Hurst Qbank

What signs/symptoms would the nurse expect to assess in a client diagnosed with multiple sclerosis (MS)? 1. Fatigue 2. Ptosis 3. Blurry vision 4. Leg weakness 5. Limited facial expression 6. Electric shock sensation when bending neck forward

1., 3., 4., & 6. Correct: Multiple sclerosis causes fatigue which often comes on in the afternoon and causes weak muscles, slowed thinking, or sleepiness. Vision problems are common with this diagnosis and include blurry vision, double vision, and pain on eye movement. Partial or complete vision loss can occur in one eye. Because this disease affects nerves, symptoms often affect movement such as extremity weakness, numbness, tingling, and coordination. Electric-shock sensations that occur with certain neck movements, especially bending the neck forward (Lhermitte sign) develop because of the nerve damage that is occurring. 2. Incorrect: Drooping of one or both eyelids (ptosis) would be seen in myasthenia gravis rather than multiple sclerosis. 5. Incorrect: Limited facial expressions occur in myasthenia gravis rather than multiple sclerosis. The muscles (not nerves) that control facial expressions have been affected.

The charge nurse is reviewing multiple events reported by staff during morning shift. The nurse is aware which event requires a written incident report? 1. A client yells loudly throughout the night shift. 2. A nurse discusses client's prognosis with family. 3. An unlicensed assistive personnel (UAP) spills water pitcher onto client. 4. A nurse tears sterile gloves and applies new gloves.

2. CORRECT: The purpose of an incident report is to document any incident or unusual event inconsistent with routine operations of hospital or staff routine and resulting in injury, or potential liability, for clients, family, or staff. The nurse has violated HIPAA regulations by discussing a client's medical prognosis with family members. The primary healthcare provider is responsible to discuss prognosis with client and only those individuals designated by the client. 1. INCORRECT: Although this client may disturb other clients at night, this event does not meet the criteria for an incident report. 3. INCORRECT: This event requires the UAP to intervene, providing clean clothes for the client. However, while an unfortunate occurrence, this incident would not require an incident report. 4. INCORRECT: Damaged sterile gloves must be removed and replaced immediately to prevent contamination of the field. The nurse followed the correct procedure and no report is needed.

The nurse is caring for a client diagnosed with pneumonia. The primary healthcare provider has prescribed erythromycin ER. What teaching points should the nurse plan to teach the client regarding this medication? 1. Crush the medication if unable to swallow capsule. 2. Take erythromycin 1 hour after eating. 3. Report clay-colored stools. 4. Do not take erythromycin with grapefruit juice. 5. Keep capsules in bathroom cabinet.

3., & 4. Correct: The client should be taught signs and symptoms of liver problems such as nausea, increased stomach pain, itching, tired feeling, loss of appetite, dark urine, clay-colored stools, or jaundice. Grapefruit juice can interfere with absorption of this medication.1. Incorrect: Do not crush, chew, or break a delayed release capsule or tablet. Swallow it whole.2. Incorrect: This medication should be taken 1 hour before or 2 hours after a meal.5. Incorrect: Keep at room temperature, away from excess heat and moisture (not in bathroom).

The nurse is caring for a client who is to receive an antibiotic in 50 mL of D5W over 30 minutes using an infusion pump. The nurse will set the infusion pump to deliver how many mL per hour? Round answer to the nearest whole number. Enter the answer for the question below.

50 mL : 30 min. = x mL : 60 min. 30 x = 3,000 x = 100

A client diagnosed Alzheimer's disease has been prescribed memantine. What should the nurse teach the caregiver about this medication? 1. When beginning this medication provide ambulatory assistance. 2. This medication is prescribed to help improve mild dementia. 3. This medication must be taken without food. 4. If a dose is missed, double the next dose. 5. If the client cannot swallow the capsule you sprinkle on applesauce.

1. & 5. Correct: This medication can cause dizziness, so safety precautions should be taught to the caregiver. Extended release caps should not be crushed, chewed, or divided. If the client cannot swallow it whole, it can be opened and sprinkled on a small amount of applesauce. 2. Incorrect: Memantine is used for moderate to severe dementia associated with Alzheimer's disease. 3. Incorrect: Memantine can be taken with or without food. 4. Incorrect: If the client misses a single dose of memantine, that client should not double up on the next dose. The next dose should be taken as scheduled.

The client has been taking divalproex for the management of bipolar disorder. The nurse should give priority to monitoring which laboratory test? 1. Alanine aminotransferase (ALT) 2. Serum glucose 3. Serum creatinine 4. Serum electrolytes

1. Correct: ALT levels will increase primarily in liver damage/disorders. A side effect of administering divalproex is drug-induced hepatitis. 2. Incorrect: Divalproex is not expected to alter glucose metabolism. 3. Incorrect: Divalproex should not cause a change in renal function. 4. Incorrect: Divalproex should not interfere with electrolytes balance.

How should the nurse respond to a pregnant client who asks, "How will I know when it is time to go to the hospital?" 1. "Go to the hospital immediately if your membranes rupture." 2. "You should leave for the hospital as soon as you lose your mucus plug." 3. "Go to the hospital when you have a burst of energy followed by a backache." 4. "You need to go to the hospital when contractions are 2 minutes apart."

1. Correct: Yes! This is the appropriate teaching. A gush or trickle of fluid from the vagina should be evaluated regardless of whether contractions are occurring. Infection and compression of the umbilical cord are possible complications. 2. Incorrect: No. The mucus plug is lost prior to the beginning of active labor, so too early to go to the hospital. Some women lose their mucus plug weeks before labor begins, others lose it right as labor starts. 3. Incorrect: Nesting? That's too early and not specific enough. This is not labor. 4. Incorrect: The client should go when contractions are 5 minutes apart, for 1 hour if it is her first pregnancy. Labor may be faster for the woman who has given birth before than for the nullipara. Multiparas are instructed to go to the hospital when contractions are regular, 10 minutes apart, for 1 hour.

The nurse is assessing a 70 year old client who was admitted several hours ago for IV hydration with lactated ringers solution after being diagnosed with dehydration. What findings would be of concern to the nurse? 1. BP 142/88 2. Bounding pulse 3. CVP 7 mmHg 4. S3 heart sound 5. Urinary output 220 mL over 4 hours

1., 2., 3., & 4. Correct: Volume overload is an adverse effect of IV therapy in the elderly. Blood pressure of >140/90 is cause for concern in this age group. A bounding pulse occurs when the vessels are fuller than normal. Normal CVP is 2-6 mmHg. A CVP reading of 7mmHg indicates FVE. S2 is a normal heart sound. S3 heart sounds are an indication of FVE. 5. Incorrect: This is a good UOP for 4 hours.

How closely monitored is access to a facility's health information system? 1. No monitoring; the system is password protected. 2. Monitored intermittently. 3. Monitored closely and constantly for inappropriate use. 4. Monitored daily and sporadically.

3. Correct: Access to a health care facility's computerized health information system is monitored closely and constantly. Records of each healthcare team member's time and date of access, as well as the information that was accessed, are kept by the information technology services department. Access can be suspended, restricted, or revoked for unauthorized or inappropriate use. 1. Incorrect: This is like doing nothing. Healthcare providers must be diligent about maintaining confidentiality, which includes the use of technology that contains confidential client information. 2. Incorrect: Intermittent monitoring is not adequate. Access should be monitored closely and constantly. A breach of confidentiality could occur if intermittent monitoring was done.4. Incorrect: Access should be monitored closely and constantly. Sporadically and once daily is not adequate for protecting client confidentiality.

Which assessment by the nurse indicates a tension pneumothorax? 1. Sudden hypertension and bradycardia 2. Productive cough with yellow mucus 3. Tracheal deviation and dyspnea 4. Sudden development of profuse hemoptysis and weakness

3. Correct: Yes, as pleural pressure on the affected side increases mediastinal displacement occurs with resultant respiratory and cardiovascular compromise. Symptoms of tension pneumothorax include dyspnea, chest pain radiating to the shoulder, tracheal deviation, decreased or absent breath sounds on the affected side, neck vein distention and cyanosis. 1. Incorrect: Hypoxia causes tachycardia rather than bradycardia. The client would more likely to be hypotensive due to decreased cardiac output. 2. Incorrect: Yellow mucus indicates infection, such as from pneumonia. This does not indicate a tension pneumothorax. 4. Incorrect: Profuse hemoptysis and weakness may indicate a serious condition such as a ruptured vessel, but it is not an indication of a mediastinum shift.

After making rounds on clients, a primary healthcare provider hands the nurse a client record and gives the following verbal order: Administer cisplatin 1 mg IV over 6 hours. What should be the first action by the nurse following this verbal prescription? 1. Call the pharmacy to prepare the drug. 2. Repeat the prescription back to the primary healthcare provider. 3. Ask the primary healthcare provider to spell the drug name for clarification. 4. Inform the healthcare provider that this medication requires a written prescription.

4. Correct: This drug is a high alert drug that should be given careful consideration. Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety. 1. Incorrect: The pharmacy should not be called to prepare this drug as it is unsafe to follow a verbal prescription for an antineoplastic. Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety. 2. Incorrect: The first action by the nurse should be to inform the primary healthcare provider that a verbal prescription is not adequate for this particular category of drug. Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety.3. Incorrect: Use the testing strategy of finding similar options to eliminate incorrect answers. Options 1, 2 and 3 insinuate the nurse is going to proceed with the prescription, which is an unsafe practice for antineoplastics. Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety.

What foods should the nurse inform the client to avoid for three days prior to a guaiac test? 1. Chicken 2. Carrots 3. Apple 4. Raw broccoli 5. Steak 6. Turnip greens

4., 5., & 6. Correct: Foods that affect this test include raw broccoli, red meats such as steak, turnip greens, cantaloupe, radish, and horseradish. All of these could cause a false positive reading for the guaiac test. 1. Incorrect: Red meats such as steak should be avoided, but chicken is okay. 2. Incorrect: Carrots are not prohibited and will not affect the results of the test. 3. Incorrect: The client can eat apples with no effect on the test results.

The emergency room nurse is assessing a client with an eye injury that occurred while chopping wood. The client states the chain saw caused a log to splinter, sending slivers of wood into the right eye. While waiting for the eye specialist, the nurse discusses future safety precautions for such an activity. What safety precautions are most important for the nurse to include in client teaching? 1. Wear heavy gloves. 2. Stand with feet together. 3. Use steel-toed boots. 4. Wear unbreakable googles. 5. Use ear covers and plugs. 6. Wear loose-fitting clothing.

1, 4 and 5. CORRECT. When engaging in a potentially risky activity, precautions should be taken even if the activity has been completed multiple times before. Functional body parts, such as hands, fingers and toes, are particularly vulnerable to injury. Heavy duty work gloves made of leather or suede along with protective eye googles should be worn even before turning on any machines. Ears should also be protected with regulation ear phones or ear plugs because of equipment noise levels. 2. INCORRECT. Any activity involving equipment poses a safety risk, no matter how often an individual completes that action. A client should have both feet firmly planted on a flat surface, approximately shoulder-width apart, with weight distributed evenly over the hips. Standing with feet together distributes body weight unevenly, increasing the risk for injury. 3. INCORRECT. While sturdy leather boots provide protection for the feet, it is not necessary to have steel-toed boots. However, the client should never wear sneakers, sandals or other light-weight, non-protective foot wear when using any type of machinery or equipment. 6. INCORRECT. Loose fitting clothing could easily become caught in equipment, yanking the body in towards sharp blades and other moving parts. A client needs snug fitting clothing to cover exposed extremities to prevent even minor injuries.

A client on the in-patient psychiatric unit was found to have lacerations on the wrist when the nurse made rounds. Which change in routine on the unit is most likely to prevent such an event from occurring in the future? 1. During the end-of-shift report, assign specific staff to check on each client. 2. Place newly admitted clients close to the nursing station. 3. Monitor level of suicide precaution needed on each client daily. 4. Ask clients to check on each other throughout the shift.

1. Correct: Assigning specific staff to perform client checks during the shift will assure that the clients, that the staff are concerned about their welfare. In addition, it assures that someone is specifically monitoring the client each shift, therefore, promoting the clients right to a safe environment. Client safety is a priority in Maslow's Hierarchy of Needs. The nurses will play a key role in reducing these self-harming behaviors through recognition of the problem, being alert to risk factors when assessing the client, and ultimately guiding the client into more acceptable outlets for stress, anxiety, anger, low-self esteem, or other related causes. 2. Incorrect: This routine may or may not prevent an injury. The clients may learn the "routine" of the nurses and will perform the self-harming behaviors when the nurses are not likely to be making individualized checks on them. 3. Incorrect: Each client should be monitored daily at irregular intervals. Self-harming behaviors typically increase the risk of suicide in the client. The nurse should determine the level of imminent risk of suicide in the client. This should be routinely performed with client checks, not simply assessed on a daily basis. 4. Incorrect: It is not the clients' responsibility to check on each other. All clients have the right to a safe environment, and it is the responsibility of the nurses and healthcare team to provide this safety.

A 15 year old is being admitted with pelvic inflammatory disease. Which client could the charge nurse assign the new admit to room with? 1. 18 year old who sustained a compound fracture. 2. 15 year old diagnosed with anorexia nervosa. 3. 13 year old admitted with pneumonia. 4. 14 year old who is taking steroids for chronic asthma.

1. Correct: The best choice would be the client with a fracture who is also an adolescent. Neither of these clients require visitor limiting or potential to transmit infections. 2. Incorrect: Usually adolescents with anorexia nervosa losing weight are put on a behavior modification program, and visitors are limited. Therefore, it would probably be best if this client did not have a roommate. 3. Incorrect: Pneumonia could be contagious and should not have a roommate. This client could be on contact or droplet precautions. 4. Incorrect: Long term steroid therapy could make this client immunosuppressed. Visitors should be limited and a private room would be recommended.

A nurse is caring for a client with a terminal illness. The nurse is educating the client about anticipatory grieving. Which statement from the client indicates a need for further teaching? 1. "My family will respond fine to my illness." 2. "I will talk to my family about my feelings." 3. "My family will still grieve after my death." 4. "My passing will cause role changes in the family."

1. Correct: The client cannot state how the family members' anticipatory grief will occur. The family members will experience anticipatory grief in different ways and their reactions will also vary. The family's response will vary according to their adaptability to the changing circumstances in the family due to the client's terminal illness. The client will need additional information related to anticipatory grieving. 2. Incorrect: The client is planning to approach the family and express feelings and concerns. The client will have feelings of sadness as the terminal illness progresses. Anticipatory grieving occurs before death. This is a true statement and will not indicate a need for further teaching. 3. Incorrect: Anticipatory grieving is mourning that occurs prior to the client's expected death. By the family and client addressing different aspects of the death of the client, they are able to begin the adjustment to the death of the client. Anticipatory grieving does not prevent grief process after the family member's death. 4. Incorrect: The roles of the different family members are affected after the death of a family member. Each family member's grief and mourning process will vary which will cause changes to their roles in the family. The client is identifying that role changes will occur. The client's response does not indicate need for further teaching.

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

1. Correct: The client's symptoms are indicative of infection, and the primary healthcare provider needs to be notified and may want diagnostic tests performed. The other actions are appropriate to treat the symptoms and provide comfort, but they are not the best action to fix the problem. 2. Incorrect: While this may be appropriate, it may also delay treatment of the problem, which is infection. Remember, you can only pick one answer to fix the problem and this action will only treat the symptoms. 3. Incorrect: The primary healthcare provider may want the site assessed, but this also delays treatment. Since you can only pick one option, this is not the best. 4. Incorrect: Comfort measures are always appropriate, but this is not the best action available.

Which postpartum client should the nurse assign to a private room? 1. Has antibodies for Hepatitis C. 2. Is rubella non-immune. 3. Is rubella immune. 4. Has lupus antibodies.

1. Correct: This client should be in a private room for her protection and the protection of other postpartum women. The presence of antibodies for Hepatitis C indicates HCV infection and possibly impaired immune function due to liver damage. In addition, Hepatitis C is transmitted by contact with body fluids and it is likely that lochia will be found on toilet surfaces. It is also common for postpartum women to have some kind of wound (perineal laceration or episiotomy) and they will be at increased risk of HCV contaminated lochia coming into contact with their wound. 2. Incorrect: Rubella non-immunity carries risks only to an unborn fetus. If a non-immune pregnant woman contracts rubella during the first trimester, it can result in serious complications in the fetus. Being rubella non-immune is not of concern when making room assignments for postpartum clients. Being non-immune to rubella does not make this client a risk to other postpartum clients.3. Incorrect: Rubella-immune woman has no risks. Being rubella immune indicates that the client has developed antibodies in response to a previous rubella infection or immunization. Rubella immunity is desired for pregnant women or those planning to become pregnant. This will help to prevent a rubella infection during pregnancy which could cause birth defects. Being rubella immune would not prevent this client from being able to be placed in the room with other postpartal clients. 4. Incorrect: The woman with lupus antibodies is not at increased risk for infection to herself or to others. The pregnant woman with lupus antibodies requires more vigilant monitoring of the fetus because they may increase the risks of neonatal lupus syndrome, certain heart defects, and miscarriage or pre-term birth. However, these antibodies in the postpartal client does not pose any risks to other postpartal clients, so this would not be a factor when making room assignments.

A client was admitted to CCU with a diagnosis of acute coronary syndrome. Continuous cardiac monitoring has been implemented. Which assessment finding by the nurse is most significant? 1. Ventricular fibrillation 2. Ventricular tachycardia 3. 2nd degree AV block 4. Atrial fibrillation

1. Correct: V-fib is the most common lethal dysrhythmia in the initial period following a myocardial infarction. 2. Incorrect: V-tach is significant as it may occur prior to V-Fib. However, V-fib is most significant. 3. Incorrect: The client will still have a cardiac output in second degree heart block. There is no cardiac output with V-fib. The most lethal is V-fib. 4. Incorrect: Atrial fibrillation involves chaotic contractions of the atria, but there is a cardiac output. It is not life-threatening.

The schizophrenic client tells the nurse, "I am Jesus, and I am here to save the world!" The client is reading from the Bible and warning others of hell and damnation. The other clients on the unit are upset and several are beginning to cry. What nursing intervention is most appropriate? 1. Set verbal limits and have the client return to assigned room. 2. Explain to the client that not all people are Christians. 3. Remove the Bible from the client and explain that the client is not Jesus. 4. Ask the client to share with the group how the client is Jesus.

1. Correct: Yes, the nurse must set limits. This is disrupting others and so the client needs to be redirected to their room for a cool down and then another activity shortly thereafter. This client is experiencing delusions of grandeur, which are not reality based, and require intervention that does not reinforce the behavior. 2. Incorrect: No, this will only reinforce the clients thought process of religion. 3. Incorrect: No, don't argue with the client. This is not therapeutic and does nothing to help resolve the disruption to the other clients. 4. Incorrect: This is ridiculing the client and also inflaming the situation. This is not desirable.

Prior to shift report, the charge nurse is making assignments for the nurses on the shift. Which client can be assigned to the LPN? 1. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. 2. Client who is a diabetic experiencing diabetic neuropathy. 3. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. 4. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. 5. Client with ureterolithiasis who requires frequent PRN pain medication.

1., 2., & 5. Correct: A LPN should be able to care for a client with arthralgia who requires pain medication on a regular schedule and is receiving warm compresses. The client is apparently stable and does not require any advanced assessment skills or specialized care. Did the words diabetic neuropathy make you think that a LPN should not be assigned to this diabetic? Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. Did you recognize ureterolithiasis as "kidney stones"? Yes! So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. 3. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. Teaching is not in the role of the LPN and therefore, this client would need to be assigned to the RN, not the LPN, for the teaching needs of the client. 4. Incorrect: What seems to be going on with this client? The abdominal pain is worsening. This could indicate a worsening of this client's condition. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN.

The home health nurse is assessing the home environment for threats to the safety of the toddler who lives in the home. Which observations should be included in this assessment? 1. Do stairs have guard gates? 2. Are safety covers on electrical outlet plugs? 3. Is the swimming pool inaccessible to the toddler? 4. Are cleaning supplies located out of the toddler's reach? 5. Are stairs brightly lit?

1., 2., 3. & 4. Correct: Toddlers may fall if left unsupervised around stairs. Make sure that gates are in place and that they are used. Toddlers are at risk for exploring the outlets by putting metal objects into the outlets or putting their fingers in them. They should be covered unless in use. Toddlers can drown in small amounts of water and they may try to explore swimming pools if they are accessible. Pools should have fences or locking stairs and the child should never be left unsupervised around the pool. Toddlers are curious and may get into cabinets containing harmful substances.5. Incorrect: This assessment would be important for the visually impaired or elderly, but not specifically for toddlers. The guard gates should be in place so that the toddler does not have access to the stairs.

An occupational health nurse works in a factory where loud equipment is used in production of the factory's product. What should the nurse emphasize to factory management persons to reduce the risk of hearing impairment? 1. Supply workers with earplugs when exposed to noise. 2. Replace high noise machinery with low noise machinery. 3. Limit amount of time a person spends at a noise source. 4. Operate noisy machines during shifts when fewer people are exposed. 5. Supply personal noise monitoring to identify employees at risk from hazardous level of noise. 6. Have all employees make an appointment for a hearing test.

1., 2., 3., 4., & 5. Correct: All of these are primary prevention methods of controlling hearing loss in employees exposed to hazardous noise levels. Earplugs, or earmuffs, are considered an acceptable but less desirable option to control exposures to noise and are generally used during the time necessary to implement engineering and administrative controls to protect worker's hearing. Engineering controls include choosing low noise tools and machinery, maintaining and lubricating machinery and equipment, placing a barrier between the noise source and employed, and enclosing or isolating the noise source. Administrative controls are changes in the workplace that reduce or eliminate the worker's exposure to noise. This includes operating noisy machines during shifts when fewer people are exposed, limiting the amount of time a person spends at a noise source, and using monitoring equipment to monitor hazardous noise level. 6. Incorrect: Some employees may need a hearing test but this will not reduce the risk of hearing impairment. This is secondary prevention, which focuses on screening and early diagnosis of disease.

A client is being evaluated for possible Rheumatoid Arthritis (RA). Which lab data and assessment findings by the nurse would be indicative of RA? 1. Joint pain, swelling, and warmth. 2. Decreased movement in joints. 3. Presence of Rheumatoid factor on lab analysis. 4. Presence of Dupuytren's contractures. 5. Elevated erythrocyte sedimentation rate (ESR). 6. Presence of Cyclic Citrullinated Peptide Antibody.

1., 2., 3., 5., & 6. Correct: Classic features of RA include joint pain, swelling, and tenderness worsened by movement and stress placed on joint. Morning stiffness that often lasts for one hour or more and limited movement in joints are common manifestations as well. The Rheumatoid Factor is present in 80% of adults who have rheumatoid arthritis. The ESR blood test is elevated with RA and is used to determine if an abnormal level of inflammation exists in the body. The cyclic citrullinated peptide antibody, if present, helps to confirm the diagnosis of RA and may indicate the risk of having severe symptoms. Levels that are at a moderate to high level may indicate that the client is at increased risk for damage to the joints. 4. Incorrect: Dupuytren's contractures are a type of hand deformity where a layer of tissue under the skin in the palms of the hands is affected. Hard knots form in the palm areas and eventually create a thick cord that can pull one or more of the fingers into a bent position. However, this is not associated with RA.

A nurse notes that a client with end-stage chronic renal failure has dry, itchy skin, white crystals on the skin, and uremic halitosis. Which nursing interventions would be appropriate for this client? 1. Encourage use of cotton gloves during sleep 2. Apply emollients to the skin 3. Increase protein rich foods in the diet. 4. Cut fingernails short 5. Provide mouth care prior to meals

1., 2., 4. & 5. Correct: The build up of uremic frost associated with end stage renal disease causes pruritus. Gloves reduce the risk of dermal injury. Emollients and lotion will aid dry, itchy skin. Apply after bathing. Cutting nails short will decrease risk of skin breakdown when scratching. Uremic halitosis occurs from a build-up of urea in the body. It produces a metallic taste in the mouth. Mouth care prior to meals will help in eliminating this taste. 3. Incorrect: A client in end stage renal disease needs to decrease the amount of protein in the diet. Dietary restrictions include protein, sodium, potassium, and phosphate.

What lab values should the nurse monitor when caring for a client diagnosed with acute leukemia? 1. Hemoglobin 2. Hematocrit 3. Lactate dehydrogenase (LDH) 4. Platelets 5. White blood cells 6. Metanephrine

1., 2., 4., & 5 Correct: The client with acute leukemia usually has a decreased hemoglobin and hematocrit level, a low platelet count, and an abnormal white blood cell count. 3. Incorrect: If lymphoma has been diagnosed, the lactate dehydrogenase (LDH) level may be checked. LDH levels are often increased in patients with lymphomas. LDH is not a lab test monitored in the client with acute leukemia. 6. Incorrect: Plasma free metanephrine is up to 99% sensitive for diagnosing pheochromocytoma. It measures circulating epinephrine and norepinephrine levels. Grossly elevated plasma norepinephrine renders the diagnosis of pheochromocytoma highly probable.

What nursing interventions should the nurse include when planning care for a client admitted with Guillain-Barre' Syndrome? 1. Monitor for contractures. 2. Place prone for 30 minutes, 4 times per day. 3. Provide therapeutic massage for pain relief. 4. Teach range of motion exercises. 5. Provide high protein meals 3 times a day. 6. Refer to physical therapist.

1., 3., 4., & 6. Correct: This client will have progressive weakness and paralysis. Contractures and pressure ulcers need to be prevented through ROM exercises and frequent turning. Muscle spasms and pain can be relieved by therapeutic massage, imagery, diversion, and pain medication. 2. Incorrect: The client will need to be repositioned every 2 hours to prevent pressure sores and pneumonia and atelectasis. Elevate the head of the bed to help with lung expansion. Prone will interfere with lung expansion ability. 5. Incorrect: Encourage small, but frequent meals that are both well-balanced and nourishing.

A client is admitted to the unit from the ED department. What acid base imbalance do the lab values indicate to the nurse? Exhibit 1. Metabolic alkalosis 2. Compensated metabolic alkalosis 3. Respiratory alkalosis 4. Compensated respiratory alkalosis

1.Correct: The pH is 7.48 which is alkalosis. PaCO2 is 38, which is normal.​HCO3 is 30, which is high (alkaline). The problem is a metabolic problem, making this Metabolic Alkalosis. 2.Incorrect: The pH is 7.48 which is alkalosis. PaCO2 is 38, which is normal. HCO3 is 30, which is high (alkaline). The problem is a metabolic problem, making this Metabolic Alkalosis. 3. Incorrect: The pH is 7.48 which is alkalosis. PaCO2 is 38, which is normal. HCO3 is 30, which is high (alkaline). The problem is a metabolic problem, making this Metabolic Alkalosis. 4.Incorrect: The pH is 7.48 which is alkalosis. PaCO2 is 38, which is normal. HCO3 is 30, which is high (alkaline). The problem is a metabolic problem, making this Metabolic Alkalosis.

How would a tendency toward stereotyping and countertransference affect the nurse's ability to complete a client's cultural assessment? 1. Facilitate the care planning process 2. Promote decisions based on the nurses value system 3. Utilize an open honest approach while responding to the client's concerns 4. Develop an unbiased approach to care.

2. Correct: Both stereotyping and countertransference will decrease the nurse's sensitivity to the client's needs and the culture they represent. Nurses who impose these values upon clients will make decisions based on their attitudes, values and beliefs and not those of the culturally different client. 1. Incorrect: Both stereotyping and countertransference also interfere with the treatment process you can't base your care plan on your general views toward a client's culture. Care plans, must be individualized and not based on stereotypes. 3. Incorrect: The nurse will make automatic responses based on preconceived ideas and expectations. The nurse is unable to be open and honest about client concerns. Remember, stereotyped behavior is based on the assumption that all people in a similar cultural, racial or ethical group think and act alike. 4. Incorrect: The nurse's need to maintain an unbiased care is important because the client's needs remain unmet. Value clarification by the nurse will assist in preventing stereotyping and countertransference to other clients. The nurse will never have an unbiased approach to care for clients unless the nurse understands and removes unhealthy values affecting the assessment process.

Which assessment finding identified in a client diagnosed with Guillain-Barre Syndrome would indicate that the nurse needs to notify the primary healthcare provider? 1. Vital lung capacity of 900 mL. 2. Breathlessness while talking. 3. Heart rate of 98 beats per minute. 4. Respiratory rate of 24 breaths per minute.

2. Correct: Breathlessness while talking indicates respiratory fatigue. Preparation for intubation needs to be made. 1. Incorrect: If the vital lung capacity drops below 800 mL, mechanical ventilation is warranted. 3. Incorrect: Imminent signs of respiratory failure include a heart rate greater than 120 beats per minute or less than 70 beats per minute. 4. Incorrect: Imminent signs of respiratory failure include a respiratory rate greater than 30 breaths per minute.

The nurse is teaching a client about the use of a cane. Which is the correct cane technique? 1. Place the cane on weaker side of the body to support the weaker leg. Using the cane for support, the client should step forward with strong leg, and then move the weaker leg and cane forward to the strong leg. 2. Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. 3. Place cane on weaker side of body. The cane is placed forward 6 to 10 inches while the client advances weaker leg to the cane. 4. Place cane on stronger side of body to help support weaker leg. Using cane for support, step forward with the strong leg and then move the weaker leg and the cane forward to the strong leg.

2. Correct: Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. The body weight is divided between the strong leg and the cane. 1. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 3. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 4. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling.

A pregnant client has been receiving daily heparin injections for a history of deep vein thrombosis (DVTs) during pregnancy. Which laboratory test result should be immediately reported to the primary healthcare provider? 1. PT of 13 seconds 2. PTT of 22 seconds 3. INR of 1.0 4. Hemoglobin of 11 g/dL (6.8266 mmol/L)

2. Correct: The test that monitors the efficacy of heparin is the PTT. The normal range for a PTT is 30-40 seconds, but desired outcome of heparin therapy is PTT of 1.5-2.5 times the control without signs of hemorrhage. This client's PTT is below therapeutic range so it is not preventing DVT formation. The dose of heparin will need to be increased. 1. Incorrect. PT monitors the efficacy of warfarin, which is contraindicated in pregnancy because it crosses the placenta which means the fetus would be receiving the medication. PT is measured in seconds. Most of the time, results are given as what is called INR (international normalized ratio). If a client is not taking blood thinning medicines, such as warfarin, the normal range for PT results is 11 to 13.5 seconds. Normal value ranges may vary slightly among different laboratories. Some labs use different measurements or test different samples. 3. Incorrect: INR monitors the efficacy of warfarin, which is contraindicated in pregnancy because it crosses the placenta which means the fetus would be receiving the medication. (Normal INR of 0.8 to 1.1.) If the client is taking warfarin to prevent blood clots, the primary healthcare provider will most likely choose to keep the INR between 2.0 and 3.0. 4. Incorrect: A hemoglobin of 11 g/dL (6.8266 mmol/L)​ is adequate in pregnancy. In pregnancy, there is an increase in plasma volume of the blood in order to help supply oxygen and nutrients to mother and baby. There can be a 20% increase in the total number of red blood cells, but the amount of plasma increases even more causing dilution of those red cells in the body. A hemoglobin level of pregnancy can naturally lower to 10.5 gm/dL (6.5163 mmol/L) representing a normal anemia of pregnancy.

The nurse enters a client's room to administer morning medications and notes that the client is praying aloud. What would be the nurse's best action? 1. Interrupt the client to administer the medications. 2. Wait quietly until the prayer is finished. 3. Join the client for the prayer. 4. Ask the client if you can provide a directed prayer.

2. Correct: This is the best action by the nurse as this is a private spiritual moment for the client. Prayer is a self-care strategy that provides comfort, increases hope, and promotes healing and psychological well-being. The nurse could either leave and return later or wait quietly for the client to finish. 1. Incorrect: Administering the medications can wait until the client finishes the prayer. 3. Incorrect: Do not assume that the client wants others to join in the prayer. This is a private moment for the client. 4. Incorrect: Do not assume that the client wants others to join in the prayer. Don't interrupt the client while praying.

The nurse is planning discharge teaching for a client with thrombocytopenia. Which should the nurse include? 1. Floss between teeth daily. 2. Eat soft foods. 3. Take docusate sodium daily to prevent straining 4. Wear well fitted shoes while ambulating. 5. Apply a cool compress to site with any soft tissue trauma.

2., 3., 4. & 5. Correct: Thrombocytopenia is a deficiency of platelets, and platelets help your blood clot which stops bleeding. Hard food can cause bleeding as it passes through the esophagus and can cause gums to bleed. A stool softener should be taken daily to prevent a hard stool. Straining and hard stools can lead to tissue trauma and bleeding from the rectum. Well fitted shoes can prevent injury while ambulating. Cool compress will prevent hematoma formation and stop bleeding. 1. Incorrect: This client should not floss the teeth, as bleeding can result. Soft bristle toothbrush will be needed also to prevent injury to gums.

An unresponsive 13 year old is brought into the emergency department. Based on the nursing assessment and current lab data, which interventions would be appropriate for the nurse to initiate? Exhibit 1. Administer kayexelate 2. Initiate IV of NS 100 ml with Regular insulin 100 units at 10 mL/hr 3. Start oxygen at 2 liters per nasal cannula 4. Start a second IV for fluid resuscitation. 5. Insert indwelling urinary catheter

2., 4. & 5. Correct: This client is exhibiting Kussmaul respirations. Potassium and glucose are high. The client has ketones which are an acid. Blood gases reveal metabolic acidosis related to diabetic ketoacidosis and hypovolemic shock. This client needs isotonic solutions and regular insulin to decrease glucose and decrease potassium. The client needs fluid resuscitation due to polyuria seen with DKA. Indwelling urinary catheter needed to measure urine output. 1. Incorrect: Regular insulin IV shifts potassium from the blood into the cell. 3. Incorrect: Oxygen saturation is 96%, so O2 not needed.

The nurse has initiated instruction for an 11 year old child newly diagnosed with diabetes mellitus. The child indicates anxiety about the need for daily insulin injections. What nursing action would best address this issue? 1. Tell the child it only hurts for a moment. 2. Have the parents administer the shots. 3. Show the child how to give self injections. 4. Provide toy syringe for the client to play with.

3. Correct: A school age child needs a sense of achievement and control of the situation. Because diabetes will be a life-long disease, it is important for the child to begin learning about self-care which includes daily insulin injections. Age eleven is not too young to begin administering self injections. 1. Incorrect: This is a false statement, considering the fact that pain perception varies. Minimizing the amount of potential discomfort will instill distrust in the child, decreasing compliance with the health regimen. 2. Incorrect: While parents may administer injections for much younger children, school aged children are capable of becoming independent with all aspects of diabetes. Additionally, an 11 year old client needs to develop a sense of mastery and achievement to accomplish this stage successfully. 4. Incorrect: The client is too old for pretend play with imitation syringes. That process is more appropriate for a preschool child. It would be beneficial to allow this child to handle regular syringes without a needle initially, and then add all the necessary equipment when the client feels more comfortable handling everything.

A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse initiate? 1. Instruct the child to extend the affected knee 2. Perform range of motion exercise on both knees 3. Compare the appearance of the left knee to the right knee 4. Have the child soak the affected knee in warm water

3. Correct: Comparing the appearance of the left knee to the right knee is the least invasive assessment and allows the nurse to assess if there is a change in the appearance of the affected knee to the unaffected knee. 1. Incorrect: The extent of the injury is not known until after an assessment is done. Remember the nursing process here. Assess first. Extending the affected knee may cause further damage.2. Incorrect: You don't want the child to move the extremity prior to assess for broken bones. Range of motion exercises may cause further damage to the affected knee.4. Incorrect: Soaking the affected knee in warm water will not help the nurse assess whether or not an injury occurred.

A client at 34 weeks gestation with pregnancy induced hypertension (PIH) reports "heartburn." Which action by the nurse has priority? 1. Administer an antacid per standing orders. 2. Check client's blood pressure. 3. Call the primary healthcare provider immediately. 4. Assure client this is a normal discomfort of pregnancy.

3. Correct: Epigastric discomfort is commonly described as "heartburn" by pregnant clients, but epigastric discomfort is a symptom of impending rupture of the liver capsule and seizures associated with worsening PIH and eclampsia. As a new nurse we need to assume the worst. Call the primary healthcare provider. 1. Incorrect: Not a concern as much as impending seizure symptoms. Administering an antacid will not fix the problem if PIH is worsing. This is delaying care. 2. Incorrect: Not a concern as much as impending seizure symptoms. Checking the client's blood pressure is not the priority in this situation. It will not fix the problem. 4. Incorrect: Not in this situation. Heartburn is a normal discomfort or right upper quadrant pain in a client with PIH may indicate impending rupture of the liver capsule which is a life threatening complication.

Two nurses are checking a unit of packed red blood cells (PRBCs) for client compatibility prior to infusion. What action should the primary nurse take after completing this process? Exhibit 1. Initiate the PRBCs transfusion at 25 mL/hour for the first 15 minutes. 2. Ask blood bank personnel to type and cross match for PRBCs sent to unit. 3. Send unit of PRBCs back to the blood bank. 4. Notify the primary healthcare provider.

3. Correct: The blood compatibility label does not match the PRBC unit sent to the unit. Note that the donor numbers are not the same. So, this unit needs to be sent back to the blood bank and the correct unit needs to be obtained. 1. Incorrect: Do not give uncrossed matched blood. This unit is not the one that was cross matched to the client. The unit numbers are different. 2. Incorrect: It takes a while to cross match blood and the blood cannot stay out of the refrigerator that long. And what if it is not compatible. A unit of blood has been wasted. 4. Incorrect: The wrong unit of PRBCs has not been hung. There is no need to contact the primary healthcare provider.

The labor and delivery charge nurse is making staff assignments, including assignments to a new nurse. What client is most appropriate for the new nurse? 1. A gravida 3 para 2 in active phase of stage one, expecting twins. 2. A gravida 2 para 0 at 41 weeks gestation, awaiting induction. 3. A primigravida in active phase of stage one, waiting for epidural. 4. A 12-hour post Cesarean section needing assistance to ambulate.

3. Correct: The primigravida presents many opportunities for basic and diverse skills that would be very educational for the new nurse. This is the most appropriate client and will provide a good experience in basic labor and delivery procedures. 1. Incorrect: While this may seem like an interesting case, there is the potential for several problems. A third pregnancy generally proceeds faster, and this client is expecting multiple births. This case can quickly become too complicated for a new nurse. 2. Incorrect: Although this may seem like an interesting case for the new nurse, induction of labor can lead to many problems which could be too complicated for this new nurse. This client requires close monitoring during the induction and would not be the best choice here. 4. Incorrect: Ambulating a post-C-section for the first time would be within the level of competency for a new nurse. However, there is very little educational value in this assignment and it is important to provide learning opportunities for this new nurse.

Which meal is most appropriate for a client during an acute manic episode? 1. Steak, salad, banana 2. Beef and vegetable stew, bread, vanilla pudding 3. Chicken leg, corn on the cob, apple 4. Fish fillets, cubed avocado, cake

3. Correct: They can hold these items in their hand and eat while walking around. 1. Incorrect: Steak requires cutting up with a knife and is time consuming. Do you also see a safety issue here? Knife? Not while the client is manic. They need something that they can eat with their hands because they don't sit long enough to eat. 2. Incorrect: It's hard to walk around and eat beef stew and pudding. 4. Incorrect: It's hard to walk around and eat fish and cubed avocado.

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

3. Correct: This action should be corrected by the supervising nurse. Because tiny pieces of glass could have gotten into the medication, the nurse should attach a filter straw to a syringe. If the syringe has a needle in place, the nurse should remove both the needle and the cap and place it on a sterile surface (e.g., a newly unwrapped alcohol pad still in the open wrapper), and then attach filter straw. 1. Incorrect: This is a correct action by the new nurse. Alternatively, the new nurse can flick the top or shake the ampule by quickly turning and "snapping" the wrist. 2. Incorrect: This is a correct action by the new nurse. This will prevent shattering of class toward the hand or face. 4. Incorrect: This is a correct action by the new nurse. Two techniques can be used to withdraw medication from an ampule. The nurse can invert the ampule, place the filter straw tip in the liquid, and withdraw all of medication. The nurse does not insert the filter straw through the medication into the air at the top of the inverted ampule. This will result in medication leaking out of the ampule. Alternatively, the nurse can tip the ampule, place the filter in the liquid, and withdraw all of the medication.

A 20 year old client has been admitted to the hospital with a diagnosis of preeclampsia. The charge nurse has only semiprivate rooms available. What roommate would be most appropriate for this client who is being admitted? 1. An adolescent primigravida with many visitors. 2. A 25 year old post induction for fetal demise. 3. A 35 year old awaiting discharge after a total abdominal hysterectomy (TAH). 4. A 30 year old post dilation and curettage (D&C) who enjoys knitting.

4. CORRECT: A client with preeclampsia will be experiencing stress and elevated blood pressure. There is a risk of seizures, and therefore a calm, relaxed environment would provide the most therapeutic setting for the client. The 30 year old client is ideal because knitting is a quiet activity. Additionally, a D&C is a relatively uncomplicated procedure and this client will most likely soon be discharged, leaving the preeclampsia client alone in that room. 1. INCORRECT: Although the client is close in age to the adolescent, the teenaged primigravida has many young visitors which would create noise or confusion in the environment. Since this client is suffering from preeclampsia, a quiet environment is necessary to prevent other complications such as seizures. This adolescent would not be the best roommate. 2. INCORRECT: The client is admitted with a diagnosis of preeclampsia, which means elevated blood pressure, edema and the possibility of seizures. A quiet calm environment would be crucial for this client. The 25 year old client is close in age; however, that client has experienced a fetal demise and delivery of that fetus. There will most likely be grieving, multiple family members, and tension in that environment which would not be helpful to the client with preeclampsia. 3. INCORRECT: Though there is a large age difference, that issue does not impact whether this client would be an appropriate roommate. A client with preeclampsia needs a restful, calm environment to prevent further complications. Depending on the reason for the total abdominal hysterectomy (TAH), this client may require special teaching, referrals for further care and treatment, or emotional support for an unexpected diagnosis. The charge nurse knows this may be too hectic of an environment for the client with preeclampsia.

A client has been admitted for evaluation of severe anxiety and new onset panic attacks following the loss of a spouse. Which client factor would the nurse consider most important in developing a plan of care? 1. Available support system 2. Perception of the situation 3. Desire to return to work 4. Coping mechanisms

4. Correct. The plan of care for a client in crisis involves a complex combination of factors to achieve a positive outcome. However, the most important consideration is the client's own coping skills. Treatment and subsequent recovery is more successful when the client has the coping skills and is able to participate in the recovery process. 1. Incorrect. Although a good support system is crucial during any psychiatric or emotional crisis, this is not the most important aspect of a client's plan of care. The priority is the client. Available support systems is not the priority when developing a plan of care. 2. Incorrect. The client's own perception of the problem can enhance or detract from a successful outcome; however, there is another facet that is more critical to a client's positive outcome. The client's coping mechanisms can affect their perception of the situation. 3. Incorrect. Having a goal, such as returning to employment, is important to the client's recovery, but by itself is not enough to ensure a positive outcome for a client. Returning to work is not the priority with new onset panic attacks.

A postpartum client who is 2 hours post vaginal delivery remains on a oxytocin infusion for bleeding. Upon examination, the nurse determines that the client's fundus is boggy and soft. What is the priority nursing intervention? 1. Ambulate in the room 2. Perform crede' exercises 3. Reassess the fundus in 30 minutes. 4. Massage the fundus.

4. Correct: If the fundus is boggy and soft, massaging the fundus until firm will increase uterine tone and decrease bleeding. This is the only option that will fix the problem. 1. Incorrect: Ambulation will not fix a boggy fundus and would not be safe. 2. Incorrect: Crede' exercises are for bladder tone. Although urinary retention will prevent uterine contraction, the appropriate nursing intervention in the case of a full bladder is to have the client empty her bladder or to catheterize her if she is unable to void. 3. Incorrect: Postponing care could make the bleeding worse. This is delaying care.

A child is brought into the school nurse's office after a fall on the playground which resulted in a nose bleed. What initial action by the nurse is most appropriate? 1. Hold cup under nose and allow fluid to drip. 2. Place an ice pack on the back of the neck. 3. Have child lie down and elevate the feet. 4. Pinch the bridge of the nose for 10 minutes.

4. Correct: The proper method to stop epistaxis is to place the client in the upright position, facing forward and pinch the bridge of the nose for approximately ten minutes. The head should not be tilted back, as that allows blood to run down the back of the throat. 1. Incorrect: Holding a cup under the nose to collect the blood does nothing to stop the bleeding. This action is only performed in the case of potential basilar skull fracture in which stopping the flow of spinal fluid would cause increased intracranial pressure (ICP). 2. Incorrect: If an ice pack is used for epistaxis, it should to be placed on the bridge of the nose. Placing an ice pack on the back of the neck will not stop a nose bleed, though it can be used to decrease fever. 3. Incorrect: Placing a client in the supine position, particularly with the feet elevated, is useful for those in shock. But with epistaxis, this action would allow blood to flow down to the stomach, resulting in vomiting.

Which client in the emergency department should the nurse identify as being the highest priority? 1. Client with emphysema reporting shortness of breath. 2. Client with a cut on the left calf with moderate bleeding. 3. Client with onset of confusion 1 hour prior to arrival. 4. Client with facial swelling and rash after taking azithromycin.

4. Correct: Were you able to recognize this as a probable reaction to the antibiotic that was taken? Next, it is important to note that there is not only a rash, but facial swelling is also present. That should alert the nurse to the possibility that there could be a rapid onset of airway swelling that could cause airway occlusion. This makes this client the priority over the other clients. 1. Incorrect: It is not uncommon for clients with emphysema to experience shortness of breath. This is a concern, and the client needs additional measures to help relieve the shortness of breath, but is not as likely to result in a rapid airway occlusion as the allergic reaction could. 2. Incorrect: Again, this is a situation that will require intervention. It pertains to circulation because there is moderate bleeding from a cut. However, this does not take priority over the airway. 3. Incorrect: We are concerned about this client and neuro checks will need to be performed. This could be many various things including a stroke, effects of medications or drugs, or other neurological conditions. But, this does not take priority over the airway.

The nurse is caring for a post op client who is drowsy but arousable. The client will take a few deep breaths when instructed but drifts to sleep when left alone. The O2 saturation while sleeping drops to 82% on 3 liters of nasal oxygen. The client received a dose of oxycodone/acetaminophen 2 tabs one hour ago. What is the nurse's best action at this time? 1. Keep the O2 sat machine at the bedside and set the alarm to beep loudly when O2 sat drops below 93%. 2. Give bath to arouse client and then report that oxycodone/acetaminophen 2 tabs is too much for next dose. 3. Let the client sleep until he has rested, then discuss abuse potential of narcotics. 4. Call the primary healthcare provider and report client assessment findings.

4. Correct: Yes, this client has unstable respirations and is in respiratory distress. The client needs naloxone,the antidote for narcotic overdose. Since that is not an option, you need to call the primary healthcare provider to get a prescription for the antidote. 1. Incorrect: That will work the first time, but the client is too sedated to remain awake and take deep breaths. The client will continue to have respiratory distress until naloxone can be given. 2. Incorrect: No, that won't fix the problem of too much medication. We need to fix the problem now. 3. Incorrect: No, client is too sedated. Naloxone is needed, so the nurse needs to notify the primary healthcare provider.

The home health nurse is preparing to hang an IV bag of total parenteral nutrition (TPN) on a client. At what rate should the nurse set the IV infusion pump? Round to the nearest whole number. Answer in numbers and decimals only.

Answer: 113 Rationale: Prescription: Administer bag of TPN over 12 hours. First, you must know how many mL are in the bag once everything is added. The final volume is 1350 mL. So, 1350 mL / 12 hours = 112.5 mL/hour Think, when an infusion pump is used, the flow rate is prescribed by the primary healthcare provider and programmed by the nurse by setting the device for milliliters per hour (mL/h). Rule - To regulate an IV by infusion pump, Total mL prescribed/Total hr prescribed = mL/hr If you forgot that, then work the formula for gtts/min - mL/hr x drop factor/time in minutes = gtts/min The drop factor for the infusion pump is 60. 112.5 mL x 60 / 60 minutes = 112.5 The instructions say to round to the nearest whole number. Therefore, the pump should be set at 113 mL per hour

A client is prescribed 1.5 grams of levodopa daily. Available forms of this drug include tablets of 250 milligrams. How many tablets should this client be given to receive the proper amount of medication? Round answer to the nearest whole number.

Changing 1.5 grams to milligrams equals 1500 milligrams as a daily dosage. Dividing 1500 milligrams by 250 milligrams equals 6.