOLALIA fundamental sign of autism and is manifestoed as thought patterns that are NOT based on reality. Rationale: A- indication of schizophrenia, manifested as inappropriate emotional reactions B- Schizophrenia, (disorganized thoughts and speech patterns) D- schizophrenia (believes their behaviors or thoughts control certain situations or people) ** Also expect to find: repetitive motor movements or speech, inflexibility to change in routine and might experience extreme distress when change occurs.

An eight year old has swallowed twelve 325 mg tabs of acetaminophen (Tylenol). The mother brings the alert child to the ED. Prioritize the nursing interventions 1- ensure a patent airway 2- prepare to administer activated charcoal 3- Complete a history of the event and phyiscal exam 4- Check the blood acetaminophen levels

#1- ensure safety of client! (patent airway) Activated charcoal will help bind the Tylenol to prevent absorption. Lab testing for acetaminophen happens at 4 hours after ingestion. Also determines how much of the med was absorbed prior to TX -Toxicity can cause acute liver failure in children and adolescents. Max dose is 4g/day in adult -90mg/kg/day in children Diagnosis of actemiphen toxicity is usually conferment with acetaminophen level Supportive care: IV fluids and anti-nausea med ****Activated charcoal should be administered within one hour of the ingestion!***** The antidote N-acetylcysteine (Acetadote/Mucomyst) should begin within eight hours of ingestion

RN is teaching a adolescent who has DM about manifestations of hyperglycemia. Which should she include? SATA A- Increased urination B- Hunger C- Dark-yellow colored urine D- Kussmaul respirations E- Sweating and pallor

A- INC URINATION -polyuria B-HUNGER -polyphagia C- DARK COLORED URINE -sign of dehydration (severe complication) Rationale: D- Kussmaul are manifestations of acidosis, DKA NOT just hyperglycemia. E- Sweating and pallor are hypoglycemia. S/S of dehydration: Thirst, Headache, Dry mouth/eyes, Dizziness, Tiredness, Dark colored urine

143) RN in ED completing a admission assessment for client with gunshot wound to the head. Which findings are indicative of increased ICP? SATA A- Vomiting B- Dilated pupils C- Tachycardia D- Decorticate posturing E- Hypotension

A- VOMITING -often projectile B-DILATED PUPILS -often non-reactive D- DECORTICATE POSTURING -or decerebrate Rationale: C- BRADY not tachy E- HYPERtension, not hypo (Cushing triad- widened pulse pressure, bradycardia and irregular RR) Priority- ABC use Glasgow Coma Scale (lower the rating the worse) ---any dec of 2 or more needs to be reported!

A RN is developing plan of care for a client with cervical cancer, scheduled for brachytherapy. Which actions should the nurse include? SATA A- Allow visitors to stay with client for 30 min intervals B- Place the client on bed rest C- Insert an indwelling cath D- Administer a suppository to prevent constipation E- Dispose soiled linens in hamper outside of room

ABC - A client who has cervical cancer can have a vaginal radiation implant. *Visitors should not stay longer than 30 min at a time. *Place on bed rest to prevent displacement of implant *Indwelling urinary cath to prevent displacement of radiation during ambulation Others: avoiding medications that promote bowel movements (suppository), keep a 6-foot distance from client, linens go in METAL container in clients room

145) RN is teaching client with epigastric pain that is suspected to be a result of peptic ulcer disease about the urea breath test for H. pylori in the morning. Which of the following should be included in the RN's education to prepare the client? A- High-fat meal morning of the test B- NPO from midnight before the test C- No bismuth salicylate (Pepto) before the test D- Clear liquids only until the test

B-NPO FROM MIDNIGHT BEFORE THE TEST ----requires only that the client be NPO after midnight. **Test performed by having the client ingest a carbon-enriched urea solution tagged with a radioisotope. Bacteria convert urea to ammonia and carbon dioxide, & the presence of radiolabeled carbon dioxide indicate presence of H. pylori H. Pylori is a frequent cause of peptic ulcer disease If H. pylori is present the TX will include a combination of two antibiotics & a proton pump inhibitor Rationale: A- NPO after midnight B- Pepto interferes with stool antigen testing for H. pylori- NOT with urea breath test. **Proton pump inhibitors interfere with urea breath test and may result in a false-negative** D- NPO after midnight

A nurse is caring for a 10-year old child who has acute poststeptoccocal glomerulonephritis (APSGN). What should the nurse report to the provider? A- Serum BUN 8mg/dL B- Serum creatinine 1.3 mg/dL C- 1+ edema to the genitalia D- Urine output 550 mL in 24 hours

B-Serum creatinine 1.3 mg/dL The edema of the glomeruli results in elevated BUN and creatinine levels; however a child is at increased risk for development of renal failure. Normal (0.4-1.0 for a 10 year old) Acute poststeptococcal glomerulonephritis (APSGN) is an immune-complex disease that occurs following a step infection. Period of latency ranging from 1-4 weeks from the time of the initial infection to the appearance of APSGN manifestations. Children who develop edema, anorexia, pallor and the presence of cola- or tea colored urine should be evaluated Nursing interventions: weighing the child daily, monitoring intake and output, establishing fluid, sodium and potentially potassium restrictions, monitor vitals every 4 hours

108) A nurse is assessing a client with jaundice who has clay-colored stool. Which of the most likely cause of these findings? A- Increased cholecystokinin production B- Inc production of bile C- Dec flow of bile into the intestine D- Inc breakdown of hemoglobin

C- DEC FLOW OF BILE INTO THE INTESTINE **Jaundice is caused by a increased level of bilirubin. -Bilirubin is a brown/yellow substance made in the liver from the breakdown of RBC's (((since is gives feces the brown color, clay colored stool with jaundice suggests obstruction of biliary tree)))) Clay-colored stool indicates obstruction of the bile ducts. Rationale: A- Cholecystokinin is a pancreatic digestive enzyme that causes the release of bile from the gallbladder B- Clay-colored stool occur from dec flow of bile into the intestine. Production inc would NOT affect the color of stool D- Inc breakdown of hemoglobin can result in jaundice but would not affect the color of stool

137) A RN in ED is reviewing ED protocol. The nurse identifies asystole on a client ECG monitor. Which of the following actions should the nurse take? A- Perform defibrillation B- Prepare for transcutaneous pacing C- Administer IV Epinephrine D- Place client in modified Trendelenburg

C- ADMINISTER IV EPI **Epi during asystole improves perfusion and myocardial contractility, inc HR and BP CPR IMM & WHILE MED IS BEING ADMIN!!!!! Client will have no palpable pulse or BP. Client looses consciousness and respirations. #1- CPR #2- Epi

A RN is assessing a client with anemia due to folic acid deficiency. Which of the following may have caused the clients condition? SATA A- Dementia B- Gastric Ulcer C- Crohns D- Methotrexate E- Aspirin

C- CROHNS D- METHOTREXATE Folic acid/ folate known as vitamin B9. Involved in the synthesis of adenosine, guanine, and thymine components of DNA Causes MEGALOBLASTIC anemia. ( large, abnormal red blood cells) Symptom: anorexia, weight loss, weakness, sore tongue, headache, palpations, irritability000 and behavioral disorders Causes of folic deficiency: heavy alcohol, smoking, intake of medications such as metformin & methotrexate. GI disorders (Crohns & celiac) Dialysis, hemorrhage, and hemolytic anemia (prevents utilization of folate) TX: involves supplementation

Normal Hemodynamic measurements

CVP- 1-8 mmHg Pulmonary artery wedge pressure- 4-12 Pulmonary artery diastolic - 5-15 Pulmonary artery systolic pressure- 15-26

Nurse manager implementing a procedural change using Lewin's stages of change theory. Which action should the nurse manager plan to take during the MOVING stage of change? A- Identify the problem B- Inform the charge nurses that a change to establish procedures is needed C- Require the charge nurses to comply with the new procedures D- Set target date for the implement of the new procedure

D- SET TARGET DATE FOR IMPLEMENT OF THE NEW PROCEDURE 2nd stage of Lewin's change theory is the moving stage. During the moving stage, the nurse manager should develop the plan for change and set the target date +task associated: -develop a plan for introducing (including goals, objectives and strategies) -Include all team members who will be affected -identify those who support the change and those that are resistant -set a target date -implement the strategies -offer support and encouragement THREE STAGES: 1st- Unfreezing (identify the problem, determine need for change then obtain buy-in from the members of the group) 2nd- Moving 3rd- Refreezing stage (focus on integration of the new procedures with the charge nurses)

A RN is preparing enteral feeding through a NG tube. For which purposed should the nurse measure gastric residual? A- To confirm placement B- To remove gastric acid that might cause dyspepsia C- To determine the clients risk for aspiration D- To identify delayed gastric emptying

D- TO IDENTIFY DELAYED GASTRIC EMPYTING -The RN should measure the amount of unabsorbed formula from the previous enteral feeing to identify delayed gastric emptying. *If it is delayed the nurse should avoid OVERFEEDING the client causing gastric distention Gastric residual is the amount of fluid, secretions and formula that remains in a clients stomach after the last intermittent eternal feeding, or the residual that is present every 4-6 hr. for client receiving continuous feeding. BEFORE withdrawing residual, the RN should flush the clients NG tube with 30mL of water to facilitate aspiration of fluid. -if it is difficult aspirating, the RN should try repositioning the client side/side.

A client with asthma is scheduled for TX with methylxanthine for nocturnal wheezing. Which of the following drugs are drugs that are appropriate for the treatment of this client? SATA A: Pirbuterol B: Salmeterol C: Fluticasone D: Theophylline E: Aminophylline

D- Theophylline E- Aminophylline Asthma, inflammatory condition causing airway obstruction. Produces symptoms such as wheezing, breathlessness, chest tightness and coughing. Allergic reaction to environmental conditions. Methylxanthines are used to prevent nocturnal asthma in adults clients and for control of airway obstruction in COPD

A nurse is positioning a client after a liver biopsy. Which of the following is the correct position?

Liver biopsy is done at the bedside. Clients with liver disease reduce production of vitamin K dependent clotting factors II, VII, X and XI with prolonged bleeding as a result. Vitamin K may be prescribed several days before Biopsy needles is inserted into the liver through the 7th intercostal space while the client is in supine position. Instruct client to Inhale and exhale deeply several times before holding the breath for approximately ten seconds Instruct the client to right-sided lying position after the position after the procedure (puts pressure on the site to prevent bleeding)

A client is in acute phase of RA. Which order or priority should the RN establish the following goals: 1- Preventing pain 2-Preventing joint deformity 3- Preserving joint function 4- Maintaining usual ways of accomplishing tasks

#1 focus on relieving pain Is important to note that acute conditions symptoms appear and change rapidly. Chronic conditions develop and worsen over and longer period of time. -Generally acute last 6 months -Chronic extends 6 months Other S/S to care for: sleep disturbance, altered mood, fatigue and limited mobility +Use scale of 0-10 (use a firm mattress/headboard instead of soft) *a warm bath/shower upon awakening can help relieve symptoms Characteristics (Knee)- bone erosion, swollen inflamed synovial fluid, cartilage wears away, reduced joint space

A RN on a med-surg unit is deciding which clients can be discharged to make beds available for injured clients following a mass-casualties event. Which client should be recommended? A- A young client who has Crohns scheduled for an ileostomy in 24 hr B- A adolescent who was admitted 24 hr ago for spontaneous pneumothorax C- A middle aged client who is 36 hr post op following an open laminectomy D- An older client who is admitted for acute pancreatitis

A- A YOUNG CLIENT WHO HAS CROHNS SCHEDULED FOR AN ILEOSTOMY IN 24 HR - A client who is scheduled for surgery in 24 hr and is MEDICALLY stable. Rationale: D- @ risk for serious complications **The role of a RN during mass casualty event recommends clients for discharge to make room for injured clients. Only recommend clients that are stable, (ambulatory, admitted for obs, or diag tests, near ready for discharge or can be transferred to another) Other responsibilities of the nurse include calling off-duty staff into work and reassigning staff to meet the needs of the high

Which type of data is the most useful for identification of patterns and trends when planning performance improvement activites? A- Aggregated data B- Critical incident report C- Formative data D- Summative data

A- AGGREGATED DATA Over time the most useful for performance improvement activites in terms of identifying patterns and trends. Data aggregation involves the gathering and collecting of data rather than looking at single peices of data. 4 steps of data management for healthcare performance improvement initiatives include collecting, tracking, analysis/ interpretation and acting on the data.

135) Select the chemotherapy agent that is accurately paired with its complication/SE. A- Alkylating therapy: Acute leukemia B- Antimetabolite therapy: Thrombosis C- Antitumor antibiotic: Neurogenic shock D- Mitotic inhibitor: Cardiac toxicity

A- ALKYLATING: ACUTE LEUKEMIA **S/E of alkylating: acute leukemia, GI problems, long-term bone marrow alterations (DNA is damaged), renal toxicity Rationale: B- Antimetabolite S/E: GI problems, stomatitis, thrombocytopenia (NOT thrombosis), leukopenia, alopecia, photosensitivity C- Antitumor in higher does- cardiac and pulmonary toxicity, bone marrow suppression, alopecia, GI problems (NOT neuro shock) D- Mitotic inhibitor (vincristine) S/E: alopecia, constipation, hyponatremia, treatment-induced peripheral neuropathy

A RN is caring for a 10-year old client with UC. Client has undergone endoscopy of the lower GI tract, revealing ulcerations and strictures. Which of the following is true about this disorder? A- Anemia is a common finding B- Onset is sudden C- Abdominal rigidity is a characteristic D- The upper GI tract is usually affected

A- ANEMIA IS A COMMON FINDING - UC is a disorder of inflammation f the colonic mucosa. Ulcerations and strictures are characteristics. Onset is usually gradual. Diagnostic- CBC, ES, Endoscopy and stool culture. *Anemia occurs in UC due to loss of blood from friable mucosa in the stool. Abdominal rigidity does NOT occur. (abdominal tenderness does) Disease is limited to the colon and rectum Other S/S- tenesmus, fever, loose/watery stool with pus or mucus, crampy abdominal pain, anorexia, fluid and elec imbalance, malnutrition

141) RN is caring for a client who has a new prescription for selegiline to treat major depression disorder. Which of the following actions should the nurse take while administering? A- Apply the medication to dry skin on clients upper thigh B- Instruct client to inhale through nebulizer C- Give the med orally at bedtime to promote sleep D- Inject the med IM into large muscle

A- APPLY MED TO DRY SKIN ON UPPER THIGH Selegiline, a MAOI administered via transdermal route to TX depression. --It can be given orally to TX Parkinson's ++when given transdermal inhibits both monoamine oxidase-B (MAO-B) & monoamine oxidase-A (MAO-A) *****Transdermal should be only route given for depression**** #1- ask client if there is current patch on to prevent overdose (only one at a time) #2- wash the area with soap and water, rinse and dry skin #3- Check dose (several strengths available) #4- Remove patch from pouch RIGHT BEFORE administration #5- remove the liner from the back of patch and apply the patch to hairless, undamaged skin on upper thigh, upper outer arm. chest or back. #6- Document site and ensure different placement next day

A RN is preparing to administer pancreplipase (Lipancreatin) to a client with cystic fibrosis. Which of the following should the nurse include in teaching? SATA A- Assess for lactose intolerance B-Monitor renal function C- Monitor blood coag D- Provide antidiuretic hormone E- Assess for SOB and leg swelling F-Monitor for joint pain

A- ASSESS FOR LACTOSE INTOLERANCE E- ASSESS FOR SOB & LEG SWELLING F- MONITOR FOR JOINT PAIN Pancreplipase (Lipancreatin) is used to TX clients with pancreatic impairment due to CF. -It enhances the digestion of protein, fats and carbs in the GI tract by supplying the enzymes protease, amylase and lipase. **Check for allergies to pork protein and/or lactose intolerance (pancreplipase contains both) A high-cal, high-pro, low-fat diet is usually recommended for clients with pancreatic insufficiency treated with pancreplipase. The dose of pancreplipase is adjusted to the fat contents of the diet. DO NOT chew tabs! Quickly swallow with liquids

A client is admitted to the hospital for acute gastritis and ascites secondary to chronic alcohol disorder and cirrhosis. It is important for the RN to assess client for: A- Blood in stool B- Food intolerance C- Complaints of nausea D- Hourly urine output

A- BLOOD IN THE STOOL Erosion of blood vessels may lead to hemorrhage, a life threatening situation further complicated by dec prothrombin production, which occurs with cirrhosis Clients with cirrhosis, or other liver disease are at risk for multiple medical complications: bleeding from the esophagus or stomach, ascites (fluid buildup in the abdomen) encephalopathy, edema, bacterial infections of the peritoneum (gut lining) and liver cancer

A nurse is caring for a client who seeks TX for opioid dependence. The RN understands that which of the following med is used for treatment of opiate withdrawal? SATA A- Buprenorphine B- bupropion C- Acamprosate D- Chlordiazepoxide E- Clonidine

A- BUPRENORPHINE E- CLONIDINE TX of opioid withdrawl and maintance therapy for individuals with opioid dependence

A nurse is teaching a group of nurses about chronic-gastritis. Which of the following should be included in this in-service? A- Clients with chronic gastritis should receive a monthly injection of vitamin B12 B- Clients with chronic gastritis may develop pernicious anemia from reduced production of hydrochloric acid by damaged cells in the stomach C- Vitamin K deficiency results in coagulopathy in these clients due to malabsorption from chronic gastritis D- Increased production of intrinsic factor results in pernicious anemia

A- CLIENTS WITH CHRONIC GASTRITIS SHOULD RECIEVE A MONTHLY INJECTION OF VIT B12 Parietal cells are damaged in clients with chronic gastritis. They procude intrinsic factors which is necessary for abosprion of vitamin B12 Chronic gastritis is associated with a risk of deficiency of B12 Monthly injections of B12 are necessary for TX

The RN is assessing a client with post-poliomyelitis syndrome. Which of the following symptoms can be found? SATA A- Cold intolerance B- Unilateral hearing loss C- Tremors D- Loss of muscle mass E- Unilateral tinnitus F- Pain

A- COLD INTOLERANCE D- LOSS OF MUSCLE MASS F-PAIN Post-poliomyelitis syndrome occurs as a complication of previous infections by the polio virus. When a virus is active, it destroys some of the motor cells of the anterior horn of the spinal cord. Later on in life, 10-40 years later. Motor neuron degenerations and weakness emerges S/S- fatigue, weakness, muscle and joint weakness, dizziness, headache, urinary incontinence, sleep disorder and pain. Diagnosis- History of polio and physical exam. Studies that involve nerve conduction and muscle strength are also preformed TX: addressing the symptoms and involving the client in physical therapy or pulmonary rehab NEW ONSET OF WEAKNESS, FATIGUE, JOINT PAIN, DEC ENDURANCE, SWALLOWING PROBLEMS ETC.

Client with advanced cirrhosis Labs show albumin-2.3, ammonia-120, platelet 50,000, bili-20 INR-2.0. Which of the following should the nurse expect on assessment of this client? SATA A-edema B- Pill-rolling tremor C- Pruritus D- Bruising E- Hypopigmented areas of skin

A- EDEMA liver synthesizes protein (albumin). Impaired syntheis of albumin results in fluid overload C- PRURITIS Bili, breakdown of heme (released by destruction of old red blood cells) D-BRUISING The liver processes nutrients, detoxifies and metabolizes endogenous and exogenous substances. The liver also synthesizes plasma protein, including albumin, prothrombin, fibrogen and various clotting factors

166) The RN is caring for a client with portal hypertension. Which of the following are likely to occur with the clients condition? SATA A- Esophageal varices B- Thrombophlebitis C- Encephalopathy D- Ascites E- Bone disease

A- ESOPHAGEAL VARICES C- ENCEPHALOPATHY D- ASCITES **Portal hypertension occurs due to impaired blood flow through the liver, causing a inc pressure in the portal venous system. This system drains into the GI tract, sleep and surface veins of the abdomen. -Since DRAINAGE is affected, symptoms affecting these organs will be manifested: -(A)Dilated veins in the GI tract=esophageal varices -(C)- Hepatic encephalopathy due to accumulation of toxic waste products, as blood bypassed the congested liver. -Hepatorenal syndrome- ARF acute renal failure, due to the disrupted blood supply to the kidneys -(D)- Ascites due to accumulation of fluid in the abdomen cavity brought by inc hydrostatic pressure in the abdominal vessels

99) A nurse is caring for a client with positive home pregnancy test. She is seen at the clinic on January 6th. Last menstrual cycle was October 6th. Which does the nurse expect to see? SATA A- The fetal heart rate can be detected by Doppler B- The client will report fetal movement C- Dysuria is common D- Expected date of delivery by Naegele's rule is July 13th E- Fundus height should be 20 cm above the umbilicus

A- FETAL HR CAN BE DETECTED BY DOPPLER - detection of HR by doppler is possible from 10-12 weeks of gestation D- EXPECTED DATE USING NAEGELE'S IS JULY 13TH -subtracting 3 months from date of last period then adding 7 days. Rationale: B- Fetal movement is usually sensed at 18-20 weeks. *the onset of awareness of fetal movement is called QUICKENING* C- Urinary frequency is common in the first trimester due to hormone fluctuation (Dysuria, back pain or fever could indicate UTI) E- The fundus height is used to measure uterine growth and correlates closely in cm with the number of weeks gestation AFTER 20 weeks.

Client receiving enteral feeding by intermittent boluses. Which of the following nursing actions is indicated before starting the next feeding? SATA A- Flush the feeding tube with water before feeding B- Discard the aspirated residual volume into a biohazard container C- Begin feeding when the residual volume is <50mL D- Confirm tube placement if the residual volume has a pH of >6.0 E- Place the client in the left lateral position

A- FLUSH THE FEEDING TUBE WITH WATER BEFORE FEEDING D- CONFIRM TUBE PLACEMENT IF THE RESIDUAL VOLUME HAS PH OF >6.0 Feeding tube should be flushed with water before and after the feeding to verify patency to prevent the formation of an obstructive bolus. Gastric aspirate should be <5. if the pH is >6.0 the feeding should be held.

181) A RN is teaching a client who has new prescription for pramipexole to TX Parkinson's. The RN should instruct the client to monitor for which adverse effect? A- Hallucinations B- Inc salivation C- Diarrhea D- Urinary retention

A- HALLUCINATIONS --Pramipexole can cause hallucinations WITHIN 9 months of the initial dose and may require discontinuation... Pramipexole, an anti-Parkinson's agents, stimulates the dopamine receptors in the brain to dec the tremors and rigidity. ***Adverse effects to report: Hallucinations, Dizziness, Ortho hypotension, Constipation, Dry mouth, Urinary frequency, Drowsiness and sleep attacks (falling asleep without warning)*** Rationale: B- Dry mouth is a adverse effect C- Constipation is adverse D- Urinary frequency is adverse

117) RN is providing teaching for a client who has a new prescription for raloxifene HCL (Evista). The nurse should advise the client about which SE? SATA A- Hot flashes B- Hematuria C- Leg cramps D- Diarrhea E- Weight loss

A- HOT FLASHES C- LEG CRAMPS D- DIARRHEA **Estrogen regulates bone mass by inhibiting the activity of osteoclasts. When estrogen levels dec in women AFTER menopause, osteoclast activity inc. Putting women at R/F osteoporosis --Effects the vertebrae. Resulting in loss of height, kyphosis (dowager's hump) +++++Raloxifene acts as an estrogen agonist in bone to PREVENT bone loss by slowing resorption and inc bone mineral density. USED TO TX OSTEOPOROSIS S/E: N/V diarrhea, hot flashed, peripheral edema, flu-like symptoms, infection, joint pain, muscle spasm and leg cramps

A nurse is teaching a client with prescription for dimenhydrinate for motion sickness. Which statement indicates and understanding? A- I might experience some dizziness while taking this medication B- It is not unusual to have my BP increase C- I will take this 24 hours before I plan to travel D- I can expect to have an INC in salivation while taking

A- I MIGHT EXPERIANCE SOME DIZZINESS a client can experience drowsiness/dizziness while taking this med and should avoid activities that require alertness (driving) Other S.E- headache, blurred vision, tinnitus, hypotension, palpations, anorexia, constipation, dry mouth, dysuria, photosensitivity Rationale: A- Dimenhydrinate can cause hypotension, not hyper C- Client should take med at LEAST 30 min preferably 1-2 hours prior to traveling D- Dimenhydrinate can cause anticholinergic effects (dry mouth, blurred vision)

153) A RN is caring for a client who is pregnant and has a TORCH infection. Which findings should RN expect? SATA A- Joint pain B-Insomnia C- Rash D- Urinary frequency E- Dec appetite

A- JOINT PAIN -flu-like symptoms C-RASH E- DEC APPETITE ****5 infections (toxoplasmosis, other (syphilis), rubella, CMV & herpes simplex (HSV)) ---Clients that are pregnant and have TORCH will exhibit flu-like symptoms (tender lymph nodes, malaise, joint pain, fever, chills and headache) Effects of infections include significant congenital anomalies and even death to fetus. Teach- proper handwashing and hygiene, avoid activities that increase risk (cleaning cat-litter, consuming raw or undercooked meat) Rationale: B- Malaise and fatigue are common, not insomnia D- Urinary frequency is not a clinical finding with TORCH

184) A RN is developing a plan of care for a client who has myxedema coma. Which of the following actions to include? SATA A- Monitor the client for cardiac dysrhythmias B- Observe the client for evidence of UTI C- Initiate IV fluids using 0.9% sodium chloride D- Administer levothyroxine IV bolus to the client E- Provide the client with cooling blankets to prevent hyperthermia

A- MONITOR FOR CARDIAC DYSRHYTHMIAS -can have flat/inverted T wave and ST elevations B- OBSERVE CLIENT FOR UTI -infection (UTI) can precipice coma... TX the underlying cause C- INITATE IV FLUID D- ADMINISTER LEVOTHYROXINE IV BOLUS -Myxedema coma is a severe complication of HYPOTHRYOIDISM, that left untreated can lead to coma/death... IV bolus treats the condition S/S- hyponatremia, hypoglycemia, hypoventilation, hypotension, bradycardia, hypothermia and changes in mental status & cardiac rhytm

A nurse is providing health education to a client with prostatodynia. Which of the following symptoms are expected? SATA A- Pelvic pain B- Anuria C- Post-ejaculatory pain D- Priapism E- Oliguria F- Insomnia G- Burning pain in the penis

A- PELVIC PAIN C- POST-EJAC PAIN G- BURNING PAIN IN THE PENIS Prostatodynia, or chronic non bacterial prostatitis is a condition affecting the pelvic area. Does not show any signs of infection or inflammatory changes. Cause is unknown. S/S- pelvic pain, myalgia, fatigue, burning in the penis. usually no definitive physical manifestations TX: Psychotherapy and anti- anxiety drugs No cure

A DR prescribes gold salts for a client with RA. What serious SE will require monitoring? A- Persistent diarrhea B- Persistent nausea C- Pulmonary emboli D- Cardiac decompensation

A- PERSISTENT DIARRHEA -Signs of gold toxicity include dec hemoglobin, leukopenia (<4K WBC) & dec platelets (<150) proteinuria, hematuria, pruritis, rash, stomatitis and diarrhea. Clients with significant GI should discontinue TX. "Gold salts are ionic chemical compounds of gold. The term, "gold salts" is a misnomer, and is the term for the gold compounds used in medicine. "Chrysotherapy" and "aurotherapy" are the applications of gold compounds to medicine. Contemporary research on the effect of gold salts treatment began in 1935, primarily to reduce inflammation and to slow disease progression in patients with rheumatoid arthritis. The use of gold compounds has decreased since the 1980s because of numerous side effects and monitoring requirements, limited efficacy, and very slow onset of action. Most chemical compounds of gold, including some of the drugs discussed below, are not salts, but are examples of metal thiolate complexes." Wikipedia

A nurse is assessing a client at 34 weeks gestation who complains of feeling faint. Her BP is supine is 100/60. Which of the following nursing interventions is most appropriate? A- Place the client lying in left lateral recumbent postion and recheck in 5 min in the left arm B- Place the client lying in left lateral recumbent postion and recheck in 5 min in the Right arm C- Ask the client to stand and recheck blood pressure while standing D- Take the client's blood pressure in the opposite arm in the same position.

A- PLACE THE CLIENT LYING IN LEFT LATERAL RECUMBENT POSITION AND RECHECK IN 5 MIN IN THE LEFT ARM BP is usually dec in the first and second trimester as the circulation expands and as hormonal changes result in dilation of blood vessels. Usually recovers to pre-preg level in 3rd trimester +The BP should be checked in the left arm, since the right arm may result in falsely lower blood pressure measurement.+

164) A RN on oncology is caring for a client that has developed DIC and is bleeding from her mucous membranes and venipuncture sites. Which lab values indicate clients clotting factors are depleted? SATA A- Platelets 100,000 B- Fibrogen level 57 C-Fibrin degradation products 4.3 D- D-dimer 0.03 E- WBC 3,000

A- PLATELETS- 100,000 (150-400) clotting times of PT, aPTT, TT are all INC B- FIBROGEN LEVEL- 57 (60-100) Rationale: C- fibrin degradation 4.3 (0-5) would be INC if DIC occurred D- D-dimer- 0.03 (<0.4), would be INC if DIC occurred E- WBC- 3,000 (5000-10000) not a indicator of DIC DIC is a potentially life-threatening condition that can be triggered (cancer, sepsis, trauma, abruptio placenta) forming hundreds of tiny clots in capillaries causing obstruction and tissue ischemia -As clotting factors are used up, bleeding occurs.. intensified by the anticoag properties of fibrin degradation products. +++Interventions- complex and extensive, administration of oxygen, heparin, platelets and/or plasm and antibiotics

The RN is caring for a client with a tumor. Which of the following are tumor markers? SATA A-Prostate-specific antigen B- Alpha- fetoprotein C- Prostatic acid phosphatase D- Amylase E- Calcitonin F- Thyroxine G- Human chorionic gonadotropin

A- PROSTATE-SPECIFIC ANTIGEN -adenocarcinoma of the prostate B- ALPHA- FETOPROTEIN -Hepatocellular and seminoma C- PROSTATIC ACID PHOSPHATASE E- CALCITONIN G- HUMAN CHORIONIC GONADOTROPIN -Tumor markers are protein molecules that increase in concentration when there is tumor or cancer. (Also known as bio-markers that are clinically used as indicators of cellular malignancy. **Antigen tumor markers- CEA, and B **Hormone- HCG (G), E, and catecholamines **Protein- Prostate-specific antigen, immunoglobins **Enzyme- PAP (C) and NSE (neuron-specific)

Amitriptyline (Elavil) is prescribed for a client with a migraine, Which should the nurse implement? SATA A- provide chewing gum B- inc fluid intake C- monitor for dyspnea D- monitor for diarrhea E- assess for constipation F- encourage to change position slowly G- assess for hypertension H- assess for blurred vision

A- PROVIDE CHEWING GUM B- INC FLUID E- ASSESS FOR CONSTIPATION F-CHANGE POSTION SLOWLY H-ASSESS FOR BLURRED VISION Prescribed for clients with MDD (major depression disorder) also used prophylaxis for migraines. Common side effects: constipation, xerostomia (dry mouth) mydriasis (dilated pupils) blurred vision, urinary hesitation, orthostatic hypotension, tremor, sweating MAOI inhibitors should be discontinued 2 weeks before starting amitriptyline Use of SSRI (fluoxetine) may result in toxicity

Charge nurse is providing education about bacterial infections of the intestine to nursing staff. What should the nurse include? SATA A- Rice water stool are associated with cholera B- Salmonella has an incubation period of 1 to 4 days C- Shigellosis causes bloody diarrhea and tenesmus D- C. diff causes travelers doarrhea E- C. diff has an incubation period of 1-4 days

A- RICE WATER STOOL ARE ASSOCIATED WITH CHOLERA C- SHIGELLOSIS CAUSES BLOODY DIARRHEA AND TENESMUS Bacterial infection of the intestine is a common occurrence. Commonly impacted bacteria include E. Coli, staph, shigella, C. Diff. Intubation periods vary from 24-72 hours= E. Coli 2-8 hr for staph 1-3 days for cholera and hemorrhagic colitis 8-48 hr for Salmonella 1-4 days for shigellosis 1-2 weeks for C. Diff Diarrhea is the primary manifestation of intestinal infection. More specific- Tenesmus=Shigellosis Rice water stool-cholera vomiting-staph bloody diarrhea- hemorrhagic colitis

140) A RN is assessing a pregnant client who states she is in labor but has not received any prenatal care. The RN attempts to identify how quickly labor is progressing. Which of the following behaviors indicates birth is imminent? A- Sitting on one buttock B- Talking and asking a lot of questions C- Complaining of pain in the lower back D- Requesting ice chips or water to drink

A- SITTING ON ONE BUTTOCK ----RN performs a rapid assessment to determine how much time is left: Several behaviors may exhibit that labor is imminent: sitting on one buttock, making grunting sounds, bearing down during contractions or making outright statements "the baby is coming NOW" Progression is 3 phases--

132) During the assessment interview, the nurse notes that a male client who was bullied about interest in chemistry not tutors students having difficulties with science. Which defense mechanism does this client exemplify? A- Sublimation B- Projection C- Displacement D- Splitting of self-image

A- SUBLIMATION -Maladaptive thoughts and feelings are channeled into socially acceptable behaviors. Unconscious coping strategies that reduce feeling of anxiety toward an event or experience. -May have positive or negative consequences. Rationale: B- projection involves BLAMING or attributing faults to another person C- Displacement involves transferring responses from one person to another person or object D- Splitting of self-image involves the inability to integrate positive and negative aspects of ones self.

The RN administering ethacrynic acid (Edecrin) for a client with decompensated heart failure. Which of the following are true about this drug? SATA A- Weigh should be taken daily B- It does not affect urine output C- It is taken orally D- Administer with NSAID E- It is ototoxic F- It is best administer at bedtime

A- WEIGH SHOULD BE TAKEN DAILY E- IT IS OTOXIC Loop diuretic. Prescribed to reduce/eliminate fluid in the body by inhibiting sodium and chloride reabsorption at the loop of Henle in the kidneys. Weigh should be assessed before, during after administration IV. Taken with meals to avoid GI disturbances. Administered in the morning and in late afternoon to prevent Nocturia that might occur is administered at bedtime Take Ethacrynic acid as directed and take missed doses as soon as possible Drug may cause orthostatic hypotension, implement fall precautions

Client with end stage renal disease, receiving hemodialysis. Which of the following should the nurse include in the plan of care. SATA A- Monitor the clients weight daily B- Encourage the client to comply with fluid restrictions C- Evaluate intake and output D- Instruct the clients about restricting calories for carbohydrate E- Monitor the client for elevated potassium levels.

A- WEIGH THE CLIENT DAILY -determine fluid retention B- ENCOURAGE THE CLIENTS TO COMPLY WITH FLUID RESTRICTIONS -helps to slow fluid retention C- EVALUATE INTAKE AND OUTPUT -increase in fluid retention E- MONITOR THE CLIENTS FOR ELEVATED K LEVEL -depends on urinary output, GFR decreases, the excretion of K decreases Carbohydrates are not restricted for a client who has ESKD ESKD will require close monitoring of calories, protein, sodium, K and fluids to determine adequate levels

A nurse is assessing a child who has leukemia. Which of the following findings should the nurse expect? SATA A- Polyuria B- Anorexia C- Petechiae on the extremitites D- Pitting edema in the legs E- Unsteady gait

B- ANOREXIA leaukemia causes a buildup of abnormal cells in spleen and liver, and the child can experiance a feeling of fullness, abdominal swelling, and a dec appetitie. Anorexia is a early manifestation of leukemia C-PETECHIAE ON THE EXTREMITIES Small, flat, red or purplish spots on the skin caused by broken vessels. E- UNSTEADY GAIT can experience bone and joint pain and an unsteady gait due to increased production of immature lymphocytes and dec production of red blood cells - Rapid production of immature lymphocytes, which also alters the production of red blood cells and platelets in the bone marrow. Diagnosed by aspiration of the bone marrow, which identifies the abnormal cells

A nurse is caring for a client who has chronic pyelonephritis. Which of the following actions should the nurse take? SATA A- Encourage the client to restrict fluid to 1L B- Arrange a consultation with a dietician C- Palpate the costovertebral angles of the client D- Instruct the client to void every 2 hours E- Monitor the clients creatinine levels

B- ARRANGE A CONSULT WITH DIETICIAN -chronic pyelonephritis is a disorder that results in renal scarring and dec kidney functioning. In order to delay development of ESKD, the clients diet should provide nutrients, control BP, and plenty of fruits and veg. C-PALPATE THE COSTOVERTEBRAL ANGLES -manifestations can be vague. (changes in urine- color, Nocturia) HTN and low grade fever. Inflammation and tenderness of the costovertebral angle can be an **indication of inflammation or infection** Observe the area for redness, edema, or asymmetry and gently palpate the angle for flank tenderness D- INSTRUCT CLIENT TO VOID EVERY 2 HOURS -caused by repeated UTIs (result in scarring and inflammation) Instruct client on how to clean area of perineum and urethral meatus. Void every 2-3 hr during day ***Prevents overdistention of bladder* E- MONITOR CLIENTS CREATININE -BUN and creatinine, GFR. Inc BUN or creatinine or a DEC in GFR are indication of increasing kidney damage (Report to provider) Rationale: A- Fluid intake is encouraged in client to prevent dehydration (inc the risk for ESKD) and promote urinary output. Encourage AT LEAST 2L/day

Which of the following lab tests would be performed on a client with suspected MI. SATA A- Anti-endomysial antibodies B- CK-MB C- Troponin D- D-dimer E- Chromogranin- A

B- CKMB C- TROPONIN & myoglobin measures the heart enzymes, which indicates heart muscle damage has occurred. D-dimer is just for diag of a PE -Troponin 1 is found only in cardiac muscle, Elevated T and 1 occur 3-6 hours after MI damage. CK-MB- less sensitive and specific marker for MI than troponins Rationale: A- Marker for celiac disease E- Tumor marker used with 5-HIAA to diagnose carcinoid tumors D- PE

A nurse is caring for a client with AIDS who is complaining about chills, night sweats, fever and diarrhea. The client has significant weight loss and malabsorption. Which of the following may have caused the clients symptoms? A- TB B- Cryptosporidiosis C- Candidiasis D- Pneumocystis carinii

B- CRYPTOSPORIDIOSIS AIDS occurs in the last stage of HIV infection. The CD4 T-cells that fight infection fall below 200/mm -Opportunistic infections arise due to dec T-cells Ex- TB, Cryptosporidiosis, candidiasis and pneumocystis carinii. ************Cryptosporidiosis is the MAJOR cause of WASTING syndrome (parasite that thrives in the intestine, absorbing nutrients causing weight loss and eventual wasting of body tissues) S/S- N/V, abdominal cramps and diarrhea TX- antiretroviral therapy, Loperamide(control of diarrhea) and IV fluid, TPN for clients with chronic disease Rationale: A,C,D are less likely to be associated with diarrhea.

86) A nurse is teaching a client who is pregnant about the variables that are scored during a biophysical profile (BPP). Which of the following should RN include. SATA A- Fetal weight B- Fetal breathing movement C- Fetal tone D- Fetal station E- Amniotic fluid volume

B- FETAL BREATHING MOVEMENT -one episode of maintained fetal breathing movements of at least 30 seconds. =score of 2 C- FETAL TONE -one extension and flexion of the extremities or spine = score of 2 E- AMNIOTIC FLUID VOLUME -amniotic fluid should measure more than 2 cm in vertical diameter= score of 2 **Non invasive performed via ultrasound in conjunction with a nonstress test to monitor 5 variables: fetal breathing, fetal movement, fetal muscle tone, amniotic fluid volume and fetal hear reactivity -Each one scores 0-2 BPP score of 8-10 indicates good fetal-well being 6- requires further evaluation 4- fetal distress

A nurse is working with a client who has a central line. But she has unable to flush the catheter or give any medication or fluids. Which of the following initial interventions should the nurse use to resolve the situation? SATA A- Tell the patient to exhale sharply through his mouth B- Have the patient turn his head and cough C- Administer 10 mL of heparin D- Ask the patient to raise his arms E- Use an enzyme clot-buster

B- HAVE THE PATIENT TURN HIS HEAD AND COUGH D- ASK THE PATIENT TO RAISE HIS ARMS When client develops occlusions in central catheter the nurse may not be able to flush the line or administer fluids #1- Reposition the client (raise his arm, turn, stand up, cough) all which may move the tip of the catheter The patency of a central venous catheter can be maintained by the SASH: Saline, Administer medication, saline, heparin

138) A RN is caring for a client who just had a coronary artery bypass graft surgery. The RN knows not to rewarm the client to fast due to a risk for which complication? A- Septicemia B- Hypotension C- Tissue necrosis D- Hypertension

B- HYPOTENSION (during surgery client is maintained in a hypothermic state to reduce the metabolic demand of the heart and vital organs to prevent ISCHEMIA) Rewarming begins immediately after completion, but clients often have residual hypothermia as a result of continuing intraoperative heat losses, vasoconstriction in tissue, a drop in temp as blood circulates to the cold areas and infusion of cold IV fluids. Warming rate of NO MORE than 1.8 F per HOUR ----(1 Celsius) to prevent vasodilation and shock Rationale: A- Septicemia is a complication of surgery, but not caused by rapid rewarming C- Tissue rewarming promotes VASODILATION, but hypothermia causes peripheral vasoconstriction. Tissue necrosis is likely to be associated with hypothermia and peripheral vasoconstriction D- Rewarming causes vasoDILATION (unlikely to cause HTN)

A nurse in caring for a client who has a pulmonary artery catheter. Which of the following interventions would the nurse provide to prevent a air embolism? A- Monitor the site dressing for drainage B- Keep patient is Trendelenburg during insertion C- Ask the patient to cough every 4 hours D- Flush with saline, followed by heparin ever shift

B- KEEP THE PT IN TRENDELENBURG DURING INSERATION An air embolism develops when air enters a large blood vessel and produces a gas bubble within the circulation. By placing the client in Trendelenburg (head down) dec the risk of air entering circulation

A RN is providing teaching for a client who has impetigo. Which of the following information should the nurse include? A- Keep an occlusive dressing over the lesions until they are healed B- Remove the crust on the lesions prior to applying the topical medication C- Impetigo does not spread to others D- Wear soft cotton gloves while sleeping

B- REMOVE THE CRUST ON THE LESIONS PRIOR TO APPLYING TOPICAL MEDICATION -Soak or wash the lesions to remove the crust prior to applying the topical antibitoic ointment. This will allow the antibotic to reach the central area of bacterail growth +Impetigo is a superficial bacterial infection that typically develops in areas where the skin integrity has been disrupted. More common in chronic health problems. Nursing actions when caring for a client with impetigo include: Wear gloves when in contact with lesions, apply warm compresses Instruct the client too: =perform hand hygiene =bathe at least once daily with antibacterial soap =avoid contact with others until lesions healed =do not share towels, washcloths or combs

114) The nurse is caring for a client with a infective endocarditis. Which of the following are likely to occur with the clients condition? SATA A- Seizures B- Splinter hemorrhages C- Osler's nodes D- Encephalopathy E- Janeway lesions F- Ascites G- Roth spots

B- SPLINTER HEMORRHAGES -splinter hemorrhages or streaks under the fingernails C- OSLER'S NODES -painful red raised growth on finger E- JANEWAY LESIONS -macular lesions of the palm G- ROTH SPOTS -spots in the retina Infective endocarditis (IE) is a condition where there is inflammation of the endocardium (inner layer of the heart) Usually caused by a bacterial infection (staph and strep) -bacteria enter the blood stream via dental procedure, surgery, urinary cath. S/S- peripheral hemorrhages, chills, fever, malaise, fatigue, arthralgia, dyspnea and splenomegaly. TX: Antibiotic therapy. Surgery in severe cases

129) A RN is teaching a client newly diagnosed with genital herpes. What should the nurse advise the client? A- Antiviral eliminates viral shedding B- The risk of HIV is inc in individuals with genital herpes C- Use of condoms eliminates the risk of transmission D- Viral transmission only occurs when herpes sores are visible

B- THE RISK OF HIV IS INC Genital Herpes is sexually transmitted VIRAL infection caused by HSV-1 or HSV-2 -Lesions increase the risk of HIV infection by 2-4% *virus is dormant in the nerve root --cannot be cured, but antiviral med prevent or shorten the duration of outbreaks Infection can be transmitted whether or not the lesions are visible. (during both active and latent periods)

A client treated with bumetanide (Bumex) has a prescription for magnesium after lab studies reveal mag level of 0.8. The nurse knows that IV MAG is used to treat which of the following rhythms? A- Third-degree heart block B- Torsades de pointes C- Multifocal atrial tachycardia D- Atrial fibrillation

B- TORSADED DE POINTES Loop diuretics, including furosemide and bumetanide, affect the balance of sodium, K and chloride in the kidney. Hypomagnesium refers to sodium level of <1.8 -Hypomagnesium and hypokalemia are associated with torsade de pointes (rapid irregular QRS complex twisting around the ECG baseline)

187) A RN is applying a wound dressing to a clients stage 3 pressure ulcer. Which dressing options are correctly matched to the wound stage? SATA A- Skin sealant for red granulating wound B- Use hydrocolloid for red granulating wound C- Use barrier ointment for red granulating wound D- Use thing hydrocolloid for moderate exudates E- Use hydrocolloid for deep granulation F- Use alginate for deep granulation

B- USE HYRDOCOLLOID FOR RED GRANULATING D- USE THIN HYDROCOLLOID FOR MOD EXUDATES F- USE ALGINATE FOR DEEP GRANULATION ***Wound healing begins with inflammation, followed by a period of granulation and proliferation and final stages of remodeling and maturation Granulation phase: initial repair as new tissues are formed.... Dressing should be based on the best evidence to facilitate healing. (film, hydrocolloid, foam and composite are appropriate for protection of red granulation tissue Wounds with minimal to mod exudates can be dressed with thin hydrocolloid, thin foam and absorbent composite (because these materials promote absorptions of exudates) Impregnated gauze, alginate, cavity foam and strip packing are used for DEEP granulation (to promote packing of the tissue) Peri wound skin require skin sealant and barrier ointment for protection

RN is informing a client entering perimenopause. Which of the following is true? SATA A- Vaginal rugae increases B- Vaginal pH increases C- Vaginal lubrication increases D- Vasomotor instability occurs E- Estrogen increases F- Vulvar tissue atrophies G- Pelvic pain

B- VAGINAL PH INCREASES D-VASOMOTOR INSTABILITY OCCURS F- VULVAR TISSUE ATROPHIES Cessation of messes. Unavoidable life event in a women's life. This is due to a increase of hormone estrogen. S/S- erratic menstrual cycles, valvular tissue atrophy, rising of vaginal pH, dec in vaginal rugae Psychological Symptoms- moodiness, nervousness, insomnia, anxiety, inability to concentrate & depression. Hot flashes and night sweats are physiological reactions from DEC in estrogen 3 primary symptoms- vasomotor symptoms, sleep difficulties and mood problems.

A RN is caring for a client ICU who has congestive heart failure and is in cardiogenic shock. Pulmonary capillary wedge pressure of 20 mmHg. The nurse understand that this pressure is which of the following? A- Below normal B- Within normal limits C- Above normal D- Consistent with pulmonary edema

C- ABOVE NORMAL PCWP is obtained by wedging a catheter in a tapering branch of one of the pulmonary arteries. A PCWP higher than 18 mmHg suggest heart failure. (Normal- 5-12) As PCWP increases, pulmonary edema may occur. Levels of 25-30 mmHg are consistent with pulmonary edema

173) A RN is creating a plan of care for a toddler who is 8 hr post op following a cleft lip repair. Which intervention should the nurse include? A- Offer the toddler fluids through a straw B- Apply restraints to toddlers wrist C- Administer opioids to toddler for pain D- Implement a soft diet for the toddler

C- ADMINISTER OPIODS TO TODDLER FOR PAIN ***Administer opioids AROUND THE CLOCK for 24-48 hr following a cleft lip repair** Rationale: A- to avoid trauma, object such as: tongue depressor, thermoter, syringes, spoons, straws should not be placed in mouth B- RN should apply bilateral ELBOW restraints D- Receive clear liquids for 24 hours following surgery. Implement liquid diet for 2 weeks followed by soft diet for 6 weeks -----Other nursing interventions: +Place infant side-lying or supine to protect site + Cleanse the site with normal saline prior to antibiotic ointment +Observe for indications of airway obstruction: =====congestion, labored breathing, tongue swelling, =====stridor, croup +Instruct parents to breastfeed or promote cup feeding +Instruct parent to remove restraints for holding infant (promote bonding)

A RN is assessing a client that came in ED for abdominal pain. Which condition would the nurse assess by using the obturator sign? A- Ascites B- Gallbladder disease C- Appendicitis D- Hernia

C- APPENDICITIS - The obturator test is performed to assess for appendicitis. During the test: client lies on his back with hip and knee flexed at 90 degrees. The RN grips the clients ankle and turns it to flexion and internal rotation of the hip. If the client feels pain in the area of the RLQ, it is said to be positive sign! -Appendicitis is the inflammation of the lining of the appendix and is a common surgical emergency. characterized by ACUTE ABD PAIN. The obturator sign is present when the internal rotation of the thigh elicits pain -The psoas sign is present when he extension of the RIGHT thigh elicits pain consistent with retroperitoneal or retrocecal appendicitis. No lab tests specific Ultrasound. CT for diagnosis. Pain typically begins in the area of the umbilics and migrates to the RLQ

RN is assessing a client for silent aspiration in a client with neurogenic disorder that is experiencing dysphagia. Which manifestation indicates silent aspiration A- Displays continual tongue rolling while eating B- Attempts to rapidly swallow with each breath C- Displays no coughing when food enters the airway D- Attempts to regurgitate food after swallowing

C- DISPLAYS NO COUGHING WHEN FOOD ENTERS THE AIRWAY Also, the client will have manifestations of silent aspiration within 24 hours, such as aspiration pneumonia

A 65 year old client with poorly controlled diabetes. Admitted to the hospital. During intake the nurse notes right hand appears deformed A- Peyronie's contractures B- Muscular dystrophy deformities C- Dupuytren's contracture D- Ehlers- Danlos syndrome deformity

C- Dupuytren's contracture In this condition the fingers are bent, in the direction of the palm and cannot be extended. Develops from fibromatosis in the palm. Characterized by progressive fibrosis of the palmar fascia, beginning with a nodule in the palm. Rationale: A- Peyronie's disease refers to an acquired, localized fibrotic disorder of the tunica albuginea of the penis. B- Variety of types of muscular dystrophy D- Ehlers-Danhos syndrome is characterized by skin hyperextensibility, joint hypermobility and tissue fragility -Dupuytren contracture should be advised to apply heat. ROM exercises should be performed several times a day

178) A client is suffering from heat exhaustion and has developed a fever, warm flushed skin, dry mucus membranes, dehydration and confusion. Which nursing interventions should be used? SATA A- Provide a sponge bath with ice water B- Monitor I&O every 24 hours C- Encourage fluid intake to 3-4 L daily D- Dec environmental temp E- Utilize cooling blankets

C- ENCOURAGE FLUID INTAKE TO 3-4 L D- DEC ENVIROMENTAL TEMP E- UTILIZE COOLING BLANKETS ***A person with heat exhaustion may exhibit: diaphoresis, fever, thirst and tachycardia as a result of inc body temp**** 3 syndromes: 1) heat cramps- 3) heatstroke TX: -provide bath with tepid water -freq assess I&O -encourage fluid intake -lower ambient temp (if able) -utilize cooling blankets

113) Which of the following situations would contribute to sensorineural hearing loss? SATA A- Cerumen impaction B- Chronic ear infections C- Exposure to loud noise D- Acoustic neuroma E- Use of ototoxic medication

C- EXPOSURE TO LOUD NOISE D- ACOUSTIC NEUROMA E- USE OF OTOTOXIC MED *Sensorineural hearing loss is a type of hearing loss that develops because of damage to the STRUCTURES of the inner ear (cochlea, vestibular duct or utricle) Conductive hearing loss develops because of something that prevents sound from reaching the inner ear, NOT actual damage to inner structures. EX: A & B **Hearing impairment is one of the most preventable chronic conditions among older adults

116) Into what position should the nurse assist a client to facilitate progress of labor when the fetus is in occiput posterior position? A- Lithotomy B- Supine with a towel roll under the right hip C- Hands to knees D- Knee to chest

C- HANDS TO KNEES Occiput posterior= baby head down and back to the side *move to hands to feet to facilitate rotation of the fetus from the posterior to the anterior position

A RN is caring for a client who complains of abdominal pain and his stool has bright red blood on the surface. This stool is most likly described as? A- Melena B- Occult blood C- Hematochezia D- Steatorrhea

C- HEMATOCHEZIA Hematochezia refers to bright red blood found on the surface of the stool. It appears when there is bleeding in the lower intestional tract or the anus. Bleeding in the lower GI tract, including the rectum. Bleeding in the upper GI is usually Tarry, black stools (melena) due to inc transit time through the bowel.

A RN is caring for a client who has been admitted after laparoscopic cholecystectomy. Client is complaining of pain in the shoulder. Which position should the nurse place the client? A- Dorsal recumbent B- Supine C- L side lying D- R side lying

C- L SIDE LYING After lapa cholecystectomy, some clients may experience referred pain to the shoulder as a result of phrenic nerve and diaphragmatic irritation by CO2. Place the client in Sim's with the left side down and right knee flexed to move gas pocket away from the Diaphram. Encourage deep breathing and early ambulation Clear liquid diet

Client with hypothyroidism, new prescription for levothyroxine. What should the nurse teach? SATA A- Weight gain is expected B- TX with this med will last for several months C- Lab testing will be required while taking D- Take med on empty stomach E- Take with calcium antacid if indigestion occurs

C- LAB TESTING IS REQUIRED -TSH levels are used to monitor effectiveness D- TAKE MED ON EMPTY STOMACH -taken on empty stomach to promote absorption Rationale: A- Speeds up metabolism, weight LOSS is common B- TX for HYPOthyroidism with levothyroxine is lifelong E- Calcium antacids reduce absorption & should not be taken together, take antacid 4 hours before * Hypothyroidism is an endocrine disorder that occurs when low levels of thyroid hormones' are produced= Dec in metabolism in body organs Management is drug therapy with thyroid hormone replacement Levothyroxine is started low and gradually increased over several weeks Instruct clients: -take at same time every morning on empty stomach. -Do not inc or Dec dosages. -Monitor TSH until therapeutic, then yearly. -TX is life-long. -Report weight loss, Inc HR & heat intolerance. - Do not take over the counter meds without approval

What is an example of a skin lesion commonly seen in older adults? A- Impetigo B- Atopic dermatitis C- lentigines D- Tinea Pedis

C- LENTIGINES lentigines, also called LIVER SPOTS are common benign skin lesions found in middle age/ older adults. They are areas of hyperpigmented skin that develop with sun exposure over the year. -Often develop on backs of hands and face, These lesions are 0.2-2cm with discrete borders, irregular shape and dark color Rationale: A- Impetigo is a contagious skin infection (common in children) B- Atopic dermatitis (Eczema) is more in younger clients D- Tinea pedis (athlete's foot) not common infection in older adults

94) A nurse is caring for a 1-day old infant who has suspected Hirschsprung disease. Which of the following should the nurse anticipate on assessment of this child? SATA A- Nonbilious vomiting B- Bright red blood per rectum C- No passage of meconium D- Increased hunger E- Abdominal distention

C- NO PASSAGE OF MECONIUM E-ABDOMINAL DISTENTION *Hirschsprung disease (congenital aganglionic megacolon) is a motor disorder of the intestine characterized by absence of neurons in sections of the colon. Caused by a failure of nerve cells to migrate during fetal development, resulting in reduced gut motility and inability to expel stool. 3-4x more common in males Usually diagnosed in neo-nates **infant will manifest failure to pass meconium by 48 hours of live, bilious vomiting and abdominal distention. Initial S/S: fever, sighs of enterocolitis and toxic megacolon.

A RN is discussing TX concerns with client who has breast cancer. Which of the following actions should the nurse take to demonstrate active listening skills? A- Sit side-by-side with the client B- Silently rehearse each response before speaking C- Use intermittent eye contact D- Lean back in the chair

C- USE INTERMITTENT EYE CONTACT The nurse should establish intermittent eye contact being careful to acoid conveying that the nurse is staring, and maintain it naturally during active listening. This demonstrates interest in what the client Rationale: A- Using active listening, the nurse should sit facing the client B- not be focusing on what to say next because it shifts focus away from the client D- the nurse should lean toward the client Active listening helps the nurse establish trust with a client because it demonstrates caring as well as interest

Which of the following are elements of tier 1 of infection control? SATA A- Placing a client in a private room B- using negative pressure C- Wearing gloves when coming into contact with blood/body fluids D- Performing hand hygiene between clients E- Bagging contaminated laundry before removing it from the room

C- WEARING GLOVES D- PERFORMING HAND HYGEINE E- BAGGING CONTAMINTATED LAUNDRY *Precautions to prevent the spread of infection (two tiers) Tier 1- standard precautions during ANY client care. Tier 2- Specific precautions against transmission (airborne, or droplet precautions) Epidemiologically important pathogenic organisms may require second-tier precautions (contact, droplet, airborne IN ADDITION to standard precautions)

Which procedure is most often consented to with an implied client consent? A- A MRI with contrast B- A minor surgical procedure C- Tube thoracostomy D- Administration of an IM injection

D- ADMIN. OF IM INJECTION Types of consent: Implied, Expressed, Verbal, Written Implied: routine procedures (vitals BS check, IM injection) consent as result of admission. Major procedures- (MRI, intubation, diagnostic tests) need written consent -Client must e competent, informed of the procedure and risks. Must be given voluntarily, without coercion.

147) A orthodox Jewish client refused a new prescription for omeprazole capsules for GERD. Which should the RN do? A-Advise the client to sprinkle the contents of the capsule on food when using B- Consult the MD for new prescription C- Tell the client failure to tx GERD may result in health problems D- Ask the pharmacist if another form is available

D- ASK THE PHARMACIST IF ANOTHER FORM IS AVAILABLE ----Capsules are generally coated in collagen-non kosher substance, from animals (some orthodox Jewish clients may refuse as unacceptable) ***Attempt to identify another form of medication that meets the dietary requirements of cultural beliefs If pharmacy doesn't have another form consult the rabbi about another form

156) Which skills do nurses need to adequate advocate for their clients, particularly when conflict arise? A- Collaboration B- Compassion C- Caring D- Assertiveness

D- ASSERTIVENESS "duty of the nurse to advocate for the client" -speaking up for a client about care issues even when others may disagree. Assertive communication: use of intermittent eye contact, nonverbal communication reflecting honestly, active listening, interest in others points of view, confident response and awareness of cultural differences in communication Rationale: A- Collaboration may be nessicarly when dealing with others or working as a team, but does not best describe advocacy B- Compassion is not considered a skill C- Caring, is not considered a skill

Which of the following items use an acceptable abbreviation dose designation, or symbol in a medical record. SATA A- Regular insulin 5 u SQ B- MSO4 2g IV q 2hr prn pain C- Cholecalciferol 1000 IU daily D- Client c/o right-sided hip pain E- Neurology check QID

D- CLIENT C/O RIGHT-SIDED HIP PAIN E- NEURO CHECK QID Institute for safe medication practices and the Joint commission have designated error-prone items. c/o- complains of QID- four times a day QOD- (every other day) NOT acceptable Rationale: A- Reg insulin 5 u SQ ="u" or "U" can be mistaken for "0" B- MSO4 2g IV q 2hr prn pain = can be mistaken for mag sulfate (MgSO4). Should be written out completely C- "IU" refers to international unit but can be mistaken for "IV" **If there is ANY confusion, the RN should consult with DR***

98) A RN is caring for a client who has pneumonia. Which of the following tools should the nurse use to assist with providing cost-effective care? A- Chart audit B- Practice guideline C- Acuity rating D- Critical pathway

D- CRITICAL PATHWAY Tool that sets out a predetermined course of progress after admission for a client who has a specific diagnosis. Rationale: A- Chart audit- used for participating in a performance improvement project. B- Practice guideline- tool to improve quality of care. (interventions for specific health care conditions allowing the nurse to personalize to client) C- Acuity rating- tool for nurse managers use for assistance when determining the hours of care and # of staff required to care for group of clients

Assessing a client using the bulge sign would most likely check for which type of injury? A- A mass in the abdomen B- A penetrating chest wound C- A DVT D- Fluid in the knee joint

D- FLUID IN THE KNEE JOINT -bulge sign indicates fluid on the knee. The nurse presses the medical aspect of the knee joint and "milks" any fluid upward. Then the nurse moves to the lateral side of the knee and presses. Bulging on the medial side with pressure on the lateral side indicates **fluid in the joint** Assessing the knee for injury: Inspect the knee, assess the temp, presence of fluid, tendonitis, cartilage tears and ligament laxity. *Another test for the presence of fluid in the joint, known as EFFUSION is the (PATELLA TAP TEST)- examiner places on hand superior to the patella and milks the suprapatellar pouch with a slight downward pressure, pushing on the patella with the other hand. The patella will bounce off the underlying bone if there is fluid in the joint!

121) RN is caring for a client who is 2 days post partum, who has a urine output of 2800mL over the past 24 hours. Which should the nurse understand concerning the clients post-partum urine output? A- The client should restrict fluid intake B- The client has overflow due to urinary retention C- The client may have uterine atony D- Fluids should be encouraged

D- FLUIDS SHOULD BE ENCOURAGED **Postpartum diuresis is normal in the initial 2-3 days after delivery and may exceed 3,000 mL/day Rationale: A: the client should be encouraged to increase oral intake B: Urinary retention can result in overflow, manifested by frequent voiding small amounts (usually less that 150mL) C- Bladder distention can result in uterine atony, and may displace the uterine fundus to one side ----Abnormal voiding patterns postpartum: urethral or perineal edema, urinary retention (overflow of small volumes of urine with freq voiding) 2800/24= 116.6=NORMAL

A mother brings her 12 month baby to the clinic for immunizations. Which vaccines should be administered SATA A: Diptheria B: Tetanus C: DTap D; hIB E: MMR F: pneumococcal conjugate vaccine G: Hep A H: Varicella I: Inactivated poliovirus vaccine J: Hep B K: Rotavirus

D- HIB E-MMR F-PVC G- HEP A H- VARICELLA I- IPV J-HEP B

144) A RN in a pedi clinic assessing a young child who was exposed to roseola. RN understands which of the following is a characteristic of roseola? A- Rash accompanied by low-grade fever B- Fever, sore throat and pustular rash C- Symptoms of cold followed by rash D- High fever followed by rash after fever subsides

D- HIGH FEVER FOLLOWED BY RASH AFTER FEVER SUBSIDES -Typically a child with roseola will have high-fever (often higher than 103F) for 2-3 days that SUDDENLY subsides. After the fever, a fine rash develops (lasting from hours to days) Other S/S- sore throat, runny nose or cough (with or without fever) Swollen lymph nodes (last 3-5 days after fever) ++++++After fever- a pink maculopapular rash usually appears.... usually beginning on chest, back and abdomen and LATER spreads to the neck & arms -rash is pruritic or painful can last for hours to several days

95) A RN is caring for a client undergoing lithium therapy for bipolor who complains of weakness, dry lips and muscle twitching. Diarrhea is also noted. Which of the following conditions may have caused the clients symptoms? A- Hyponatremia B- Hyperkalemia C- Hypokalemia D- Hypernatremia

D- HYPERNATREMIA ***Fluid and electrolyte imbalance producing either dehydration or fluid overload Hypernatremia is a condition where excessive serum. (((((((((((Produces symptoms such as weakness, dry lips and muscle twitching!)))))))) Na level of >145 (135-145) Lithium is the most common medication cause of Hypernatremia.

A RN is providing palliative care at home for a dying client. With no sign of impeding death. Which intervention does not represent palliative care? A- IV administration of Robinul (glycopyrrolate) B- Injection of Zofran (odansetron) C- Providing oral tab of Levsin (hyoscyamine) D- IV administration of Nipent (pentostatin)

D- IV ADMIN OF NIPENT (PENTOSTATIN) Drug or meds that's purpose is to cure the central health problem is not considered palliative. Chemo are not palliative but curative. Nipent is an antimetabolite cancer drug that inhibits the enzyme deaminase from interfering with cells ability to process DNA (CURES cancer) ****Drugs that relieve symptoms (such a dec resp secretions) promote comfort and are palliative! Rationale: A- Robinul dec resp secretions B- Zofran relieves N/V C- Levsin dec resp secretions PALLIATIVE CARE IS NOT CURATIVE!!

Following a spinal cord injury, the nurse instructs the client to drink fluids primarily to: A- Maintain fluid and electrolytes balance B- Prevent dehydration C- Prevent skin breakdown D- Prevent infection of the urinary tract

D- PREVENT INFECTION OF THE URINARY TRACT Atonic bladder is a complication of spinal cord injury which leads to urinary stasis and infection. Increased intake of fluids help to prevent infection by diluting the urine and increasing urinary output. Individals with spianl cord injury are at increased risk of urinary tract infection. clients with SCI should drink a minimum of 1.5 L of liquid each day.

A nurse is providing care to a client who is scheduled for a hemicolectomy. Which of the following actions should the nurse take? A- Encourage the client to void after sedative medication is administered B- Administer antibiotics 2 hr. prior to surgical procedure C- Perform hair removal using a disposable razor D- Remove nail polish on the clients fingers and toes

D- REMOVE NAIL POLISH ON THE CLIENTS FINGERS AND TOES Ensure the clients nail beds are visable to allow for monitoring of color and circulation

A nurse is caring for a client with chronic cirrhosis of the liver. RN knows that which of the following is a potentially life-threatening complication of chronic liver cirrhosis? A- Spider angiomas B- Fetor hepaticus C- Asterixis D- Varices

D- VARICES Esophgeal varies can potentially result in a life- threatning emergeny complication of chronic liver cirrhosis if they begin to bleed. Hemorrhage of esophageal varices can lead to death Rationale: A: Spider angiomas (harmless red lesions on the skin, resulting from capillary fragility) are a sign of chronic liver cirrhosis and NOT life threatening B: Fetor hepaticus (fruity odor to the breath) develops with liver cirrhosis, NOT like threatening C: Asterixis (Tremors and a sign of liver cirrhosis) not life threatening approximately one-third will experience variceal hemorrhage- LIFE THREATNING Portal hypertension causes splenomegaly, ascites and development of esophageal varices

89) Caring for a client that has been resuscitated after cardiac arrest with PEA. What are the "H's" associated with this rhythm? B- Hypovolemia, hypoxia, hypothermia, hyperkalemia, hypokalemia, and hydrogen ion accumulation

Hydrogen ion accumulation refers to acidosis PEA refers to any organized rhythm that does NOT result in a pulse, including sinus rhythm without a pulse, EXCEPTION: V-fib, Ventricular tachycardia and asystole. Electrical activity without cardiac output. Consider reversible causes "H's & T's" Hypoxia Hydrogen Ion Hypovolemia Hypo/hyper Kalemia Hypothermia Toxins Tamponade Tension pneumothorax Thrombosis (pulmonary embolism/ coronary artery thrombosis)