ARCHER FUNDAMENTALS

The nurse is caring for a client who was prescribed a clear liquid diet. Which dietary items would be appropriate for the nurse to include? Select all that apply. sherbert chocolate pudding vanilla yogurt apple juice coffee with oat milk fat-free bouillon with added salt tomato juice clear hard candy gelatin hot tea with added sugar

Explanation Correct responses A clear liquid diet is usually transparent (to light) dietary items that do not contain dairy or pulp. Items such as water, gelatin, fat-free bouillon, hot tea, apple juice, seltzer, lemonade, and ginger ale are acceptable. Clear hard candy is acceptable because it is a clear liquid when melted. Salt and sugar are food additives that are permitted. Incorrect responses A full liquid is the next step when the diet is advanced. This diet contains opaque liquids. A full-liquid diet usually contains pulp and dairy. For example, coffee is a clear liquid, whereas a coffee with creamer or milk is a full liquid. Items that are full liquid include sherbert, milkshakes, frozen yogurt, pudding, strained soups, and coffee with dairy (or nondairy alternatives such as oat milk). Additional Info ✓ A clear liquid diet is easily absorbed and digested ✓ This diet often is used for a PO (by mouth) challenge if the client is experiencing nausea and vomiting, if they can tolerate it without further vomiting it is considered a successful challenge ✓ The disadvantage of a clear liquid diet is that it provides very little nutritional value ✓ Salt and sugar additives are permitted

The nurse plans care for a client admitted with Haemophilus influenzae, type b Meningitis. When caring for this client, the nurse should gather which appropriate personnel protective equipment (PPE)? Correct A. Boot (shoe) covers [0%] B. Face shield [16%] C. Surgical mask [74%] D. Gown [10%]

Explanation Choice C is correct. Haemophilus influenzae, type b Meningi requires droplet precautions. Droplet precautions require the nurse to don a surgical mask upon entry to the client's room. Cohorting with droplet precautions is permitted as long as the other individual has the same pathogen. Clients who require transport or want to ambulate outside their room should don a surgical mask.

The nurse is ambulating a client who is wearing a gait belt. The client begins to fall. The nurse should take which appropriate action to minimize injury? A. Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor. B. Let go of the gait belt, grab the client under each arm, and gently lower the client to the floor. C. Grasp the gait belt, and instruct the client to fall gently down to the floor in a side-lying position. D. Hold the gait belt, and lower the client to the floor by using a narrow base of support.

Explanation Choice A is correct. For a client who is ambulating, the nurse should always be slightly behind the client and positioned on the affected (weaker) side. If a client starts to fall, the nurse should hold the gait belt, try to extend one leg, let the client slide against the leg, and gently lower the client to the floor, protecting the head. The nurse can help prevent client injury by maintaining a wide base of support.

patient states, "My friend beat cancer using complementary therapies; I think I should try that too." Which of the following responses from the nurse is most appropriate? Correct A. "Complementary therapies are not safe with your chemotherapy." [1%] B. "I would be desperate if I had cancer too." [0%] C. "Let us go get your healthcare provider so that we may discuss it with him." [17%] D. "Tell me more about what you mean when you say complementary therapies."

Explanation Choice D is correct. This is the most therapeutic statement. Effective communication always begins with an open-ended statement. It addresses the question asked by the client and will lead to further discussion. The nurse should explore what therapies the client is interested in talking about first, so that she may better help the client when discussing the therapies with the healthcare provider.

When the nurse begins to irrigate a Salem Sump tube, she notices that the gastric drainage is dark brown. What is the first intervention the nurse should take? Incorrect Correct Answer(s): A A. Perform a hemoccult test on the contents. [33%] B. Irrigate the tube and check the returns. [22%] C. Remove the tube from the suction. [9%] D. Check the pH of the gastric contents. [36%]

Explanation Answer and Rationale: The correct answer is A. The presence of dark brown drainage may indicate the presence of bleeding or blood in the GI tract.The first nursing intervention is to perform a hemoccult test to determine the presence of blood. B and C are not accurate nursing interventions in this case. D is incorrect. Checking the pH of the gastric contents only determines the gastric acidity.

The nurse is preparing to suction a tracheostomy tube. Place the following actions in the correct order for this procedure:

Explanation Answer: E, A, C, B, D First, the nurse will perform hand hygiene and identify the client. Second, hyper-oxygenate the client to prepare them for the procedure and prevent desaturations. Third, insert the suction catheter without suctioning to the pre-measured depth. The nurse should be sure to not allow the suction catheter to touch anywhere other than the inside of the tracheostomy. It is recommended to insert the suction catheter with the non-dominant hand. Fourth, apply intermittent suction and rotate the suction catheter as you remove it from the tracheostomy. The nurse should ensure that the suctioning does not exceed 10 seconds. Lastly, replace the cap, mist collar, oxygen mask, or other apparatus to the tracheostomy and monitor the client to ensure that they return to baseline. Additional Info ✓ Set the suction pressure to a safe and appropriate level, usually between 80-120 mmHg for adult clients. Higher pressures can damage the airway lining. ✓ Maintain a sterile technique throughout the procedure. Use sterile gloves, maintain a sterile field, and handle the suction catheter and tracheostomy tube with care to prevent contamination. ✓ Observe the client's oxygen saturation, heart rate, and respiratory rate during suctioning. If there is a significant drop in oxygen saturation or signs of distress, stop suctioning immediately and administer oxygen.

The LPN is caring for a client scheduled for surgery who has a diet order of nothing by mouth (NPO). Which of the following prescriptions should the LPN clarify with the primary healthcare physician (PHCP)? A. Lispro insulin 5 units SubQ before meals TID B. Glargine insulin 15 units SubQ QHS C. Vitamin B12 100 mcg IM Daily D. Clonidine patch transdermal TTS-1 0.1 mg/24 hours q 7 days

Explanation Choice A is correct. A client who is NPO awaiting surgery should not receive rapid or short-acting insulin. This insulin is intended to be given before meals, and the client could develop life-threatening hypoglycemia if given this type of insulin with no meal. Choices B, C, and D are incorrect. Glargine insulin is long-acting and has no peak. This basal insulin is appropriate to give to a client who is NPO. It is unlikely that the client would develop hypoglycemia with this insulin because it has no peak. Vitamin B12 IM may be given to a client as it is to be given parenterally. Finally, the clonidine patch may be applied to this client because it is not absorbed orally. This patch is applied for seven days and changed as prescribed thereafter. Additional Info ✓ For a client that is NPO, it is essential that the nurse examine the MAR closely for medications that are appropriate and inappropriate to administer. ✓ Classes of medications that should be clarified include - Endocrine medications (levothyroxine, rapid- and short-acting insulin) Neuropsychiatric medications (anti-psychotics, anti-epileptics) Cardiovascular (antihypertensives, anti-dysthymic)

The nurse is caring for a client three hours postoperative following a laparoscopic appendectomy. Which of the following client data indicates the client is ready for discharge home? Select all that apply. Positive gag reflex Hypoactive bowel sounds Blood pressure 90/60 mm Hg Incisional pain '2' on a scale of 0 to 10 Urinary output of 240 mL since surgery

Explanation Choice A is correct. A positive gag reflex is a reassuring finding supporting the client's readiness for discharge home. Sedation used during surgery often suppresses the gag reflex, and this is an important element to be assessed after surgery. Choice B is correct. Hypoactive bowel sounds are an expected finding. Medications used intraoperatively to sedate the client reduce peristalisis. The reduction of bowel sounds (hypoactive) is evidence of this decrease in peristalsis and is not an abnormal finding. Full colonic motility usually returns within 72 hours following surgery. Choice D is correct. The client reporting incisional pain rated as a 2/10 is an expected finding. This is regarded as mild pain and would not inhibit discharge. Choice E is correct. The client's urinary output is optimal. A client, during surgery, often receives fluids that are excreted postoperatively. Low urinary output is more likely to occur because of the anticholinergic effects of the anesthesia. It would be a concern if the client had low (or no) urinary output. Choice C is incorrect. This blood pressure is clinical hypotension and requires correction before discharge. The nurse should report this finding to the primary healthcare provider. The nurse must investigate the cause of this low blood pressure (bleeding, dehydration, etc.). Additional Info For a client to be discharged following surgery, the following criteria must be met - Adequate urinary output (at least 30 mL/hr) Return of reflexes (cough, gag, swallow) Ability to ambulate Vital signs within normal limits Ability to tolerate oral fluids Minimal nausea and vomiting Adequate pain control

The licensed practical/vocational nurse (LPN/VN) is reviewing client room assignments. Which room should the nurse assign to a client with hepatitis B? A client with A. heart failure receiving diuretics. B. bacterial meningitis receiving antibiotics. C. prostate cancer receiving brachytherapy. D. varicella prescribed antivirals.

Explanation Choice A is correct. Although hepatitis B needs to be reported to the public health department, a client with hepatitis B does not need to be isolated. An appropriate patient to room with would be an individual receiving intravenous diuretics for heart failure, as this client has no transmissible pathogens. Choices B, C, and D are incorrect. A client with bacterial meningitis requires droplet precautions, a client receiving brachytherapy requires a private room and airborne/contact isolation must be initiated for an individual with varicella. Additional Info ✓ Hepatitis B virus (HBV) is a blood-borne pathogen that also may be transmitted via unprotected sexual contact ✓ Hepatitis B is not spread through food or water, unlike hepatitis A ✓ Hepatitis B does not require isolation ✓ HBV vaccination is strongly recommended and is a three-dose

What is the nurse's most appropriate action to take on his/her shift for a client currently in 4 point restraints due to combative behavior? Correct A. Assess the client's skin integrity around the restraints hourly. [81%] B. Ensure that the physician has renewed the order for restraints, as should be done every 12 hours. [11%] C. Release the leg restraints to give the client a break and see if his combative behavior has improved. [7%] D. Have the attending physician discontinue the restraints and give the client a chance to behave better.

Explanation Choice A is correct. Combative clients should be assessed hourly and non-combative clients every two hours to ensure that skin breakdown around the restraints has not occurred.

The nurse observes a client clutching her abdomen and complaining of cramping, accompanied by sharp pain. Which of the following types of pain is the client experiencing? Correct Answer(s): A A. Cutaneous or superficial somatic [36%] B. Visceral [22%] C. Deep somatic [27%] D. Radiating [15%]

Explanation Choice A is correct. Cutaneous or superficial somatic pain arises in the skin or subcutaneous tissue. Such pain is described as sharp, aching, gnawing, or cramping. It is often localized. The client is experiencing sharp pain, which goes more in favor of cutaneous pain. Physical pain is either nociceptive or neuropathic. These two types of pain differ in how they affect the client and how they are treated. Nociceptive pain is the most common type of pain experienced. It occurs when pain receptors, which are called nociceptors, respond to potentially damaging stimuli, for example, as a result of noxious thermal, chemical, or mechanical stimuli. Nociceptive pain may occur because of trauma, surgery, or inflammation. Two types of nociceptive pain are: visceral pain (i.e. pain originating from internal organs) and somatic pain (i.e. pain originating from the skin, muscles, bones, or connective tissue). Choice B is incorrect. Visceral pain is caused by the stimulation of deep internal pain receptors. It is most often experienced in the abdominal cavity, cranium, or thorax. Visceral pain is not well localized and can be described as tight, pressure, deep squeeze, or aching pain. Choice C is incorrect. Deep somatic pain originates in the ligaments, tendons, nerves, blood vessels, and bones. It is localized and can be described as achy or tender. A fracture or sprain, arthritis, and bone cancer can cause deep somatic pain. Choice D is incorrect. Radiating pain starts at the origin but extends to other locations. Additional Info ✓ Be sensitive to cultural differences and language barriers that may affect the client's perception and expression of pain. Ensure that information is conveyed in a way that the client can understand. ✓ Pain is a subjective experience, and it can change over time. Reassess the client's pain regularly to ensure that the pain management plan remains effective. Adjust interventions as needed based on the client's changing pain levels and responses. ✓ Communicate with the interdisciplinary healthcare team to ensure a comprehensive approach to pain management. Collaborate with physicians, wound care specialists, and physical therapists, as needed.

The nurse is helping the unlicensed assistive personnel pass meal trays. When providing a meal tray for a client diagnosed with pheochromocytoma, which dietary item should the nurse remove? Correct A. Macaroni and cheddar cheese [62%] B. Watermelon slices [10%] C. Caffeine free cola [22%] D. Baked chicken [6%]

Explanation Choice A is correct. Pheochromocytoma is caused by a tumor on top of the adrenal medulla, causing a surge in catecholamines to be released, thus causing the client to experience headaches, hypertension, hyperglycemia, tremor, and unintentional weight loss. A client with pheochromocytoma is advised to modify their diet so that it does not increase blood pressure. Cheddar cheese contains tyramine and should not be included in the client's diet. Other dietary modifications include limitations of caffeinated beverages which may also raise blood pressure. Choice B is incorrect. Watermelon slices are a hydrating fruit choice and do not contain caffeine. This option is suitable for the client with pheochromocytoma and can be included in the meal. Choice C is incorrect. Even though this option is caffeine-free, colas can still contain other ingredients that might impact the client's blood pressure. It's safer to avoid cola products altogether. Choice D is incorrect. Baked chicken is a lean protein source and does not contain caffeine. This option is appropriate for the client with pheochromocytoma and can be included in the meal. Additional Info ✓ Pheochromocytoma is a condition caused by a tumor that sits on the adrenal medulla, causing a discharge of catecholamines ✓ This causes a surge in catecholamine discharge resulting in headaches, palpitations, weight loss, marked hypertension, and hyperglycemia ✓ Treatment includes antihypertensives (α-Adrenergic blocking agents are started 7 to 10 days before β-adrenergic blocking agents) and removal of the tumor via adrenalectomy ✓ Diagnosis is confirmed with a 24-hour urine collection looking for elevations in creatinine, total catecholamines, vanillylmandelic acid, and metanephrines ✓ The client should be educated to avoid sources of caffeine, smoking, and stressful situations, as this would further increase blood pressure

The nurse in the emergency department (ED) is caring for a child with erythema infectiosum (Fifth disease). Which transmission-based precautions should the nurse implement? A. Standard B. Droplet C. Contact D. Airborne

Explanation Choice A is correct. Standard precautions are used for a client with erythema infectiosum. Droplet precautions would only be necessary if the client is immunocompromised. Choices B, C, and D are incorrect. Isolation is not necessary for this virus. The exception to this would be if the client was immunocompromised which would then require standard + droplet. Additional Info Erythema infectiosum (Fifth disease) The causative agent is Parvovirus B19 Mode of transmission for this pathogen is respiratory secretions and blood, blood products Isolation is not necessary unless the child is immunosuppressed (standard/droplet will then be used) Manifestations include erythema on the face (slapped face appearance). It also causes the appearance of maculopapular red spots distributed on the upper and lower extremities. Finally, the client will have mild flu-like symptoms such as a fever, headache, and malaise Treatment is primarily supportive (antipyretics and analgesics) A blood transfusion may be needed for transient aplastic anemia

What is the most important factor to consider when assessing a home health client on fall risk? Correct A. Correct the illumination of the environment. [91%] B. Amount of regular exercise. [3%] C. The resting pulse rate. [3%] D. Amount of salt intake. [2%]

Explanation Choice A is correct. To prevent falls, the environment should be well-lit. Night lights should be used if necessary. Other factors in assessing include removing loose scatter rugs, removing spills, and installing handrails/grab bars as appropriate. While home health nurses cannot expect to change a family's living space and lifestyle, they can express their concerns and react appropriately when a situation suggests an imminent injury. Nurses must document the information they provide and the family's response to the instruction and make ongoing assessments about the family's use of safety precautions. For walkways and stairways (inside and outside), it is important to note uneven sidewalks or paths, broken or loose steps, absence of handrails or placement of handrails on only one side of the stairs, insecure handrails, congested hallways, or other traffic areas, and adequacy of lighting at night. Some important things for the home health nurse to assess, educate the client about, and document include: Floors: note uneven and highly polished or slippery floors and any unanchored rugs or mats. Furniture: note the hazardous placement of furniture with sharp corners. Note chairs or stools that are too low to get into and that provide inadequate support. Bathroom(s): note the presence of grab bars around tubs and toilets, nonslip surfaces in bathtubs and shower stalls, handheld showerhead, adequacy of night lighting, need for a raised toilet seat or bath chair in the tub or shower, ease of access to shelves, and water temperature regulated at a maximum of 49° C (120° F).

When a client receiving oxygen at a flow rate of 6 L/min by nasal cannula complains of nasal passage discomfort, what intervention should the nurse suggest to improve the client's comfort? Correct Answer(s): A A. Suggest adding humidification to the oxygen delivery system. [58%] B. Suggest that a simple face mask be used instead of a nasal cannula. [26%] C. Suggest that the patient be provided with an extra pillow. [7%] D. Suggest that the client sit up in a chair at the bedside. [8%]

Explanation Choice A is correct. When the flow rate of oxygen is higher than 4 L/min; the mucous membranes can become dry. The best treatment is to add humidification to the oxygen delivery system. The application of water-soluble jelly to the nares can also help decrease mucosal irritation. Choice B is incorrect. Changing the oxygen delivery method from a nasal cannula to a simple face mask may not address the issue of nasal passage discomfort. Additionally, switching to a face mask may not be indicated. Generally, face masks deliver a higher concentration of oxygen. Choice C is incorrect. While providing an extra pillow may be helpful for some clients to improve comfort, it does not directly address the issue of nasal passage discomfort related to oxygen therapy. Choice D is incorrect. Sitting up in a chair can promote comfort and respiratory function for some clients, but this does not address the nasal passage discomfort associated with dry oxygen flow. Additional Info ✓ Monitor the client's response to the humidification intervention. Assess for any improvement in the client's comfort and respiratory status. ✓ Ensure that the nasal cannula remains secure and properly positioned to prevent accidental disconnection or displacement, which may further irritate the nasal passages. ✓ Collaborate with other members of the healthcare team, such as respiratory therapists. So they are aware of the client's discomfort and know to keep the humidification in place for the client.

The nurse working with geriatric clients understands that falls are likely to occur in elderly clients who are: A. Living on disability insurance B. In their 80s C. Living in their own home D. Hospitalized

Explanation Choice D is correct. Unfamiliar surroundings are a significant risk factor for falls, especially in the elderly. The hospitalized client may become confused or bump into furniture, which could result in a fall. Age-related changes may affect the mobility and safety of older adults. For example, decreased muscle strength reduced balance, and osteoporosis put older adults at risk for falls and fractures. For health promotion, the nurse assesses the musculoskeletal functioning of the older adult and identifies any risk factors that may contribute to falls or the ability of the older adult to perform ADLs. Health promotion interventions often include providing information about the risk factors for osteoporosis and the importance of adequate calcium and vitamin D intake. Choice A is incorrect. An individual's source of income has no bearing on the risk of falls. Choice B is incorrect. While age-related changes may cause weakness and slowed reflex response, age is not the most likely risk factor for falls among the available answer choices. Choice C is incorrect. An elderly client living in his own home will be less likely to fall than a client who is in unfamiliar surroundings.

Which of the following would be a priority action for a nurse who sustained a needlestick injury while working with an AIDS client? A. Contact a social worker right away. B. Start prophylactic AZT. C. Start prophylactic Pentamidine treatment. D. Make an appointment with a psychiatrist.

Explanation Choice B is correct. AZT (Zidovudine) is the most critical intervention. It is an antiretroviral medication used to prevent and treat HIV/AIDS by reducing the virus's replication. Choice A is incorrect. A social worker consultation is not the most emergent action at this point. Choice C is incorrect. Pentamidine is a synthetic antibiotic used chiefly in the treatment of pneumocystis carinii pneumonia. Choice D is incorrect. A psychiatric appointment is not indicated. Additional Info ✓ The nurse's first priority should be to provide immediate first aid to themselves at the site of the needlestick injury. This may include gently washing the area with soap and water and applying pressure if there is bleeding. Afterward, the nurse should report the incident promptly to their supervisor or designated person responsible for managing workplace injuries. Early reporting is essential to initiate the appropriate follow-up procedures. ✓ The incident should prompt a review of infection control and safety protocols in the healthcare setting. Educational initiatives should be implemented to reinforce safe work practices, proper handling of sharp objects, and the importance of adhering to standard precautions to minimize the risk of needlestick injuries. ✓ Needlestick injuries can be distressing for healthcare workers, causing fear and anxiety about potential infection. The nurse should be offered emotional support and counseling services to address the psychological impact of the incident.

Which of the following findings would prompt immediate investigation when performing an assessment of a client on a medical/surgical unit? A. Bowel sounds of 14 per minute. B. High-pitched bowel sounds at a rate of 4 per minute. C. Bowel sounds greater than 60 per minute. D. Low-pitched bowel sounds at a rate of 30 per minute.

Explanation Choice B is correct. Bowel sounds less than 5 per minute may indicate blockage and should be evaluated. Bowel sounds are high-pitched, occasional gurgles, or clicks that last from one to several seconds. They occur every 5 to 15 seconds in an average adult. Choices A, C, and D are incorrect. A is incorrect. Bowel sounds of 14 per minute are considered normal. C is incorrect. Although bowel sounds of more than 30 per minute are considered hyperactive, it is not an immediate concern as answer choice B. D is incorrect. Bowel sounds usually are high-pitched. However, the rate of bowel sounds is normal. This option does not pose as much of a concern as answer choice B. Additional Info ✓ Monitor the client for any signs of abdominal distention, which could suggest a possible bowel obstruction. ✓ The healthcare provider may order diagnostic tests such as abdominal X-rays (KUB) or CT scan. Be prepared to facilitate these orders. ✓ Perform regular and thorough assessments of the client's vital signs, symptoms, and any changes in condition. Report any abnormalities or concerns to the registered nurse or healthcare provider promptly.

Which of the following steps is the final step used during the physical assessment of the abdomen? Correct A. Inspection [3%] B. Deep palpation [53%] C. Percussion [26%] D. None of the above [18%]

Explanation Choice B is correct. Deep palpation is cautiously done after light palpation when necessary because the client's responses to deep palpation may include tightening of the abdominal muscles. When this occurs, it could make light palpation less effective, particularly if an area of pain or tenderness has been palpated. A complete health assessment may be conducted starting at the head and proceeding systematically downward (head-to-toe evaluation). However, the procedure can vary according to the individual's age, the severity of the illness, the preferences of the nurse, the location of the examination, and the hospital's priorities and procedures.

The nurse plans to use a mechanical lift to transfer a client from a stretcher to a wheelchair. Which appropriate action should the nurse take? Correct A. Keep the stretcher's side rails raised during the transfer [6%] B. Instruct the client to fold their arms over their chest [91%] C. Apply gloves and gown for this procedure [0%] D. Unlock the wheels on the stretcher and wheelchair [2%]

Explanation Choice B is correct. During any mechanical lift transfer, the nurse should instruct the client to fold their arms over the chest, preventing injuries to the client's arms during the transfer. Choices A, C, and D are incorrect. The side rails of the stretcher should be lowered during the actual transfer because the side rails being raised may impede the client from transferring the stretcher to the wheelchair. If the side rails were raised, this would cause the nurse to raise the client even higher using the lift, which could cause injury if the client were to fall. Gloves and a gown are unnecessary for this procedure and would waste facility resources. Standard precautions are sufficient for this task. The wheels of the stretcher and wheelchair should be locked to prevent the client from slipping from either. Additional Info ✓ A mechanical lift should only be used by staff who have been appropriately trained. ✓ A mechanical lift may be hydraulic or be affixed to the ceiling. ✓ The nurse (or UAP) should always check the weight restrictions for the lift before its use. ✓ When applying a mechanical lift to a client, the lift will be applied with the client lying supine in bed. ✓ A second staff member must assist the hydraulic lift to lower the client into the chair (or back to bed).

The LPN is reinforcing education to a client about modifiable risk factors and risk factors that are not. Which of the following is most likely able to be corrected? A. Genetic predisposition B. Lifestyle choices C. Depression D. All of the above

Explanation Choice B is correct. Lifestyle choices are the risk factors that are most likely able to be corrected. Poor lifestyle choices place a person at risk and they are often considered risky behaviors. Choices A, C, and D are incorrect. A is incorrect. While genetics, age, and gender may predispose a person to certain risk factors, they are NOT modifiable risks. C is incorrect. Depression may be a risk factor for developing other health issues. However, depression is not independently modifiable. Depression is an illness that must be treated and monitored. Since A and C are incorrect, D is also wrong.

The nurse is caring for a 26-year-old patient who is unable to meet their nutritional needs by mouth. The interdisciplinary team decides it would be best to insert an NG tube for enteral feedings. After inserting the tube, the nurse knows that which of the following is the most accurate way to verify the placement of the tube? A. Aspiration of stomach contents B. pH verification of the aspirate C. Auscultation of air in the LUQ when injected into the tube D. Visualization on x-ray

Explanation Choice D is correct. Visualization on x-ray is the gold standard for verification of nasogastric tube placement. This allows the radiologist to visualize the tip of the tube in the stomach and recommend any changes in placement that may be needed, such as pulling the tube back or advancing further.

The nurse is collecting data on a client in bilateral wrist restraints. Which observation or finding would require follow-up? Correct A. Restraint secured to the bed frame [16%] B. The client is in the prone position [65%] C. Quick release buckle is present [4%] D. Radial pulse is 2+ bilaterally [14%]

Explanation Choice B is correct. Placing a client in the prone position while in restraints can be unsafe as it may impede proper breathing and increase the risk of respiratory distress. The nurse should follow up on this finding to ensure the client's safety and comfort. Choice A is incorrect. This is an appropriate way to secure restraints, ensuring the client's safety and preventing self-harm. There is no immediate need for follow-up based on this observation. Choice C is incorrect. The presence of a quick-release buckle is an essential safety feature in restraints. It allows for the quick removal of restraints in case of an emergency. This finding indicates proper restraint usage and does not require follow-up. Choice D is incorrect. A 2+ radial pulse suggests that the client's peripheral circulation is intact. It's a positive finding indicating adequate blood flow to the wrists, which is essential when using restraints. No follow-up is needed for this observation. Additional Info ✓ Restraints should be used as a last resort if alternative methods are not effective. ✓ A nurse should never threaten a client with restraints. This is considered assault. ✓ Restraints are never as needed (PRN). They should be discontinued at the earliest possible time. ✓ The nurse should observe the client at frequent intervals to offer nutrition & toileting, assess their behavioral status, obtain vital signs, and provide range of motion. These intervals are determined by the facility and the type of restraint—the more restrictive the restraint and the younger the client, the more frequent assessment. ✓ Restraints must be able to quickly be removed via a quick release buckle (knots are no longer recommended). ✓ The nurses' documentation must be comprehensive, describing the reasoning for the restraints, alternatives utilized, the education provided to the client, the type of restraint utilized, how it was secured, and the ongoing behavior necessary to continue the restraint. The nurse should also document the intervals at which the restraints were released.

The nurse is assisting a client using a fracture bedpan. Which action should the nurse take? A. Position the client prone while applying the bed pan B. Raise the head-of-bed to 30 degrees C. Place the open rim of the bedpan facing toward the head of the bed D. Lower all of the side rails

Explanation Choice B is correct. Placing the head-of-bed at 30 to 60 degrees will facilitate comfort by preventing strain on the lumbar spinal column. Choices A, C, and D are incorrect. When applying the bedpan, the client should be supine, not prone. The open rim of the bedpan should be facing toward the foot of the bed. This will prevent spillage and promote comfort. All of the side rails should not be lowered. The nurse should raise the side rail on the opposite side of the bed. This will allow the client to turn so the nurse may place the bedpan. Additional Info Two types of bedpans are available The regular bedpan, made of plastic, has a curved smooth upper end and a sharper-edged lower end and is about 5 cm (2 inches) deep. The smaller fracture pan, designed for clients with lower-extremity fractures, has a shallow upper end about 2.5 cm (1 inch) deep. The shallow end of the pan fits under the buttocks toward the sacrum; the deeper end, which has a handle, goes just under the upper thighs. The pan needs to be high enough that feces enter it. The appropriate position for the client is 30 to 60 degrees. A client may be positioned on a bedpan by having them roll to the opposite side (using the side rail for leverage) or lifting up their buttocks so the pan may be placed.

The nurse is caring for a client with a Sengstaken-Blakemore tube. When the safety check is performed at the beginning of the shift the nurse ensures which one of the following priority items is readily available at the bedside? A. Trach kit B. Scissors C. Obturator D. Yaunker

Explanation Choice B is correct. Scissors must be kept at the bedside of any client with a Sengstaken-Blakemore tube. The nurse should check for this essential item at the beginning of her shift to ensure the safety of the client. Scissors are necessary for this client because if the Sengstaken-Blakemore tube were to rupture the tube would move upward and could obstruct the airway. This is an emergency, and the nurse would need to immediately notify the RN so that the balloon can be cut. Choice A is incorrect. An extra trach kit does not need to be at the bedside of a client with a Sengstaken-Blakemore tube, rather this is a priority item for a client with a tracheostomy. Choice C is incorrect. An obturator does not need to be at the bedside of a client with a Sengstaken-Blakemore tube, rather this is a priority item for a client with a tracheostomy. Choice D is incorrect. A Yankauer suction catheter is kept at the bedside of most clients in the event that they need oral suctioning. While this is an appropriate item to keep at the bedside, it is not the priority for this client. Additional Info ✓ LPNs should be aware of the potential complications associated with the tube and the need for rapid response in emergencies. Having the appropriate scissors or wire cutters at the bedside allows for quick and safe removal if necessary. ✓ LPNs should prioritize client safety and follow established protocols when dealing with the tube, including securing scissors or wire cutters nearby and adhering to infection control practices. ✓ Effective communication with the healthcare team is vital. LPNs should report any concerning signs or symptoms related to the tube to registered nurses or physicians promptly.

The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. This specimen is then : A. Placed in a separate container and later added to the collection. B. Discarded, then the collection process begins. C. Tested, then discarded. D. Saved as part of the 24-hour collection.

Explanation Choice B is correct. The client should collect the first specimen, which is considered "old urine" or urine in the bladder before the test began. After the first discarded specimen, urine is collected for 24 hours. A 24-hour urine collection may be prescribed to evaluate some renal disorders by showing kidney function at different times of the day and night. The nurse is responsible for providing the collection container and educating the client on how to collect the specimen.

The nurse is monitoring a client with a chest tube for crepitus. Which of the following actions is appropriate for this? A. Press down on the client's abdomen, releasing, and assessing for pain. B. Palpate the skin around the chest tube and observe for a crackling sensation. C. Auscultate the bowel sounds in each quadrant. D. Inspect the client's chest for even rise and fall.

Explanation Choice B is correct. The nurse may assess for crepitus by palpating the skin around the chest tube and observing for a crackling sensation. Crepitus is defined as the infiltration of air in the subcutaneous layer of skin, also known as subcutaneous emphysema. It is caused by air leaking into the subcutaneous space and can be assessed by palpating the skin and noting a crackling sensation. Choice A is incorrect. When the nurse presses down on a client's abdomen and then releases it, the nurse is collecting data regarding rebound tenderness. This occurs when pain is present upon letting go of the client's abdomen, not pressing inward. It is a sign of peritonitis. Choice C is incorrect. Auscultating the bowel sounds in each quadrant is not an appropriate way to assess for crepitus. Choice D is incorrect. Inspecting the client's chest for even rise and fall will not allow the nurse to monitor for crepitus; rather this will help the nurse collect data on the symmetry of the chest and breathing rate/pattern. Additional Info ✓ Concentrate on areas around the insertion site of the chest tube and also extend the assessment along the chest wall. Crepitus might be felt under the skin when air escapes from the pleural space and travels along tissue planes. ✓ If LPNs feel crepitus or observe any signs of subcutaneous air, communicate the findings to the registered nurse or appropriate healthcare provider. Prompt communication ensures timely evaluation and intervention. ✓ Ensure the client's privacy and dignity are maintained during the assessment. Use appropriate draping and communication techniques to create a comfortable environment.

According to guidelines issued by the Joint Commission, which of the following represents the proper use of restraints? Correct A. The nurse positions the client in a supine position before applying wrist restraints. [7%] B. The nurse ensures that two fingers can be inserted between the restraint and the client's ankle. [88%] C. The nurse applies a cloth restraint to the left hand of a client with an IV catheter in the right wrist. [3%] D. The nurse ties an elbow restraint to the raised side rail of a client's bed. [2%]

Explanation Choice B is correct. The nurse should be able to place two fingers between the restraint and a client's wrist or ankle. Choice A is incorrect. The client should not be placed in a supine position with restraints due to the risk of aspiration. Choice C is incorrect. Due to the client having an IV in the right wrist, alternative forms of restraints should be tried, such as a cloth pit or an elbow restraint. Choice D is incorrect. Securing the restraints to a side rail may injure the client when the side rail is lowered. Additional Info ✓ Restraints should be employed as a last resort when all other less restrictive alternatives have been exhausted, and only if there is an immediate risk to the client's safety or the safety of others. ✓ A qualified healthcare professional, such as a physician or advanced practice nurse, must assess the client and provide a written order for the use of restraints. The order should include the reason for restraint use, the type of restraint, and the duration. ✓ Clients in restraints require continuous monitoring and frequent reassessment to evaluate their condition, ensure their well-being, and identify the earliest possible opportunity to discontinue the restraint.

The nurse is observing a student nurse feed a client requiring aspiration precautions. The nurse should intervene if the student Correct A. asks the client to remain sitting upright for at least 30 to 60 minutes after a meal. [6%] B. reminds the client to tilt their head backward when eating and drinking. [82%] C. avoids mixing foods of different textures in the same mouthful. [6%] D. places salt and pepper on the client's food at their request. [6%]

Explanation Choice B is correct. This action by the student nurse requires intervention. The client should assume the chin-down position and be reminded not to tilt backward when eating or drinking. The client should be instructed to have their head turned and chin tucked to reduce the risk of aspiration. Reminding the client to tilt their head backward would increase their risk for aspiration. Choice A is correct. This is an appropriate action by the student and does not require intervention. Remaining upright after meals or snacks reduces the chance of aspiration by allowing food particles remaining in the pharynx to clear. Choice C is correct. This is an appropriate action by the student and does not require intervention. For a client with aspiration precautions, foods should not be mixed with different textures in the same mouthful. Single textures are easier to swallow. Choice D is correct. This is an appropriate action. Condiments on food items are permitted, including salt and pepper. Food should be seasoned to taste. Additional Info ✓ When feeding a client requiring aspiration precautions, the nurse should ensure the client is rested prior to eating. ✓ Suction should be available, and a pulse oximetry device may be applied as a reading that decreases by 2% may signify aspiration. ✓ Head-turn-plus-chin-down maneuver may be more successful in reducing aspiration.

The nurse is obtaining vital signs for a client who has acquired immune deficiency syndrome (AIDS). Prior to entering the room, the nurse should do which of the following? Correct A. Wear gloves and a gown. [9%] B. Perform hand hygiene. [81%] C. Review the client's viral load. [4%] D. Obtain a disposable stethoscope. [6%]

Explanation Choice B is correct. When caring for a client who has AIDS, the nurse should maintain standard precautions. Applying PPE such as a gown, pair of gloves, and mask would be inappropriate. Standard precautions require appropriate hand hygiene and other PPE as needed. Choices A, C, and D are incorrect. The diagnosis of AIDS requires standard precautions which mandate appropriate hand hygiene. It would be inappropriate for gowns or gloves to be worn during client care. Assessing the client's viral load prior to obtaining vital signs would not change the fact that this client requires standard precautions. A disposable stethoscope and blood pressure cuff may be useful for a client with contact precautions, but it would not be necessary for a client with AIDS. Additional Info For a client with standard precautions, hand hygiene is required before and after client care. The nurse may use alcohol-based hand sanitizers only if the hands are not visibly soiled. Another exception to the use of alcohol-based hand sanitizers is if the client has a pathogen such as C. difficile, which requires that the hands be washed with soap and water. Gloves should only be worn when contact with mucous membranes, blood, or non-intact skin will be anticipated. This type of contact is not expected during the collection of vital signs.

The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure? Correct A. Nasogastric tube (NGT) [7%] B. Bottle of sterile water [10%] C. Suction equipment [72%] D. Tracheostomy [10%]

Explanation Choice C is correct. A cheiloplasty is a procedure to repair a cleft lip (CL). This procedure is typically done by age three to six months. A concern after this procedure is that the child may have excessive secretions that may trigger aspiration. The nurse should have a bulb syringe or some other suction equipment available if the infant begins to choke. While routine suctioning is not done to minimize pain or trauma, this is necessary to have it available to prevent respiratory distress. Choices A, B, and D are incorrect. An NGT is not necessary following this procedure. Following a CL repair, some infants can return to breastfeeding or bottle feeding, where some may have to be fed via a syringe. A bottle of sterile water is necessary if a client has a chest tube and it becomes disconnected from the drainage system. A chest tube is not used in this surgery. A tracheostomy is necessary at the bedside for a client immediately after a thyroidectomy, which may be used if the client gets airway edema. Additional Info ✓ Following a cleft lip repair, some surgeons allow the infant to return to breastfeeding or bottle-feeding, whereas others require syringe-feeding once the child is awake and alert. ✓ The nurse should provide pain management which may include acetaminophen. ✓ The nurse should ensure that no rigid objects are inserted into the mouth that may disrupt the suture line. ✓ After the infant is fed, the suture line may be cleaned with water, and a thin layer of antibiotic ointment may be applied. ✓ Finally, the infant should not be positioned prone and positioned to prevent airway obstruction. ✓ The ideal position is the infant positioned on their back, slightly upright.

The nurse is caring for a client with streptococcal pharyngitis (tonsillitis) who has been placed on droplet precautions. Which of the following statements indicates the best understanding of this type of isolation? Correct A. The client can be placed in a room with another client with measles (rubeola). [10%] B. A special mask (N95) should be worn when working with the client. [28%] C. Must maintain a spatial distance of 3 feet. [46%] D. Gloves should be worn only when giving direct care. [15%]

Explanation Choice C is correct. A spatial distance of at least 3 feet is recommended. The most common forms of transmission of an organism in a client with tonsillitis are coughing, sneezing, and talking. Droplets can travel no more than 3 ft, so precautions should be maintained when there is a possibility of entering this distance. Choice A is incorrect. This client requires a private room. Choice B is incorrect. An N95 mask is not required for this client. A face mask instead can be used when dealing with the client. Choice D is incorrect. Gloves, gowns, face masks, and eye protection should be worn when providing direct care. Additional Info ✓ Ensure that you and all healthcare personnel follow proper hand hygiene and wear appropriate personal protective equipment (PPE), including masks and eye protection ✓ Educate the client and their family about the nature of streptococcal pharyngitis, its mode of transmission, and the importance of isolation precautions. Encourage the client to follow good respiratory hygiene, such as covering their mouth and nose when coughing or sneezing. ✓ Streptococcal pharyngitis, often referred to as strep throat, is a common bacterial infection primarily affecting children and adolescents. It is estimated that strep throat accounts for a significant proportion of sore throat cases in this age group. However, it can occur in people of all ages.

Upon entering a client's room, the nurse finds the client lying on the floor. What is the first action the nurse should implement? A. Call for help to get the client back in bed. B. Assist the client back to bed. C. Establish if the client is responsive. D. Ask the client for details about what happened.

Explanation Choice C is correct. Assessing if the client is responsive is the primary concern of the nurse in this example. Consciousness should be assessed first, and the nurse should move on to the subsequent action of moving/assisting the client. Choice A is incorrect. Assessing the client's responsiveness is a priority before moving the client. Choice B is incorrect. Assessing the client's responsiveness is a priority before moving the client. A medical emergency may be taking place which takes priority over getting the client back to bed. Choice D is incorrect. Knowing how the fall occurred will help identify the cause and enable the nursing staff to initiate actions to prevent future falls. However, the nurse should assess responsiveness before attempting to obtain further information regarding the incident.

When teaching medication safety to a toddler's parent, which statement by the parent would be a cause for concern? Correct A. "I always check to make sure the safety cap clicks when I close it." [2%] B. "We store all of our medicines on a really high shelf." [4%] C. "To get her to take her medicine, we tell her it's candy." [77%] D. "We store our medicines and vitamins together." [16%]

Explanation Choice C is correct. Children should never be told that medication is candy.

The process of absorbing drugs before elimination after they have been excreted into bile and delivered to the intestines is called: Correct Answer(s): C A. Hepatic clearance [28%] B. Total clearance [12%] C. Enterohepatic cycling [38%] D. First-pass effect [22%]

Explanation Choice C is correct. Drugs and drug metabolites with molecular weights higher than 300 may be excreted via the bile, stored in the gallbladder, delivered to the intestines by the bile duct, and then reabsorbed into the circulation. This process reduces the elimination of drugs and prolongs their half-life and duration of action in the body. Before drugs can be clinically useful, they must be absorbed. Absorption is the process of a drug moving from its site of delivery into the bloodstream. The chemical composition of a drug and the environment into which a drug is placed work together to determine the rate and extent of drug absorption. Absorption can be accomplished by administering the drug in various ways (orally, rectally, intramuscularly, subcutaneously, inhalation, topically, etc). If a drug is administered intravenously, the need for absorption is bypassed entirely. For drug absorption to be most efficient, the drug's properties and the pH of the environment where the drug is located must be considered. Most drugs are either weak acids or weak bases. Drugs that are weak acids will pick up a proton when placed in an acidic environment and will, thus, be de-ionized. Other factors that also impact drug absorption include the following: A drug's absorption is enhanced physiologically if there is a large surface area available for absorption (villi/microvilli of the intestinal tract). Suppose there is a large blood supply for the drug to move down its concentration gradient. The presence of food/other medications in the stomach may impact drug absorption - sometimes enhancing absorption and other times, forming insoluble complexes that are not absorbed (it depends on the specific drug). Some drugs are inactivated before they can be absorbed by enzymes, acidity, bacteria, etc.

The LPN is working on the pediatric floor caring for a 2-year-old who receiving 100% FiO2 via a nasal cannula. At the end of her shift, the hospital receives a tornado warning. Which of the following actions should the nurse take to best protect her patient? A. Clock out, her shift is over and she is not responsible. B. Remove the nasal cannula and carry the child to a tornado shelter. C. Move the patient as close to the interior of the room as possible. D. Close all of the doors.

Explanation Choice C is correct. During a tornado warning, the appropriate nursing action is to move patients away from windows and as close to the interior of the room as they can safely be moved. This best protects them in the event of a tornado.

The son of a client with early Alzheimer's disease states, "I'm so tired of hearing Dad talk about the past all the time." What is the nurse's best response? Correct A. "You should have more patience with your father and accepting of his disease." [4%] B. "He is quite anxious at this stage. Reliving the past helps him become calm again." [24%] C. "He has lost his short-term memory but can still remember events from long ago." [63%] D. "Just remind him when he repeats himself and that will reinforce better behavior." [8%]

Explanation Choice C is correct. Family members can become frustrated when clients with Alzheimer's disease lose short-term memory. The nurse should explain to the family member that it is the "short-term memory" that is declining and encourage the client to talk about things that he/she can remember. Choice A is incorrect. During the early stages of Alzheimer's, family members are still trying to learn about and cope with the changes that their loved ones are experiencing. Patience with the family will be more beneficial than the scolding tone that this answer choice portrays. Choice B is incorrect. Early Alzheimer's symptoms are not usually reflective of anxiety. Also, it is not true that the client is reliving past experiences because it makes him calm. Instead, his behavior is expected as Alzheimer's first affects short-term memory. Choice D is incorrect. Reminding an Alzheimer's client that he is repeating himself will not improve the behavior as his short-term memory is affected. The hippocampus is the structure responsible for creating new memories from experiences. When it is damaged, short-term memory is compromised.

The nurse knows it is important to monitor a client's use of complementary and alternative medicine (CAM) because? A. Clients should be warned that most CAM therapies are potentially dangerous. B. Additional treatment may not be needed if the client is using CAM. C. CAM therapy could interact with prescription and over-the-counter medications. D. Most CAM therapies are essentially ineffective.

Explanation Choice C is correct. One key concept to remember when dealing with alternative therapies is that natural does not always mean "better or safe." Some herbal products contain ingredients that may interact with prescription drugs. For example, clients taking medications with potentially dangerous adverse effects, such as insulin, warfarin, or digoxin, should be warned to never take dietary supplements without first discussing their needs with a physician. Complementary and alternative medicine (CAM) comprises an incredibly diverse set of therapies and healing systems. CAM is considered to be outside the mainstream of healthcare. From a therapeutic perspective, much of the value of CAM therapies is their ability to reduce medication needs. Choice A is incorrect. Most CAM therapies are not considered dangerous. However, clients should discuss CAM therapy with their physician before beginning therapy. Choice B is incorrect. While some therapies may reduce the need for conventional medical intervention, the use of CAM does not always reduce the need for that type of response. Choice D is incorrect. CAM therapies are considered valuable in the prevention and treatment of disease. For example, meditation, massage, yoga, and prayer have been used for centuries to treat the body and mind.

What consideration should the nurse keep in mind regarding the use of side rails for a confused client? A. They prevent confused clients from wandering. B. A history of a previous fall from bed with raised side rails is insignificant. C. A person of small stature is at increased risk for injury from entrapment. D. Alternative measures are ineffective to prevent wandering.

Explanation Choice C is correct. Studies of restraint-related deaths have shown that people of small stature are more likely to slip through or between the side rails. Additional Info ✓ Before implementing side rails, conduct a thorough risk assessment to determine if they are necessary for the client's safety. Consider factors such as the client's level of confusion, mobility, and history of falls. ✓ Explore alternative measures to ensure client safety, such as placing the bed at its lowest position, using bed alarms, providing constant supervision, or using soft padding to reduce the risk of injury. ✓ Regularly assess the client to determine if the side rails are still necessary. Side rails should not be used as a restraint unless absolutely necessary, and their use should be reassessed regularly.

The nurse detects an elevated temperature in a client who is scheduled for surgery. The client has been afebrile and has no other symptoms of fever. What should be the first nursing action? Correct A. Inform the charge nurse. [27%] B. Inform the surgeon. [24%] C. Validate the finding. [37%] D. Document the finding. [12%]

Explanation Choice C is correct. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Choices A and B are incorrect. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. Choice D is incorrect. The nurse should be sure that all data recorded is accurate. Thus the data should be validated before documentation if there are any doubts about the accuracy. Additional Info ✓ While the client may not exhibit other symptoms of fever, it is crucial for the LPN to perform a comprehensive assessment. Look for signs of infection or other concerning symptoms, such as increased heart rate, respiratory rate, or changes in the appearance of surgical sites. ✓ If an elevated temperature is confirmed, promptly communicate this finding to the registered nurse (RN) or charge nurse on duty. Collaboration and timely communication are essential to ensure that the appropriate actions are taken promptly. ✓ Ensure that the preoperative orders are reviewed carefully to identify any specific instructions or interventions related to the elevated temperature. This may include notifying the surgeon, anesthesia provider, or other members of the surgical team.

The nurse observes sparks fly from a client's bathroom light. Which action should the nurse take first? A. Obtain a fire extinguisher B. Close the bathroom door C. Remove the client from the room D. Activate the fire alarm.

Explanation Choice C is correct. The safety of the client is the highest priority in any emergency situation. Removing the client from the room is the first and most crucial action to protect them from potential harm, such as electrical shock or fire-related injuries. Choice A is incorrect. While a fire extinguisher can be a valuable tool for addressing a fire, especially if it's small and contained, it is not the first action to take in this scenario. The priority is ensuring the safety of the client by removing them from potential harm. Choice B is incorrect. Closing the bathroom door can be a useful action if a fire has already started, as it may help contain the fire and prevent its spread. However, the immediate concern is the client's safety, and removing them from the room takes precedence. Choice D is incorrect. Activating the fire alarm is an essential step to alert others in the facility and initiate a coordinated response to the incident. However, it should come after ensuring the client's safety by removing them from the room.

The licensed practical/vocational nurse (LPN/VN) conducts infection control audits in the nursing unit. Which client is at the greatest risk for infection? A client who Correct A. is withdrawing from alcohol and is malnourished. [4%] B. is receiving methylprednisolone for an asthma exacerbation. [9%] C. has an external urinary catheter device for urinary incontinence. [37%] D. is receiving total parenteral nutrition (TPN) via a central line. [49%]

Explanation Choice D is correct. A central line is a significant risk factor for a client to develop a central line-associated bloodstream infection (CLABSI). This occurs because of suboptimal sterile technique during insertion and/or inappropriate dressing changes. Additionally, TPN is a risk factor as the high glucose content makes the client more likely to develop a bacterial or fungal infection. TPN increases the risk for a CLABSI compared to solutions such as 0.9% saline. Choices A, B, and C are incorrect. A client withdrawing from alcohol has a risk for delirium tremens but not a risk for an infection. Further, being malnourished increases the risk of impaired skin integrity but not an infection. Methylprednisolone is a corticosteroid that, if used intermediate to long term, may increase the risk for infection. Asthma is a chronic disease that does not raise the risk of infection. An external urinary catheter is preferred over an internal catheter as this substantially decreases the risk of cystitis. This is a non-invasive way to collect urine. Urinary incontinence may raise the risk factor for cystitis, but this depends on the type (stress, urge, overflow). Additional Info ✓ Standard precautions are executed for all clients and include appropriate hand hygiene ✓ By adhering to standard precautions, the nurse may reduce the risk of a client getting a healthcare-acquired infection Other strategies that a nurse may employ to reduce the risk of infection include - ✓ Chlorhexidine baths for those immobile or having a central line ✓ Minimizing the use of internal urinary catheters ✓ Surgical asepsis when completing a central line dressing change ✓ Absolute adherence to appropriate hand hygiene

The nurse is reinforcing education to a client scheduled for an upcoming total hip arthroplasty. Which of the following statements by the client would require follow-up? Correct A. "I will need to bathe with chlorhexidine gluconate solution (CHG) the night before surgery to prevent an infection." [23%] B. "I will need to deep breathe and cough every 2 hours." [10%] C. "I will have to attend physical therapy sessions following my surgery." [7%] D. "I will be prescribed an anticoagulant and need to take it with a sip of water on the day of surgery."

Explanation Choice D is correct. After the surgery, the client will be prescribed VTE prevention (sequential compression devices, subcutaneous enoxaparin). The client should not take an anticoagulant or antiplatelet for 5-7 days or as directed by the surgeon before the surgery. This would raise the risk for intra- and postoperative hemorrhage. Other medications such as vitamin E, garlic, and aspirin should be avoided because these will increase the risk of bleeding. Choice A is incorrect. Infection is a concern following this surgery, and the client will be prescribed to take a bath with CHG the night before. Once the bath has been completed, the client should then sleep on clean linens and not with pets. Choice B is incorrect. The client will be instructed to deep breathe and cough and will be shown how to use the incentive spirometer. Choice C is incorrect. Aggressive physical therapy (PT) is part of the postoperative process. The PT continues after the client has been discharged, and the client must adhere to these appointments. Additional Info A total hip arthroplasty (THA) carries several postoperative complications ✓ To reduce the risk of a surgical site infection, the client is typically prescribed CHG soap so they can perform a CHG bath the night before. A preoperative antibiotic is typically administered within 60 minutes of the incision. ✓ To reduce the risk of pneumonia, the client will be instructed to deep breathe and cough and to use the incentive spirometer every 2 hours. ✓ To reduce the risk of venous thromboembolism, mechanical (sequential compression devices) and chemical (subcutaneous enoxaparin) prophylaxis are prescribed. ✓ To decrease the risk of hemorrhage, serial hemoglobin and hematocrit (H&H) levels may be ordered every six to eight hours for the first 24 hours postoperative.

Malnutrition, wasting, and ill health due to chronic disease are associated with: A. Surgical asepsis B. Catabolism C. Venous stasis D. Cachexia

Explanation Choice D is correct. Cachexia is associated with malnutrition, wasting, and ill health due to chronic illness. It can also result from the rupture of wound closure or the dehiscence of a surgical wound.

A nurse is preparing the plan of care for a client with stage 2 ovarian cancer who is a Jehovah's witness. The client has been told that surgery is necessary. Taking into consideration the client's religious preferences in developing the plan of care, the nurse documents which of the following? Correct A. Religious sacraments and traditions are unimportant. [1%] B. Medication administration is not allowed for this group. [1%] C. Surgery is strictly prohibited in this religious group. [2%] D. Blood transfusion or the administration of blood and blood products is forbidden for this group. [96%]

Explanation Choice D is correct. For Jehovah's witnesses, surgery is allowed, but the administration of blood and blood products is forbidden.

The nurse is caring for a client who has type 2 diabetes mellitus and hypertension. The client is nothing by mouth status (NPO) before a scheduled surgery. Which of the following prescribed medications should the nurse question? A. Metoprolol B. Phenytoin C. Levothyroxine D. Glipizide

Explanation Choice D is correct. Glipizide is a sulfonylurea and is given to the client with meals to manage blood glucose. This medication will lower blood glucose and could potentially cause hypoglycemia. The client is NPO and will not receive any food. Thus, the nurse should question the administration of this medication to prevent the client from developing hypoglycemia. Choices A, B, and C are incorrect. Endocrine medications (steroids, thyroid hormone), anticonvulsants, and beta-blockers are okay to give with a sip of water. Beta-blockers are given to clients with a sip of water before surgery to prevent intra- and post-procedure cardiac dysrhythmias. Additional Info Drugs for cardiac disease, respiratory disease, seizures, and hypertension are commonly allowed with a sip of water before surgery. Clients at risk for intra- and post-procedure cardiac dysrhythmias and hypertension are typically prescribed a presurgical beta-blocker to prevent this complication. Before administering a beta-blocker, the nurse should obtain the client's pulse and blood pressure.

Which of the following questions is the least useful in assessing a client who is requesting an AIDS test? A. Are you a drug user? B. Do you have many sex partners? C. What is your method of birth control? D. How old were you when you became sexually active?

Explanation Choice D is correct. The age at which sexual activity began is not relevant as it does not usually provide information that identifies risk factors for AIDS. When interviewing clients who are seeking/receiving care, the nurse needs to be nonjudgmental. Also, many clients are reluctant to disclose illicit drug use unless a safe environment has been established. Use words that describe behaviors like "drinking" and "using cocaine" instead of words that describe people such as junkie, crackhead, addict, alcoholic, and other pejorative terms. Start with less threatening questions. Examples: What over-the-counter and prescription medications are you taking? Do you inject any of those? How often do you use alcohol? Tobacco? When was the last time you used a drug from a non-medical source? Do not assume anything. Drug use occurs in all socioeconomic statuses. If a client says s/he uses or has used drugs, ask about specific medications (e.g. marijuana, heroin, methamphetamine). Don't forget that people also inject insulin, steroids, and hormones. Sharing injection equipment with these medications can also increase the risk of HIV transmission. Choice A is incorrect. Drug use is a risk factor for AIDS. Choice B is incorrect. Having multiple sex partners is a risk factor for AIDS. Choice C is incorrect. Although birth control methods may not prevent the spread of AIDS, practicing birth control methods is essential to prevent pregnancy and the risk of having a baby born HIV positive. Additionally, clients should be educated that using a condom is the best way to prevent AIDS/HIV transmission through sex. Additional Info ✓ When discussing potentially sensitive topics like sexual health and HIV/AIDS testing, approach the client with empathy and non-judgment. Create a safe and comfortable environment for open communication. ✓ If the client's risk factors suggest a potential need for testing, collaborate with the nurse or healthcare provider to ensure appropriate testing is conducted. Follow any protocols or guidelines in place at your healthcare facility. ✓ Be aware of cultural factors that may influence the client's willingness to discuss sexual health or undergo testing. Approach the conversation with cult

What is the highest priority nursing goal for a client whose hemoglobin is 10 g/dL(Male: 14-18 g/dL / Female: 12-16 g/dL) and hematocrit is 30%(Male: 42-52% / Female: 37-47%)? A. Encourage mobility B. Promote skin integrity C. Prevent constipation D. Conserve the client's energy

Explanation Choice D is correct. These test results indicate anemia. The impaired oxygen-carrying capacity of red blood cells causes cellular hypoxia which results in fatigue. Conserving energy limits oxygen expenditure and minimizes fatigue. The hematocrit, also known by several other names, is a blood test that measures the volume percentage of red blood cells in the blood. The measurement depends on the number and size of red blood cells. It usually is 40.7% to 50.3% for men and 36.1% to 44.3% for women. Hemoglobin, abbreviated Hb or Hgb, is the iron-containing oxygen-transport metalloprotein in the red blood cells of almost all vertebrates and the tissues of some invertebrates. Hemoglobin in the blood carries oxygen from the lungs or gills to the rest of the body.

The nurse is teaching a group of clients strategies to promote effective sleep. The nurse should recommend that the clients Select all that apply. empty their bladder before bed. take more naps throughout the day. eat a high amount of calories before bed. plan to vigorous exercise earlier in the day. use multiple nightlights in the bedroom.

Explanation Choices A and D are correct. Strategic ways for a client to get a restful night's sleep include emptying their bladder before bed and engaging in vigorous exercise in the early morning and afternoon. Vigorous exercise within two hours of bed may increase the client's arousal level and decrease sleep induction. Choices B, C, and E are incorrect. These measures would be detrimental to promoting sleep. The client should be instructed to eliminate naps. If naps cannot be eliminated, they should be done in the earlier part of the day and limited to thirty minutes. To prevent reflux, the client should be instructed to avoid heavy meals within three hours of bedtime. A light snack may be permitted, but it should be low in calories (a glass of skim milk or peanut butter with crackers). The light should be minimized (or eliminated) in the room. Having a dark room promotes the release of melatonin. Thus, the client should have dark shades and limited nightlights. Additional Info When educating a client about ways to promote sleep, the nurse should encourage the following - ➢ If unable to sleep for 15 to 30 minutes, do a relaxing activity such as reading ➢ Eliminate naps unless they are a routine part of the schedule ➢ If naps are taken, limit them to 30 minutes and time them early in the day ➢ Establish a nightly bedtime routine ➢ Do not eat a heavy meal within three hours of planned sleep ➢ Empty your bladder immediately before bed ➢ Limit caffeine and nicotine in the late afternoon and evening ➢ Discontinue use of electronic devices about 30 minutes before going to bed ➢ Avoid vigorous exercise in the evening within 2 hours of bedtime

When preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA, which PPE should the nurse plan to use? Select all that apply. 2/2 Your Score/Max +/- Scoring Rule Gloves N95 respirator Surgical mask Goggles Gown

Explanation Choices A and E are correct. A gown and gloves should be used when coming in contact with linens that may be contaminated by wound secretions. Approximately half of all MRSA infections are acquired in the hospital. One-fourth is associated with having received health care, but onset is in the community; the remainder is considered community-acquired. Due to aggressive health care emphasis on preventing MRSA transmission using standard and contact precautions, rates have decreased but are still unacceptably high. More Americans die each year from MRSA than from AIDS.

The nurse is discussing infection control with a group of nursing students. Which indication would be appropriate for the nurse to use an alcohol-based sanitizer? Select all that apply. Immediately before touching a client If the hands are visibly soiled with blood or bodily fluids When changing linens for a client infected with Clostridium difficile After changing a diaper for an infant infected with norovirus Before moving from work on a soiled body site to a clean body site on the same client Clostridium difficile

Explanation Choices A and E are correct. Alcohol-based hand rubs (ABHRs) are recommended over hand hygiene with soap and water because of the risk of errors associated with washing hands with soap and water. Specific criteria have been established for when a healthcare worker should use an ABHR, and these two circumstances are appropriate. Choice B is incorrect. If hands are visibly soiled with blood or bodily fluids, the hands should be washed with warm soapy water. Choice C is incorrect. Specific pathogens are resistant to ABHRs, including norovirus and Clostridium difficile. Choice D is incorrect. Contaminated items such as linens and clothing require the nurse to wash their hands with warm soapy water. Additional Info Circumstances when alcohol-based hand rubs (ABHRs) are permitted: ✓ Immediately before touching a client ✓ Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices ✓ Before moving from working on a soiled body site to a clean body site on the same client ✓ After touching a client or the client's immediate environment ✓ After contact with blood, body fluids, or contaminated surfaces ✓ Immediately after glove removal

Which steps should the LPN reinforce with a patient regarding blood glucose monitoring at home? Select all that apply. Washing and drying hands before testing. Choosing a different puncture site for each test. Read the monitor's instructions as each monitor may have different requirements. Recording the glucose level and the date/time of the test. When using an alcohol wipe, make certain the alcohol is completely dry before lancing. Submit Answer

Explanation Choices A, B, C, D and E are correct. A is correct. Washing and drying hands before testing. Clean hands are essential to ensure that the blood sample is not contaminated. Washing hands also helps to remove any residue that could affect the reading. B is correct. Choosing a different puncture site for each test. This helps prevent soreness or callus formation at one spot. It's recommended to rotate the puncture sites for each test. C is correct. Read the monitor's instructions, as each monitor may have different requirements. It's always essential to follow the instructions provided by the manufacturer of your specific glucose meter and test strips, as they may have specific guidelines on whether or not to wipe away the first drop of blood. D is correct. Recording the glucose level and the date/time of the test. Maintaining glucose readings and the date and time helps track trends and patterns in blood glucose levels. This is valuable information for healthcare providers when adjusting diet, exercise, or medication regimens. Choice E is incorrect. E is correct. Washing and drying hands thoroughly is sometimes recommended in lieu of an alcohol swab. However, if an alcohol swab is used, the alcohol must be entirely dry before testing as it can impact the result. Additional Info ✓Prepare Supplies: Gather all supplies, including glucose meter, testing strips, lancet device, and lancets. ✓Wash Hands: Start by washing hands with warm water and soap. This helps to ensure that the blood sample is not contaminated. Dry hands well. ✓Insert the Test Strip: Insert a new test strip into the glucose meter according to the instructions for a specific device. ✓Prepare the Lancet Device: Place a new lancet in the lancet device and set it to a depth that allows a good drop of blood with minimal discomfort. ✓Select a Site: Choose a different puncture site each time to avoid developing sore spots. The sides of the fingertips are often recommended because they are less sensitive than the tips. ✓Lance Finger: Press the lancet device against the side of the fingertip and trigger the device to lance skin. ✓Collect the Blood Sample: Gently squeeze or massage the finger (from base to tip) to get a drop of blood. It's al

What are the benefits of providing oral care to a client in critical care? Select all that apply. It promotes the client's sense of well-being. It prevents deterioration of the oral cavity. It contributes to a decreased incidence of aspiration pneumonia. It eliminates the need for flossing. It decreases oropharyngeal secretions. It compensates for an inadequate diet.

Explanation Choices A, B, and C are correct. Adequate oral hygiene is essential for promoting a client's sense of well-being and preventing oral cavity deterioration. Diligent oral hygiene care can also improve oral health and limit pathogens' growth on oropharyngeal secretions, decreasing the incidence of aspiration pneumonia and other systemic diseases. Choices D, E, and F are incorrect. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition. Additional Info ✓ Oral care helps to reduce the bacterial load in the mouth, preventing the spread of harmful bacteria to other parts of the body, such as the lungs or bloodstream. ✓ Oral care can improve the client's ability to eat and drink comfortably, ensuring adequate nutrition and hydration, which are vital for recovery and overall health. ✓ Regular oral assessments during care can help identify potential oral health problems early, allowing for timely interventions and preventing complications.

The nurse incorporates the therapeutic use of reminiscence into the client's care plan. Which statement best explains the rationale for implementing this intervention? Select all that apply. 4/5 Your Score/Max +/- Scoring Rule Improve communication skills and social interactions in elderly clients. Reduce agitation and behavioral disturbances in clients with dementia. Promotes the development of new neural pathways and improves cognitive function. Reminiscence enhances self-esteem and a sense of personal worth in elderly clients. Assists in addressing unresolved emotional issues and promoting emotional healing.

Explanation Choices A, B, C, D, and E are correct. A is correct. Reminiscence therapy helps elderly clients improve communication and social interactions. By reminiscing activities, clients can enhance their communication skills and connect with others, promoting social interactions. B is correct. Reminiscence therapy reduces agitation and behavioral disturbances in clients with dementia. Recalling positive memories and discussing the past can help calm and soothe individuals with dementia, reducing agitation and behavioral issues. C is correct. Reminiscence therapy stimulates cognitive function and mental abilities. Memory recall and storytelling exercise the brain, potentially improving memory, attention, and overall cognitive function. D is correct. Reminiscence therapy boosts self-esteem and a sense of personal worth. Reflecting on past achievements and positive life experiences reinforces a client's self-esteem and validates their sense of identity and value. E is correct. Reminiscence therapy addresses unresolved emotional issues and promotes emotional healing. Through reminiscing, clients can revisit and process past experiences, leading to insights, closure, and emotional healing in a supportive environment.

The nurse is teaching a client about a vegan diet. Which of the following foods should the nurse recommend for this diet? Select all that apply. 5/5 Your Score/Max +/- Scoring Rule Legumes Tofu Almonds Prunes Baked fish Grapefruit

Explanation Choices A, B, C, D, and F are correct. The crux of the vegan diet is that it excludes foods that come from animals, including dairy products and eggs. Foods such as vegetables, nuts, legumes, plant-based oils, and seeds are encouraged. Choice E is incorrect. The vegan diet excludes anything from an animal, including seafood, cheese, eggs, and cream. Additional Info ✓ The vegan diet focuses on no meat or animal fats. ✓ The diet is generally high in fiber. ✓ Foods such as nuts, legumes, tofu, grapefruit, melon, and soy are permitted. ✓ Vegan diet is generally safe during pregnancy but requires appropriate meal planning. ✓ The primary difference between a vegan and a vegetarian diet is that a vegetarian diet includes eggs and dairy.

Which of the following are components of building trust in the nurse/client relationship? Consistently demonstrating competence and knowledge in nursing care. Practicing open and honest communication with the client. Ignoring the client's cultural beliefs and practices because they might not align with medical recommendations. Maintaining confidentiality of the client's information. Being consistent and reliable in delivering care and following through on promises.

Explanation Choices A, B, D, and E are correct. A is correct. When nurses demonstrate competence and knowledge, patients can trust they receive high-quality care, which is critical to building a trusting relationship. B is correct. Open and honest communication fosters understanding and reduces potential misunderstandings or misinterpretations. It encourages the client to feel more secure and trust the nurse's intentions and actions. D is correct. Keeping client information confidential is a key ethical and professional requirement in nursing. It also ensures the client trusts the nurse and the healthcare system. E is correct. When nurses are consistent and reliable, it shows the client they can be depended upon. This builds trust over time as the client learns that the nurse will do what they say they will do. Choice C is incorrect. C is correct. Respecting and acknowledging the client's cultural beliefs and practices is crucial for building trust. Ignoring these aspects can cause the client to feel unheard or disrespected, undermining trust. Additional Info ✓Consistent Competence: Demonstrating knowledge and skill assures patients of their safety and well-being. ✓Empathy: Understanding and acknowledging patients' feelings can help build a deeper connection. ✓Reliability: Consistency in delivering care and fulfilling promises helps establish dependability. ✓Honesty: Even when the truth is complicated, honesty respects the patient's autonomy. ✓Communication: Clear, open, and respectful communication helps avoid misunderstandings and fosters mutual understanding. ✓Confidentiality: Keeping patient information private shows respect for their rights and fosters trust. ✓Respect for Cultural Differences: Understanding and respecting patients' cultural beliefs and practices contributes to personalized care and mutual respect. ✓Patient Advocacy: Representing patients' needs and wishes to other healthcare professionals demonstrates alignment with the patient's interests. ✓Time Management: Spending adequate time with the patient for care and communication shows the patient they are a priority. ✓Professional Boundaries: Keeping interactions professional and appropriate helps maintain the focus on the patient's needs

While caring for a 6-week-old child, the LPN measures the client's temperature as 38.7 degrees Celsius. Which diagnostic tests does the LPN anticipate the provider to order? Select all that apply. Complete blood count (CBC) Blood cultures Urinalysis X-ray of the chest Electrocardiogram (ECG)

Explanation Choices A, B, and C are correct. A is correct. Complete blood count (CBC): A high temperature in a 6-week-old child may prompt the provider to order a CBC to evaluate for signs of infection, such as an elevated white blood cell count. B is correct. Blood cultures: Blood cultures may be ordered to identify the presence of bacteria or other pathogens in the bloodstream, especially if there are concerns about a systemic infection. C is correct. Urinalysis: A urinalysis may be requested to assess for urinary tract infections (UTIs) as a potential cause of the fever in the 6-week-old child. Choices D and E are incorrect. D is correct. X-ray of the chest: This option is incorrect because a chest X-ray is not typically the initial diagnostic test ordered for a fever in a 6-week-old child. While it may be considered in specific cases, such as suspected pneumonia, it is not the most likely test in this scenario. E is correct. Electrocardiogram (ECG): This option is incorrect because an ECG is not typically ordered as a routine diagnostic test for evaluating a fever in a 6-week-old child. ECGs are primarily used to assess the heart's electrical activity and are not directly related to evaluating the cause of a fever. Additional Info According to "Wong's Nursing Care of Infants and Children" by Hockenberry, here is a bullet point list of potential causes of fever in infants: ✓Infections: Fever is commonly associated with infections in infants, including viral infections (such as colds, flu, and respiratory syncytial virus), bacterial infections (such as urinary tract infections, pneumonia, and meningitis), and other infections. ✓Immunizations: Some infants may experience a low-grade fever as a response to immunizations or vaccinations. Monitoring the temperature and following the healthcare provider's recommendations for managing post-immunization fevers is essential. ✓Teething: When an infant's teeth begin to emerge through the gums, teething can sometimes be associated with mild elevations in body temperature. However, fever should not be solely attributed to teething and should be evaluated further if other symptoms are present. ✓Overheating: Infants can experience a rise in body temperature due to exc

A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will you need to put on when preparing to assess the client? Select all that apply. Goggles Gown Gloves Shoe covers N95 respirator Surgical face mask

Explanation Choices B, C, and E are correct. Since herpes zoster is spread through airborne means and direct contact with the lesions, contact and airborne precautions should be followed. This means the nurse should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves. Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus (VZV), the same virus that causes varicella (chickenpox). Primary infection with VZV causes varicella. Once the illness resolves, the virus remains latent in the dorsal root ganglia. VZV can be reactive later in a person's life and create a painful, maculopapular rash called herpes zoster. Active herpes zoster lesions are infectious through direct contact with vesicular fluid until they dry and crust over. People with active herpes zoster lesions should cover their injuries and avoid contact with susceptible people in their household and occupational settings until their wounds are dry and crusted.

The nurse is assigned to multiple clients with fever. Taking a rectal temperature would be contraindicated in which of the following cases? Select all that apply. A client with rectal surgery and a post-operative abscess A child who has pneumonia. Post myocardial infarction patient. A teenager who has leukemia with low white blood cell count. An adult client with recent rectal surgery.

Explanation Choices A, C, D, and E are correct. (Choice A) Rectal temperature should not be used in clients with a history of rectal surgery. Because of the risk of disruption of surgical anastomosis, it is preferred to refrain from rectal temperature checks in such clients. Additionally, the rectal temperature should not be used in clients with diarrhea and newborns under 12 weeks. Many healthcare providers prefer axillary temperature screening in newborns because of the theoretical risk of rectal perforation. However, if an accurate temperature reading is desired in a newborn, rectal temperature may be performed because the available evidence does not substantiate the fears of rectal perforation using a rectal thermometer. (Choice C) The insertion of the thermometer can slow the heart rate by stimulating the vagus nerve. Therefore, clients who are post-MI should not have a rectal temperature taken. (Choice D) Assessing a rectal temperature is contraindicated in neutropenic clients. A leukemia client with neutropenia and anemia shouldn't be subjected to rectal temperature checks. A normal absolute neutrophil count should be more than 1500/ microfiber ( 1500/ul). A neutrophil count of less than 1500/ul is mild neutropenia, whereas a count of less than 500/ul is severe. Neutropenia predisposes to infections, and any invasive procedures with the potential to introduce pathogens into the body must be avoided. (Choice E) Assessing rectal temperature is also avoided in those with certain neurologic disorders and clients with thrombocytopenia (low platelet count). Acute pancreatitis can be complicated with DIC in severe cases. Disseminated intravascular coagulation (DIC) causes consumptive thrombocytopenia. Thrombocytopenia increases the bleeding risk when invasive procedures are performed. Therefore, a client with acute pancreatitis and DIC should not get a rectal temperature assessment. Choice B is incorrect. A child with pneumonia can have a rectal temperature taken. Learning Objective While rectal thermometry to confirm fever is one of the most accurate methods, recognize that there are conditions where it is contraindicated. Additional Info ✓ Clients who are uncooperative or agitated may not tolerate the

Which actions are recommended guidelines when providing foot care for residents in a long-term care facility? Select all that apply. Bathe the feet thoroughly in mild soap and tepid water solution. Soak the feet in warm water and bath oil. Dry feet thoroughly, including the area between the toes. Use an alcohol rub if the feet are dry. Use an antifungal foot powder if necessary to prevent fungal infections. Cut the toenails at the lateral corners when trimming the nails.

Explanation Choices A, C, and E are correct. The following are recommended guidelines for foot care: Bathe the feet thoroughly in mild soap and lukewarm water solution Dry feet thoroughly, including the area between the toes Use antifungal foot powder, if necessary, to prevent fungal infections

The nurse on the medical-surgical floor is preparing to receive a newly admitted client who reports an allergy to latex. The nurse should plan to take which action? Select all that apply. Verify the allergy is documented in the medical record Use disposable equipment during client care Assign the client to a private room Post a sign in the client's room noting the allergy Communicate the allergy to the dietary department

Explanation Choices A, D, and E are correct. When a client is newly admitted, it is essential that the nurse verify the client's allergies and ensure that they are appropriately documented. A sign noting the allergy should be placed in the client's room because other healthcare personnel who have not reviewed the chart should be made aware of the allergy. Finally, the allergy should be communicated to the dietary department because certain foods (bananas, kiwi, avocado) have the latex protein. Choices B and C are incorrect. Disposable equipment is not required for a client with a latex allergy. This would be recommended for a client on transmission-based precautions. A private room is not required for individuals with a latex allergy. Additional Info Foods that may contain the latex protein may include - Kiwi Avocado Tomatoes Apple Carrots Celery For a client with a latex allergy, a collection of supplies that are free of latex should be readily available. This allergy should be communicated in the form of a placard, so all healthcare professionals recognize this allergy.

The licensed practical/vocational nurse (LPN/VN) is reinforcing teaching to a group of students about medications and fall prevention. The nurse would be correct to identify which of the following medications can increase the risk for falls? Select all that apply. Naproxen Alprazolam Bumetanide Verapamil Allopurinol Thiamine

Explanation Choices B, C, and D are correct. Medications that may hasten the risk for falls include benzodiazepines such as alprazolam. This medication causes drowsiness and may impair judgment. Bumetanide is a loop diuretic; this medication may cause a client to experience orthostatic hypotension and the urgency to use the bathroom. Both of which pose a fall hazard. Verapamil is a calcium channel blocker and is utilized in the management of migraines and hypertension. This medication causes vasodilation; therefore, it will allow the client to become orthostatic if they do not shift positions slowly. Choices A, E, and F are incorrect. Naproxen is an anti-inflammatory medication not implicated in raising the risk of falls. Allopurinol is indicated to lower uric acid levels and would not increase the risk of falls. Thiamine is a water-soluble vitamin indicated for alcoholism. Additional Info ✓ Medications that may raise the risk for falls include any agents that may cause drowsiness (benzodiazepines, opioids), shifts in blood pressure (diuretics, beta-blockers), or alterations to the sensorium (melatonin). ✓ The nurse should diligently work to ensure a safe environment for the client and assess their fall risk.

The nurse is reinforcing education with a student about how to bathe a newborn correctly. Which of the following statements by the student indicates a need for further instruction? Select all that apply. 3/3 Your Score/Max +/- Scoring Rule Always cover the newborn during the bath, except for the part of the body being washed. Clean their eyes from the outer canthus to the inner canthus. Start with the body and work your way up to the face for the bath. Be sure to support the weight of the newborn's head during the bath. Dry the baby vigorously with a stiff towel to promote circulation

Explanation Choices B, C, and E are correct. B is correct. This statement is incorrect and demonstrates a need for further instruction. The newborn's eyes should be washed from the inner canthus to the outer canthus to prevent infection, not vice versa, as the student stated. C is correct. This statement is incorrect and demonstrates a need for further instruction. The nurse should start with the face, wash the baby's body, and move to the diaper area last. E is correct. The baby should not be rubbed vigorously. Gently pat the baby dry with a clean towel, paying special attention to skin folds and creases. Then, dress the baby in a clean diaper and clothes. Choice A is incorrect. This statement demonstrates understanding by the student and does not indicate a need for further instruction. It is crucial to always cover the newborn during the bath, except for the part of the body being washed. The newborn cannot yet regulate its temperature and may quickly become too cold if fully exposed during a bath. Choice D is incorrect. This statement demonstrates understanding by the student and does not indicate a need for further instruction. It is crucial always to support the weight of the newborn during the bath. The nurse should place her hands under the infant's head and neck, as they cannot yet support their weight. NCSBN Client Need Topic: Effective, safe care environment, Subtopic: Infection control and safety; Fundamentals - Prioritization, delegation, and leadership Additional Info Some of the NCLEX topics on newborn care may include: ✓Newborn assessment: This includes physical assessment of the newborn, assessing vital signs, and assessing newborn reflexes. ✓Feeding and nutrition: This includes knowledge of breastfeeding, bottle feeding, and newborn nutrition needs. Newborn hygiene: This includes knowledge of how to bathe and dress a newborn, changing diapers, and skin care for newborns. ✓Developmental milestones and newborn reflexes: This includes understanding the normal physical and cognitive developmental milestones for newborns. ✓High-risk newborn care: This includes knowledge of how to care for newborns with special needs or who are at risk for complications, such as premature babies or babies with

Which procedures necessitate the use of surgical aseptic techniques? Select all that apply. Intramuscular medication administration. Central line intravenous medication administration. Donning gloves in the operating room. Neonatal bathing. Foley catheter insertion. Emptying a urinary drainage bag.

Explanation Choices B, C, and E are correct. Surgical asepsis is used when managing central line intravenous medication administration when donning sterile gloves in the operating room and inserting an indwelling Foley catheter. Asepsis is the freedom from disease-causing microorganisms. To decrease the possibility of transferring microorganisms from one place to another, the aseptic technique is used. The two basic types of asepsis are medical and surgical. Medical asepsis includes all practices intended to confine a specific microorganism to a specific area, limiting the number, growth, and transmission of microorganisms. In medical asepsis, objects are referred to as clean, which means the absence of almost all microorganisms; whereas, dirty (soiled, contaminated) means likely to have microorganisms, some of which may be capable of causing infection. Surgical asepsis, or sterile technique, refers to those practices that keep an area or object free of all microorganisms; it includes practices that destroy all microorganisms and spores (microscopic dormant structures formed by some pathogens that are very hardy and often survive common cleaning techniques). Surgical asepsis is used for all procedures involving the sterile areas of the body. Sepsis is the condition in which acute organ dysfunction occurs secondary to infection.

The nurse performs a home safety survey for an individual with epilepsy Click to specify the findings that require intervention by the nurse

Explanation The findings that require intervention by the nurse include the following - Multiple glass tables in the living room: multiple glass tables are concerning because the client may fall and sustain a serious injury during a seizure. Tables should be limited; if used, the edges should be covered with padded covers to reduce head injury. Multiple feather pillows are present on the bed: seizure-safe pillows are available for sale as they reduce asphyxiation. Seizure-safe pillows should be used; the fewer pillows, the better to reduce the risk of asphyxiation. Wall-to-wall carpeting was removed and replaced with scattered rugs on hardwood flooring: wall-to-wall carpeting is highly recommended because if the client falls while having a seizure, this will reduce the injury when compared to a hardwood floor. Kitchen knives were readily accessible: Knives should not be used because a serious injury can be sustained if a seizure occurs while using a knife. A food processor should be used instead of knives. Locks on the bathroom door: Locks should not be on the door because if the client has a seizure in the bathroom, immediate access would be hampered by the lock. Instead, the client should have a placard that can be flipped over on the door indicating whether the bathroom is occupied. A shower chair with a handheld nozzle should be used instead of the client bathing in a tub (drowning). It is wise for the client to have relocated their bedroom to the first floor, which will reduce the risk of injury associated with a seizure occurring on the stairs. Additional Info To promote home safety for a client with epilepsy, the nurse should recommend the following - ✓ Remove scatter rugs and frayed carpet, cover rooms with wall-to-wall carpeting ✓ Edges of countertops are padded ✓ Medic-alert tag is worn by the client while at home ✓ Knives are removed, and meals should be chopped using a food processor ✓ Microwaving food is safer than using a stove ✓ Showering in a bathroom that is unlocked is recommended ✓ Shower chair with a wand should be used. The client should not take a bath because of the risk of drowning ✓ Seizure-safe pillows should be used to prevent asphyxiation

The nurse performs a home safety survey for an older adult Click to specify the findings that require intervention by the nurse

Explanation The findings that require intervention by the nurse include the following - Scatter rugs at the bottom of the stairs: scatter rugs should not be used because they reduce the traction on the ground, and the edges of these rugs may cause a client to fall. Smoke detector present without a battery: the smoke detector should have a functioning battery. The battery should be tested every six months. Extension cord covered with a rug: a rug should not cover an extension or electrical cord because of the fire risk. Instead, electrical and extension cords should be against a wall behind furniture. Unlabeled household chemicals under the sink: household chemicals should be labeled to avoid accidental mixing (for example - bleach being mixed with ammonia) that may create a significant hazard. Medications mixed in various containers: medications should not be mixed in containers. This may cause a client to take the wrong medication inadvertently. Medications should be in their original labeled container, and the client may request labels that have a bigger font size. Additional Info To promote home safety for the older adult, the nurse should verify the following: ✓ Remove scatter rugs and frayed carpet ✓ Ensure that hallways and steps are well lit ✓ Do not run wires under carpeting ✓ Smoke detectors are present and are tested every six months ✓ The recommendation is one smoke detector per room and one per floor ✓ Ensure fire extinguishers are readily available ✓ Add additional lighting to the bathroom ✓ Medications are clearly labeled and are reviewed periodically by a family member or healthcare provider ✓ Household chemicals are clearly labeled ✓ Rubber mats in the bathtub

The nurse cares for a client on the oncology floor Item 1 of 1 Admission Note The client was admitted for observation after reporting increasing fatigue, dyspnea, malaise, and a fever of 102oF (38.8oC). The client is currently being treated with doxorubicin for uterine sarcoma. The initial diagnostic testing revealed pneumonia and neutropenia.

The nurse recognizes that this client is at increased risk for developing systemic infection therefore, the nurse should implement neutropenic precautions which involves washing hands frequently. Considering the client has a fever, the nurse anticipates an order for collecting blood cultures.

The nurse is instructing unlicensed assistive personnel (UAP) on how to modify activities of daily living for a client receiving a continuous infusion of heparin. The nurse should instruct the UAP to Select all that apply. obtain the client's temperature rectally. use a soft-bristled toothbrush for oral care. use an electric razor when shaving. use a lift sheet when repositioning the client. use an emery board instead of nail clippers.

explanation Choices B, C, D, and E are correct. This risk of bleeding is substantial for a client receiving a continuous infusion of heparin. The UAP should be instructed to perform oral care with a soft bristle toothbrush to prevent gingival bleeding. An electric razor is preferred over a traditional razor because of the decreased risk of trauma. A lift sheet should be used to reposition the client over sliding the client, reducing the risk of shearing injuries. Nail clippers may cause skin trauma. Thus, an emery board is preferred. Choice A is incorrect. A rectal thermometer should not be used, as it could cause a tear in the rectal tissue. Additional Info When a client is receiving an anticoagulant, the client should be monitored for signs and symptoms of bleeding, including hematuria, frank or occult blood in the stool, ecchymosis, petechiae, altered mental status (indicating possible cranial bleeding), or pain (especially abdominal pain, which could indicate abdominal bleeding).

The nurse, working at an outpatient clinic, is collecting data on a client who is complaining of abdominal pain, diarrhea, shortness of breath, and epistaxis. What should the nurse's first action be? A. Ask the client about any recent travel to Asia or the Middle East. B. Screening clients for upper respiratory tract symptoms. C. Determine whether the client has received all the recommended immunizations. D. Call an ambulance to take the client to the hospital immediately.

xplanation Choice A is correct. The client's clinical symptoms suggest possible avian influenza (bird flu). If the client has traveled recently to Asia or the Middle East, where outbreaks of bird flu have occurred, you will need to institute airborne and contact precautions immediately. Nursing priority is always client safety. This includes not only the client that the nurse is assessing but also those who are present within the facility and the staff. Determining where a client has been and their recent activities will help pinpoint the possible illness/infection source. Choice B is incorrect. While upper respiratory tract symptoms are indeed important to address, such as coughing, sneezing, or sore throat, they should be addressed within the context of the client's overall presentation. Choice C is incorrect. Collecting data on the client's immunization status is a valuable aspect of healthcare but is not the most immediate concern in this scenario. Choice D is incorrect. While providing timely care for clients with acute and severe conditions is crucial, calling an ambulance should not be the first action without a comprehensive exam to determine the cause of the client's symptoms. Additional Info ✓ Along with recent travel history, a comprehensive medical history should be obtained. This includes asking the client about any preexisting medical conditions, allergies, medications, recent illnesses, or surgeries, as this information may provide important clues to the underlying cause of the symptoms. ✓ Collect data on the client's vital signs such as blood pressure, heart rate, respiratory rate, and temperature is crucial to evaluate the client's overall condition. Abnormal vital signs, especially in the context of shortness of breath, can indicate a more urgent situation. ✓ If there is a suspicion of an infectious disease, adhere to appropriate infection control protocols to minimize the risk of transmission to healthcare providers and other clients.