NCLEX

Birth control, STD, HIV, Pregnancy consent is

13 year and up

Sarin Gas - heavy vapor

30 min to dissipate atropine is the antidote

maximum recommended dosage for acetaminophen (Tylenol)

4000 mg/24h for adult

Children based on weight

5 max doses a day

Cancer Diagnostics

BIOPSY - Must to diagnose Endoscope (bronchoscopy, colonscopy) Diagnostic imaging (CXR, IVP) Radiosotope studies (bone scanning) CT, MRI, PET Ultrasound Laboratory Alkaline phosphatase blood levels Calcitonin Carcinoembryonic antigen Tumor markers Stool for occult blood

Living will:

Client wishes regarding future care in the event of terminal illness

Answers to any questions the client has about a procedure are the responsibility of the

HCP who will perform the procedure

START (simple triage and rapid treatment)

Identify the walking wounded; move them to an area where they can be evaluated later.

Iron is best absorbed on an empty stomach, however, if nausea and vomiting occur, drink orange juice with the iron.

It will help decrease nausea and vomiting, and will enhance absorption of the iron.

COPD Nursing/Collaborative Care

Keeping SaO2 to greater than 90% during rest, sleep, and exertion, or the PaO2 greater than 60mmHg

TB

Low-grade fever

HIV Diagnosis - Laboratory testing

Positive result on enzyme immunoassay (EIA) Confirmed on western blot test Polymerase chain reaction (PCR) (used for neonate) Oraquick In-Home HIV test: Positive result is only preliminary: it must be confirmed by HCP

Hypermagnesemia

Renal failure, adrenal insufficiency, excessive replacement Mg > 2.1mEq/L Bradycardia & hypotension peripheral vasodilation prolonged PR interval with a widen QRS complex Decreased to absent deep tendon reflexes - patient will code If client has difficulty holding head up or breathing, notify RN and expect the administration of calcium gluconate

Hyperphosphatemia

Renal failure, excess intake Phosphate >4.5 mg/dL Monitor for hypocalcemia

Stage 1 of shock: nonprogressive/early

Restlessness MAP decreased 10-15 mm Hg from baseline Increased heart rate Decreased blood pressure Pulse oximetry 90%-95% Increased respiratory rate

The nurse should continue to monitor the client, and administer the warfarin. The normal range for INR is 0.8 - 1.1 for a client not prescribed an anticoagulant.

The optimal therapeutic INR range for a client on warfarin should be 2.0 - 3.0.

The client's blood glucose is extremely high and needs to be quickly reduced.

The prescription given by the primary healthcare provider is for 30 units of NPH insulin, an intermediate acting insulin whose onset is about 1 ½ hours. That is too long to wait to start reducing this elevated glucose. This client should have been prescribed regular insulin.

water seal chamber of chest tube

This chamber contains 2cm of water, which prevents backflow and acts as a one-way valve.

a patient can deviate from living will when

alert and awake

PN can never do

initial assessment

delegation

the process by which responsibility and authority- but not accountability - are transferred to another individual

HIV

unexplained fever

When disposing of waste in a client's room, the nurse would place which item(s) in a biohazard red bag? 1. Chest drainage unit 2. Doxorubicin IV bag and tubing 3. Staples removed from an abdominal incision 4. Tramadol 50 mg tablet prescribed but refused by client 5. Soiled dressing 6. Paper trash with identifying client information

1. Chest drainage unit 5. Soiled dressing Rationale: Chest drainage units should be capped and placed in a large red biohazard bag for disposal. Dressings soiled with human waste, blood or body fluids should be disposed of in a red biohazard bag. Doxorubicin is an intravenous antineoplastic chemotherapy agent. IV bags and tubing used to administer chemotherapy medications should be disposed of intact and placed in a yellow or purple chemotherapy waste container with a lid.

The nurse is looking at the plan of care for a child with a fractured femur in Bryant's traction. The nurse is aware that planned interventions should focus on preventing what major complication? 1. Infection at the pin sites. 2. Slipping counter traction. 3. Neurovascular impairment. 4. Skin breakdown and decubiti.

3. Neurovascular impairment. Rationale: Bryant's traction is a type of skin traction with the potential for several complications. Though the traction is important, this child is being treated for a fractured femur. The major complication with any fracture is neurovascular integrity. The nursing priority is monitoring neurovascular status, including areas such as pulses, sensation, motor function, edema, skin temperature and capillary refill in bilateral toes.

Pco2 Normal 35-45 mm Hg

>45 = acidosis < 35 = alkalosis

The ED nurse is assessing a client with a vesicular rash as a result of suspected smallpox exposure. Which transmission precautions should be most appropriate for this client? (select all that apply) A. Airborne B. Contact C. Aplastic D. Droplet

A. Airborne B. Contact D. Droplet E. Standard

Emphysema

Abnormal enlargement of the air spaces distal to the terminal alveolar walls

Do it my way

Aggressive communication Authoritarian communication

Let's consider the options available

Assertive communication Democratic leader

Three-step evaluation of others, done one at a time

Assess respirations Assess circulation Assess mental status

Pneumonia etiology

Bacterial (gram-negative is the most severe), viral, fungal (rare), or aspiration Community acquired (CAP) or hospital acquired (HAP) Ventilator-associated pneumonia (VAP)

Which situation warrants a variance (incident) report by the LPN? A. Refusal by a client to take prescribed medication B. Improved status before completion of the course of medication C. An allergic reaction to a prescribed medication D. A client received medication prescribed for another client

D. A client received medication prescribed for another client

a client who has hyperparathyroidism is scheduled to receive a prescribed dose of oral phosphate. The PN notes that the client's serum calcium level is 12.5 mg/dL. Which action should the PN implement? A. Hold the phosphate and notify the healthcare provider B. Review the client's serum parathyroid hormone level C. Assist with giving a PRN dose of IV calcium per protocol D. Administer the dose of oral phosphate

D. Administer the dose of oral phosphate

Inhaled corticosteroids include:

Fluticasone (Flovent HFA) Budesonide (Pulmicort Flexhaler) Mometasone (Asmanex Twisthaler) Beclomethasone (Qvar RediHaler) Ciclesonide (Alvesco)

Care of client receiving radiation therapy - external radiatio

Instruct the client in self-care of the skin Instruct the client not to remove the markings Protect radiated area from direct sunlight Avoid heat/cold applications Encourage fluid intake Encourage a high-protein/high-calorie diet

acute respiratory distress syndrome (ARDS)

Is a severe form of respiratory failure considered to be present if the client has hypoxemia that doesn't improve with oxygen

Chest tubes and water or dry seal management

Monitor the fluid drainage and mark the time of measurement and the fluid level; notify the healthcare provider if there is >70mL/h drainage Assess for tidaling; observe for air bubbling in the water seal chamber and fluctuations (tidaling) Replace the unit when full no vigorous bubbling dry sterile dressing - not allowing air in petroleum gauze if no option for sterile dressing petroleum doesn't let air out

Nurses are responsible for performing all procedures correctly and exercising professional judgement as they carry out physicians' or health care providers' orders.

Nurses follow physicians' or health care providers' orders unless they believe the orders are in error or are harmful to the clients.

Color-coded system (in order of priority)

Red: Life threatening need immediate intervention Yellow: Injuries with systemic effects and complications Green: Minor injuries, no systemic complications Black: dying or deceased - catastrophic injuries

COPD Medication goals

Reduce exacerbations Long-acting beta agonists Intercostal space inhaled corticosteroids internal carotid stenosis (ICS)

SBAR

S - Situation - state the issue or problem B - Background - Provide the client's history A - Assessment - Give the most recent vital signs and current findings R - Recommendation - State what should be done

Care of client receiving radiation therapy - Internal radiation

Sealed: brachytherapy or intracavity radiation Unsealed: radioactive iodine Place client in private room No pregnant caretakers or visitors allowed in room Keep lead-lined container in room Wear radiation badge when providing care Monitor vitals every 4 years Assess for rash Monitor I&O (oral, catheter)

Penicillins

Semisynthetic penicillin Oxacillin Antipseudomonal penicillin Piperacillin sodium Tetracyclines Aminoglycosides - Peaks & Trough Gentamycin Vancomycin

Advanced directives

can limit life-prolonging measures when there is little to no chance of recovery

Other cancer therapies

chemotherapy external radiation internal radiation - patient secretion become radioactive - patient needs private room Bone marrow transplant - leukemia and lymphoma

stages of grief

denial, anger, bargaining, depression, acceptance

HIV symptoms

flu like symptoms for first year 8-10 years asymptomatic fatigue, severe weight loss, swollen glands, unexplained fever, dry cough, night sweats neurological disease cancers Secondary infection

Use ABC - Airway, breathing, circulation except

in CPR use CAB - Circulation, airway, breathing

POA can sign

living will

Nonverbal Behaviors of Pain

moaning, grimacing, clenching teeth, pacing, and inactivity

Restraints or safety reminder devices

only used with a written prescription from the HCP

Phosphate calcium relationship

phosphate lowers calcium

Red flag: injury doesn't match story

report to physician first or charge nurse

The most important goal is to prevent the progression of SIRS

to MODS

NCLEX always confront directly and professionally

using the proper chain

The PN is making assignments for five clients at the nursing home. The nursing team includes PN and two UAPs. Which client(s) tasks would be assigned to the UAPs? (select all that apply) A. Administering an injection of Lovenox to a client who requires anticoagulant therapy B. Repositioning a client with stage 3 pressure ulcer who needs a bath C. Checking the residual for a client with an external feeding absorbing at 30mL/h D. Changing the IV tubing on a client recovering from pneumonia E. Performing a straight catheterization on a client prescribed intermittent catheterization

B. Repositioning a client with stage 3 pressure ulcer who needs a bath

dry stoma

possible necrosis

Cancer therapies: surgery

preventative, diagnostic, curative, palliative Teach specific to the surgery Assess nutritional status Referrals

Hemodialysis is like voiding

you use potassium such as when a patient is prescribed a lasix

if out of scope with enough information

call physician

The nurse is caring for a client taking lithium. Which comment by the client indicates lack of understanding of the therapeutic regimen? 1. "I must keep my sodium intake steady over time. " 2. "If I miss a dose of lithium, I should make it up with the next dose." 3. "I must check with my primary healthcare provider before changing my diet for weight loss." 4. "I must keep my exercise routine the same or discuss with my primary healthcare provider. "

2. "If I miss a dose of lithium, I should make it up with the next dose." Rationale: If a client misses a dose of lithium, the client should take the next dose as prescribed without doubling it. If the client adds the missed dose, toxicity may occur. If sodium intake is reduced or the body is depleted of its normal sodium (due to sweating, fever, diuresis), lithium is reabsorbed by the kidneys, increasing the possibility of toxicity.

A client with a history of uterine fibroids had a cesarean delivery 12 hours earlier and delivered healthy twin girls. At shift change, the nurse assesses the client and notes SOB, cool extremities, and oozing of blood from the incision site. Based on the client's presentation, which nursing action has the highest priority? A. Assess the client's temperature B. Notify the healthcare provider C. Clean the blood from the incision site. D. Draw labs from PT, PTT, CBC, and fibrinogen

B. Notify the healthcare provider

The PN needs to prepare an 8-year old child for an IV insertion. Which intervention is appropriate? A. Encourage the child to use guided imagery to cope. B. Place the patient in the treatment room, not the child's room C. Apply lidocaine-based cream just before inserting the IV catheter. D. Ask the parents to leave the room while performing the procedure

B. Place the patient in the treatment room, not the child's room

A non-English speaking postpartum client admitted for observation of gestational hypertension angrily ejects her English-speaking partner from the birthing room. A few minutes later the client screams "comidal" (food). When the PN enters the room, the client is having a seizure. What actions should the PN take? (select all that apply) A. Place something soft in the client mouth to protect the tongue from being bitten B. Pull the emergency call light C. Notify the RN immediately D. Administer a dose of calcium gluconate E. Giving oxy tocin 10 mg IM per protocol

B. Pull the emergency call light C. Notify the RN immediately

Cephalosporins

Ceftriaxone sodium Cefepime hydrochloride Macrolides Clarithromycin (biaxin) Fluoroquinolones Ciprofloxacin (cipro)

hypovolemic shock - Trendelenburg position

Decreased circulating volume related to internal or external blood loss or dehydration Older adults are at risk diuretic therapy. Decreased thirst reflex anticoagulation therapy

Nursing negligence

Failure to exercise the proper degree of care required by the circumstances that a reasonably prudent person would exercise under the circumstances to avoid harming others.

Nursing malpractice

Failure to use that degree of care the a reasonable nurse would use under the same or similar circumstances.

Diagnosis of AIDS

HIV positive and CD4+ t-cell count < 200 cells/mm3 and/or an opportunistic infection

Hypocalcemia

Renal failure, hypoparathyroidism, malabsorption, pancreatitis, alkalosis Ca++ <9.0 mEq/L +Chvostek sign, +Trousseau sign, diarrhea, numbness, convulsions Administer calcium supplements Give IV calcium slowly Increase dietary calcium

Never delegate

assessment

Penicillin sister drug to

cephalosporins

Chronic airflow limitation (CAL)

cigarette smoking environmental exposure occupational exposure genetic predisposition

pulmonary tuberculosis (TB)

communicable disease caused by mycobacterium tuberculosis or the tubercle bacillus an acid-fast organism spread by airborne transmission low-grade fever Purified protein derivative (PPD) (Mantoux Test) screening -- treating with INH (isoniazid) for 6 months 3 clear sputum can be removed from isolation - considered clear of TB sputum cultures need to take 2 to 3 weeks apart

Maslow's hierarchy

physiological, safety, love/belonging, esteem, self-actualization

Multiple Organ Dysfunction Syndrome (MODS)

prognosis is poor

Electrolyte imbalance - calcium

bone strength and density, activates enzymes, skeletal and cardiac muscle contraction, nerve impulse transmission, blood clotting

Treatment of shock

restore cardiac function based on effect of shock on preload, afterload, and contractility Data collection vital signs Mental status Urine output

Newborns exposed to GBS can go

septic and die in one hour

The PN can witness the

signature for informed consent

HIPAA sets standards for:

verbal, written, and electronic exchange of private health information

In cardiogenic shock

volume expanders may precipitate pulmonary edema

Less than 100mL in 24 hrs

anuria

Chronic bronchitis - pathophysiology

Chronic sputum with cough production on a daily basis for a minimum of 3 months per year; chronic hypoxemia, cor pulmonale (right sided HF with JVD); increase in mucus, cilia production; increase in bronchial wall thickness which obstructs the airflow; reduced responsiveness of respiratory center to hypoxemic stimuli

Most common cancer in men

Prostate, lung, colon, rectum

Pediatric HIV

For infants younger than 18 months born to HIV mothers HIV polymerase chain reaction (PRC) For children aged 18 months and older ELISA for HIV Western blot immunoassay Symptomatic for 1 year Full blown AIDS in 4-8 years No live vaccines

Levels of prevention in disaster management

Primary: Planning, training, educating personnel and the public Secondary: triage, treatment shelter supervision Tertiary: follow-up recovery assistance prevention of future disaster

Clients with paranoid delusions believe that others may harm them. Because they cannot determine what is accurate, they may react in a violent manner. The clients age falls within the range for males who are most likely to present a risk of violence toward others

The clients age (24) falls within the range for males who are most likely to present a risk of violence toward others

HIPAA establishes the client's rights:

To consent to use and disclosure of health information To inspect and copy their medical records To amend mistaken or incomplete information

HIV Routes of transmission

Unprotected sexual contact exposure to blood through drug-using equipment perinatal transmission Can occur during pregnancy, at time of delivery, or after birth through breastfeeding AZT (azidothymidine) - through pregnancy and 1st year of life C-section is absolute must for delivery Breastfeeding is contraindicated for HIV positive moms

Hypernatremia - Cushing's

Water deprivation, diabetes insipidus, renal failure NA > 145 mEq/L Pulmonary edema, seizures, thirst, fever No IVs that contain sodium restrict sodium in diet weigh daily

eliminate red flag words

all, nothing, never, always

Pneumonia

high grade fever

A nurse is communicating with a newly hired LPN regarding the plan of care for a client with delusions on an inpatient psychiatric unit. The client has a psychiatric advance directive (PAD) in the medical record, which was executed when the client was mentally competent. Which explanations made by the nurse about the client's PAD are correct? 1. "The PAD permits a client to express his/her wishes regarding future treatments, such as administration of medications and electroconvulsive treatment." 2. "The PAD should be followed even if an emergency situation exists." 3. "The PAD should be followed even if the client expresses that he does not wish to be involuntarily committed." 4. "The PAD should be followed even if the client's wishes conflict with accepted practice standards." 5. "The PAD is usually created by a client who experiences acute episodes of psychiatric illness and becomes unable to make treatment decisions."

1. "The PAD permits a client to express his/her wishes regarding future treatments, such as administration of medications and electroconvulsive treatment." 5. "The PAD is usually created by a client who experiences acute episodes of psychiatric illness and becomes unable to make treatment decisions." Psychiatric advance directives permit clients to express their wishes regarding future treatments. Psychiatric advance directives are usually created by clients who experience acute episodes of psychiatric illness and become unable to make treatment decisions. Psychiatric advance directives do not have to be followed in an emergency situation. Psychiatric advance directives do not have to be followed if the client must be involuntarily committed to prevent harm to self or others. A client's PAD is not followed if it conflicts with accepted practice standards.

A young adult diagnosed with schizophrenia is admitted to the crisis center with exacerbation of psychotic behaviors. The client responds well to a medication regime of chlorpromazine three times daily. The nurse is reinforcing discharge instructions and knows teaching was successful when the client makes what statements? 1. "This medication will help me control my behavior." 2. "I should take this medication only if I feel anxious." 3. "I need to have blood levels checked periodically." 4. "My medication will eventually cure my disorder." 5. "I must apply sunscreen and wear a hat if outside."

1. "This medication will help me control my behavior." 5. "I must apply sunscreen and wear a hat if outside." Chlorpromazine is an antipsychotic medication used to control psychotic or hyperactive behaviors such as those noted in schizophrenia and attention deficit hyperactivity disorder (ADHD). If the medication regime is followed consistently, psychotic behaviors can be minimized. However, chlorpromazine also sensitizes the skin, making the client susceptible to sunburn even on cloudy days. Using sunscreen is vital at all times.

A client newly diagnosed with insulin dependent diabetes mellitus is started on insulin aspart protamine suspension/insulin aspart solution mixture. The nurse knows that the insulin should start to lower the blood sugar within how many minutes? 1. 15 2. 30 3. 45 4. 90

1. 15 Rationale: Insulin aspart mixture is a rapid-acting insulin and starts to work within 15 minutes after given subcutaneously. Insulin aspart mixture is a rapid-acting insulin and starts to work within 15 minutes after given subcutaneously. Long acting insulin has an onset of 45-48 minutes. An example of long acting insulin would be lantus. Intermediate acting insulin such as NPH insulin has an onset of 90 minutes.

Which is a therapeutic technique that can be utilized by the nurse for clients with anxiety disorders? 1. Activity assignments 2. Careful monitoring 3. Goal setting 4. Relaxation techniques 5. Group activities

1. Activity assignments 2. Careful monitoring 3. Goal setting 4. Relaxation techniques Group activities may increase anxiety.

A client states, "I have not had a drink for 24 hours and I am beginning to feel anxious". What additional signs/symptoms would indicate to the nurse that the client is in the early phase of alcohol withdrawal? 1. Agitation 2. Insomnia 3. Course tremors 4. Visual hallucinations 5. Confabulation 6. Tachycardia

1. Agitation 2. Insomnia 3. Course tremors 6. Tachycardia The earliest signs of alcohol withdrawal are anxiety, agitation, insomnia, and tremors. Tachycardia of 120-140 /min persists throughout withdrawal. The onset of hallucinations indicates alcohol withdrawal delirium, a potentially fatal complication of alcohol withdrawal that occurs when the withdrawal process has not been medically managed. It begins the 2nd or third day after the client's last drink and lasts 48-72 hours. Confabulation is a symptom of alcohol amnestic disorder or Korsakoff syndrome. Thiamine deficiency is thought to cause this syndrome.`

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. Alanine aminotransferase (ALT) Rationale: ALT levels will increase primarily in liver damage/disorders. A side effect of administering divalproex is drug-induced hepatitis.

When shopping at the mall, a nurse witnesses an individual collapse in cardiac arrest. A bystander begins CPR while the nurse opens an automatic external defibrillator (AED) brought by security. What critical actions should the nurse perform before delivering a shock? 1. Apply defibrillator pads to bare skin. 2. Verify that synchronizer button is on. 3. Continue CPR until advised to deliver shock. 4. Stop CPR while machine analyzes the rhythm. 5. Shout "clear" prior to activating shock button. 6. Apply cream under de-fib pads to prevent burns.

1. Apply defibrillator pads to bare skin. 3. Continue CPR until advised to deliver shock. 4. Stop CPR while machine analyzes the rhythm. 5. Shout "clear" prior to activating shock button. Rationale: Even in a public setting, the defibrillator pads must be applied directly to bare skin for a solid connection, with one pad in the left axillary area and the other pad just below the right clavicle. CPR should be initiated immediately while the machine is set up and the pads are positioned. CPR should stop momentarily while the AED analyzes the rhythm. Then, if a shock is advised, the nurse shouts "clear" to any individual near the client prior to administering a shock. If no shock is advised, CPR should continue. The synchronized cardioversion mode is used only when converting erratic rhythms back into sinus rhythm, such as atrial fibrillation or atrial flutter. Cardioversion administers a low-voltage shock at a specific point during a heartbeat and can only be used on beating heart. When utilizing the AED for a client in cardiac arrest, the machine must be set to the defibrillate mode only.

The nurse is caring for a client receiving digoxin. What information should be reinforced by the nurse to the client about this medication? 1. Check your pulse daily before taking the medication. 2. Report a marked decline in pulse rate. 3. Consume foods high in potassium to maintain adequate serum potassium levels. 4. Report pulse rate of 64 or more. 5. Report symptoms of nausea, loss of appetite, or visual disturbances.

1. Check your pulse daily before taking the medication. 2. Report a marked decline in pulse rate. 3. Consume foods high in potassium to maintain adequate serum potassium levels. 5. Report symptoms of nausea, loss of appetite, or visual disturbances. Rationale: The client should be told to take his pulse daily to assure pulse rate is above 60. Any marked decline in pulse rate should be reported as it could indicate heart block or toxicity. Digoxin works best when potassium levels are adequate. Symptoms of toxicity include anorexia, nausea, bradycardia, visual disturbances.

When inspecting the equipment in a client's room, what would the nurse recognize as electrical safety hazard(s)? 1. Flickering overhead light 2. Ground-fault circuit interrupter electrical sockets 3. Hospital labeled UL power strip 4. Bent electrical bed cord 5. Cracked electrical socket

1. Flickering overhead light 4. Bent electrical bed cord 5. Cracked electrical socket Rationale: Dim or flickering lights are indications that there is a possible electrical wiring problem. Use of a damaged electrical cord or socket increases the risk of an electrical fire, shock, or burn. Ground-fault circuit interrupter (GFCI) electrical sockets should be in place in hospital and healthcare facilities. A GFCI socket will immediately cut off power if it detects someone receives a shock, helping prevent serious injury.

The nurse is caring for a client admitted with heart failure. Which prescriptions would necessitate that the nurse seek clarification from the primary healthcare provider? 1. Furosemide 20.0 mg p.o. daily. 2. Rosuvastatin 5 mg p.o hs 3. Digoxin 0.125 mg PO every 8 hours for three doses 4. Folic acid 1 mg daily. 5. Heparin 1000 IU subcutaneously daily.

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

A primary healthcare provider prescribes contact precautions for a newly admitted client. What equipment does the nurse need to place outside of the client's room for use when entering the room? 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. N95 respirator

1. Gown 2. Gloves Rationale: Healthcare personnel caring for clients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the client or potentially contaminated areas in the client's environment. Goggles are not required with contact precautions. It is used when splashing is anticipated. A surgical mask is not required with contact precautions. It would be used for droplet precautions`

A nurse is participating in a health education program about early warning signs of Alzheimer's Disease (AD). What signs should be included in the program? 1. Mild disorientation 2. Difficulty with words and numbers 3. Poor personal hygiene 4. Agitation 5. Visual agnosia 6. Dysgraphia

1. Mild disorientation 2. Difficulty with words and numbers Early warning signs of Alzheimer's Disease include mild disorientation and difficulty with words and numbers. This client may have difficulty recognizing numbers or doing basic calculations. The person may begin to have trouble with words. 3. Incorrect: Poor personal hygiene occurs as Alzheimer's Disease progresses due to ongoing loss of neurons. 4. Incorrect: Behavioral manifestations occur later in the disease process as a result of changes that take place within the brain. They are not intentional or controllable by the person with this disease.

The charge nurse of a large medical-surgical unit is admitting several clients requiring specific infection control precautions. The LPN/VN is aware that droplet precautions are necessary for which client diagnosis? 1. Mumps 2. Methicillin resistant Staphylococcus aureus (MRSA) 3. Shingles (Herpes Zoster) 4. Human immunodeficiency virus (HIV) 5. Pertussis

1. Mumps 5. Pertussis Rationale: Droplet precautions are utilized whenever a client has specific microorganisms that are spread by coughing, sneezing or talking. Individuals within three feet of the client can be contaminated by breathing in those respiratory droplets. Mumps require approximately 9 days of isolation with droplet precautions after the swelling becomes visible. Clients with pertussis also require droplet precautions. Pertussis is a very contagious disease only found in humans. It is spread from person to person. People with pertussis usually spread the disease to another person by coughing or sneezing or when spending a lot of time near one another where you share breathing space.

What medications should the nurse anticipate the primary healthcare provider prescribing for the client with portal hypertension and bleeding esophageal varices associated with advanced cirrhosis? 1. Oxygen 2. Clopidogrel 3. Propranolol 4. Vitamin K 5. Lactulose

1. Oxygen 3. Propranolol 4. Vitamin K 5. Lactulose Rationale: We know that they need oxygen because they may have been bleeding. Propranolol acts to reduce portal venous pressure and reduce esophageal varices bleeding. Vitamin K is a clotting factor and helps to correct clotting abnormalities because of the damaged liver. Lactulose decreases what? Ammonia, which is elevated with cirrhosis. You don't want to give them a platelet aggregation inhibitor. They are already bleeding.

A client is seen in an outpatient clinic for anxiety after losing the family home in a hurricane. What actions would be appropriate for the nurse to make? 1. Reinforce teaching the client how to use progressive muscle relaxation. 2. Assist the client in correcting any distortion being experienced. 3. Suggest that the client might recover faster by moving away from the coastal area. 4. Refer the client to the family primary healthcare provider for a complete physical examination. 5. Allow the client time to talk about the loss

1. Reinforce teaching the client how to use progressive muscle relaxation. 2. Assist the client in correcting any distortion being experienced. 5. Allow the client time to talk about the loss The correct answers are appropriate interactions for this client and will help the client with anxiety reduction. Allowing the client time to talk shows them that someone cares. Muscle relaxation helps relax the client. Helping the client see the situation accurately helps decrease a distorted view of the experience. When a person is feeling anxious or stressed, these strategies can help him or her cope: Practice yoga, listen to music, meditate, get a massage, or learn relaxation techniques. Stepping back from the problem helps clear your head. Eat well-balanced meals. Do not skip any meals. Do keep healthful, energy-boosting snacks on hand. Limit alcohol and caffeine, which can aggravate anxiety and trigger panic attacks. Get enough sleep. When stressed, your body needs additional sleep and rest. Exercise daily to help you feel good and maintain your health. Check out the fitness tips below. Take deep breaths. Inhale and exhale slowly. Talk to someone. Tell friends and family you're feeling overwhelmed, and let them know how they can help you. Talk to a physician or therapist for professional help.

What actions should the nurse take when administering fentanyl? 1. Remove old fentanyl patch prior to applying new patch. 2. Cleanse area of old fentanyl patch. 3. Shave hair where fentanyl patch will be applied. 4. Place fentanyl patch over dry skin. 5. Apply adhesive dressing over the fentanyl patch. 6. Dispose of fentanyl patch in trash

1. Remove old fentanyl patch prior to applying new patch. 2. Cleanse area of old fentanyl patch. 4. Place fentanyl patch over dry skin. Rationale: These are correct actions. Apply patch to dry, hairless area of subcutaneous tissue, preferably the chest, abdomen, or upper back. The old patch should be removed prior to applying a new patch so that too much medication is not given. This is also why the old site should be cleaned. The patch should be placed on dry skin. Do not place over emaciated skin, irritated or broken skin, or edematous skin.

Which signs and symptoms would indicate to the nurse that the client is having an anaphylactic response after receiving penicillin? 1. Reports a scratchy throat 2. Faint expiratory wheeze on auscultation. 3. Client statement, "I feel like something is wrong." 4. Bounding radial pulse rate of 100/min 5. BP 100/70

1. Reports a scratchy throat 2. Faint expiratory wheeze on auscultation. 3. Client statement, "I feel like something is wrong." Rationale: Swelling of face, mouth, throat, and a scratchy throat are indicative of an inflammatory response that could obstruct the airway. Wheezes and stridor are indicators of breathing difficulties seen with anaphylactic reaction. A sense that something bad is happening should serve as a warning that something bad is really going on. Suspect anaphylactic response.

The client has been prescribed promethazine for reports of nausea. The nurse makes rounds to the client's room approximately one hour after the medication was administered. What can the nurse expect to find when seeing the client? 1. Reports feeling sleeping 2. Reports dry mouth 3. Reports that the drug has already stopped working 4. Reports blurred vision 5. Reports feeling calm

1. Reports feeling sleeping 2. Reports dry mouth 4. Reports blurred vision 5. Reports feeling calm Rationale: Promethazine causes sedation in most people. The medication has anticholinergic effects. Blurred vision is one of the anticholinergic side effects that the client may have. The medication works also as an antianxiety agent.

What action by the unlicensed assistive personnel (UAP) would require the nurse to intervene? 1. Returning clean unused linens for a client to the linen supply closet. 2. Tying the linen bag securely and tightly at the top. 3. Filling the linen bag with as much soiled linen as possible. 4. Shaking linens after removing from the bed to check for personal items. 5. Washing hands after removing linens from the bed.

1. Returning clean unused linens for a client to the linen supply closet. 3. Filling the linen bag with as much soiled linen as possible. 4. Shaking linens after removing from the bed to check for personal items. Once linen leaves the supply closet, it should not be returned. It should be sent to be laundered. Filling the linin bag too much can cause linen to spill out onto the floor. This can lead to contamination and the spread of infection. Never shake linen as it can spread pathogens.

The nurse is caring for a client diagnosed with alcohol dependence who is prescribed a benzodiazepine. Which potential side effect of benzodiazepine has a higher priority for the nurse to monitor? 1. Sedation 2. Drowsiness 3. Drug dependence 4. Impaired coordination

1. Sedation Rationale: Maintaining a client's airway is always a priority. The nurse should observe the client for excessive sedation. After a benzodiazepine is administered, the client may fall asleep, transition into respiratory depression and apnea. A side effect of benzodiazepine is drowsiness. Though the actions of the client may be slower, and the client may feel drowsy, the nurse's priority is to assess the client's sedation level.

A nurse is discussing with the family of a client in the middle stages of Alzheimer's disease how to encourage independence during meals. What points should the nurse include? 1. Serve meal in a quiet environment 2. Give 30 minutes to eat 3. Serve finger foods 4. Serve one dish at a time 5. Do not worry about neatness

1. Serve meal in a quiet environment 3. Serve finger foods 4. Serve one dish at a time 5. Do not worry about neatness

The nurse is educating a group of sexually active teenagers about Chlamydia. What instructions should the LPN/VN reinforce with these teenagers to prevent them from acquiring or transmitting this disease ? 1. Use a latex condom when having sex to protect against Chlamydia. 2. Seek the advice of a primary healthcare provider if there is vaginal discharge or burning on urination. 3. Suggest that the teens be screened for Chlamydia. 4. Reassure the teens that if they have no symptoms, they have no disease. 5. Take prescribed medication if diagnosed with Chlamydia, and repeat screening in three months.

1. Use a latex condom when having sex to protect against Chlamydia. 2. Seek the advice of a primary healthcare provider if there is vaginal discharge or burning on urination. 3. Suggest that the teens be screened for Chlamydia. 5. Take prescribed medication if diagnosed with Chlamydia, and repeat screening in three months.

The nurse cares for a client who takes multiple antibiotics for treatment of an infection. The microbiology laboratory informs the nurse the client's stool is positive for Clostridium difficile. Which actions are most appropriate for the nurse to take? 1. Use standard precautions. 2. Perform hand hygiene by using alcohol hand rub. 3. Implement contact precautions. 4. Perform hand hygiene by washing hands with soap and water. 5. Implement droplet precautions.

1. Use standard precautions. 3. Implement contact precautions. 4. Perform hand hygiene by washing hands with soap and water. Rationale: Since Clostridium difficile is a spore (killed by sterilization), the friction performed during washing hands with soap and water rinses organisms off the hands. The nurse should also implement standard and contact precautions to protect the client and the nurse.

A client diagnosed Alzheimer's disease has been prescribed memantine. The nurse is reinforcing education about this medication. What points should the client know 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. When beginning this medication provide ambulatory assistance. 5. If the client cannot swallow the capsule you sprinkle on applesauce. Rationale: 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. Memantine is used for moderate to severe dementia associated with Alzheimer's disease.`

The nurse is caring for a client admitted to rule out myocardial infarction. The nurse has administered sublingual nitroglycerin. What time frame should the nurse expect the earliest onset of effectiveness? 1. 15 seconds 2. 3 minutes 3. 5 minutes 4. 15 minutes

2. 3 minutes Rationale: The onset of action for nitroglycerin sublingual is 1 to 3 minutes. So the effectiveness can be assessed 3 minutes after the drug is administered. Sublingual doses of nitroglycerin can be repeated every 5 minutes. The drug would start to be effective before 5 minutes.

When explaining to caregivers how to reduce the risk of falls in their elderly parent, the nurse should educate about which measure? 1. Allow the parent to wear shoes that are most comfortable. 2. Assure there is adequate lighting with minimal glare. 3. Use sharply contrasting colors at edges of stairs. 4. Install grab bars beside the shower, tub, and toilet. 5. Encourage the parent to have an inside pet for comfort. 6. Rearrange the furniture for the parent to prevent stagnation.

2. Assure there is adequate lighting with minimal glare. 3. Use sharply contrasting colors at edges of stairs. 4. Install grab bars beside the shower, tub, and toilet. Rationale: Adequate lighting with minimal glare is best to assure there is the amount of illumination needed for safe mobility. Marking the edges of stairs with sharply contrasted colors can help to reduce falls by alerting the elderly client of the change in the elevation of the walkway. The risk of falls in the bathroom can be diminished by installing grab bars to help stabilize the elderly client as they make position changes or transition from the tub, shower, or toilet. Adequate lighting with minimal glare is best to assure there is the amount of illumination needed for safe mobility. Marking the edges of stairs with sharply contrasted colors can help to reduce falls by alerting the elderly client of the change in the elevation of the walkway. The risk of falls in the bathroom can be diminished by installing grab bars to help stabilize the elderly client as they make position changes or transition from the tub, shower, or toilet.

An elderly client who lives alone is being discharged home following a total hip replacement. The home care nurse is collecting data about the home environment prior to the client's arrival. Which conditions would require modifications to ensure client safety? 1. Wall-to-wall carpeting 2. Entrance throw rugs 3. Downstairs bathroom 4. Rail-free porch stairs 5. Step stool in kitchen

2. Entrance throw rugs 4. Rail-free porch stairs 5. Step stool in kitchen Rationale: Throw rugs are loose fall hazards that should be removed or tacked down to prevent tripping, particularly for a client whose mobility is impaired by hip surgery. Both inside and outside stairs should have hand rails to provide stability when in use. The presence of a step stool in the kitchen indicates that some items in the cupboards are out of reach for the client. Rearranging frequently used items to within the client's reach would be much safer than using a step stool. The existence of a downstairs bathroom is a positive feature that alleviates the need for the client to climb stairs frequently during the day. Stairs are challenging for elderly adults, plus this client also has limited mobility following a total hip replacement.

When the surgical transport team arrives to take a client to the operating room, the client is sitting in a chair in the room. What is the best way for the nurse to get the client onto the transport litter? 1. Using a foot stool, assist client to step up and crawl onto litter. 2. Have client return to bed and utilize slide board to transfer to litter. 3. With feet placed apart, grasp client around waist and lift onto litter. 4. Put Hoyer pad under client, using Lift to move client from chair to litter.

2. Have client return to bed and utilize slide board to transfer to litter. Rationale: The safest, most efficient manner by which to place the client on the litter properly is to have client first return to bed. The bed can then be raised to the height of the litter, allowing staff to utilize a slide board to easily position the client onto the litter. This method decreases safety risks for both staff and client.

Which signs/symptoms should the nurse monitor for when caring for a client diagnosed with bulimia nervosa? 1. Increased thirst 2. Muscle cramps 3. Blurred vision 4. Tingling of lips 5. Constipation

2. Muscle cramps 4. Tingling of lips 5. Constipation The typical abnormalities associated with bulimia are hypokalemia and metabolic alkalosis because of the binging and purging process. This leads to muscle cramps, weakness, fatigue, constipation, and arrhythmias are all symptoms of this electrolyte and acid-base imbalance. Hypokalemia leads to metabolic alkalosis. Blurred vision is a sign of hyperglycemia because of the effect of too much glucose in the small vessels of the eye. Microvascular damage is one of the biggest concerns with hyperglycemia; the bulemic client would be hypoglycemic.

A client scheduled for electroshock therapy becomes anxious prior to the initial treatment and refuses the procedure. What is the nurse's priority at this time? 1. Administer pre-op sedation to help the client relax. 2. Notify the charge nurse of the client's refusal. 3. Remind the client that the consent is already signed. 4. Ask the family to help convince the client to re-consider.

2. Notify the charge nurse of the client's refusal. The client has withdrawn consent for the procedure; therefore, the charge nurse should be informed immediately. The charge nurse will notify the primary healthcare provider (PHP) that the client refused the electroshock therapy. The PHP may wish to speak with the client, but the client can legally refuse any procedure at any time.

What interventions should the nurse plan to implement when caring for a client diagnosed with measles? 1. Admit to a semi-private room with a client diagnosed with tuberculosis (TB). 2. Place a surgical mask on the client when transferring to x-ray. 3. Initiate airborne precautions. 4. Wear surgical mask when entering the client's room. 5. Assign a nurse who has received the measles vaccine to take care of this client.

2. Place a surgical mask on the client when transferring to x-ray. 3. Initiate airborne precautions. 5. Assign a nurse who has received the measles vaccine to take care of this client. Rationale: If the client must leave the room, a surgical mask should be worn to prevent transmission to others. Measles can be transmitted via contact, droplet, and airborne methods, so airborne precautions are needed. Healthcare providers who are not immune to measles should not care for a client with measles. A particulate or N95 respirators should be worn by staff entering the room of a client on airborne precautions. N95 respirators filter particles that you may inhale. A surgical mask prevents the spread of particles during exhalations.

A nurse is working with community officials to decrease the incidence of violence in the community. Which primary preventive measures might the nurse suggest? 1. Provide a safe haven for victims of violence. 2. Provide educational programs about types of violence. 3. Form a neighborhood watch program. 4. Develop a media campaign identifying risk factors of potential abuse. 5. Provide for the immediate removal of a victim of violence from the home.

2. Provide educational programs about types of violence. 3. Form a neighborhood watch program. 4. Develop a media campaign identifying risk factors of potential abuse. Rationale: These are all appropriate interventions for the nurse to suggest to the community. The key is prevention. The nurse is teaching ways to prevent violence before it occurs. Primary prevention is true prevention. Primary prevention aims to prevent disease or injury before it ever occurs. This is done by preventing exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury should exposure occur. Examples include: legislation and enforcement to ban or control the use of hazardous products (e.g. asbestos) or to mandate safe and healthy practices (e.g. use of seatbelts and bike helmets); education about healthy and safe habits (e.g. eating well, exercising regularly, not smoking); immunization against infectious diseases. 1. Incorrect: This is a true statement but is not a preventive measure. This does not prevent violence from occurring; it is an intervention to decrease the chance of future violence making it tertiary prevention. Tertiary prevention aims to soften the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries (e.g. chronic diseases, permanent impairments) in order to improve as much as possible their ability to function, their quality of life and their life expectancy. Examples include: cardiac or stroke rehabilitation programs, chronic disease management programs (e.g. for diabetes, arthritis, depression, etc.); support groups that allow members to share strategies for living well; vocational rehabilitation programs to retrain workers for new jobs when they have recovered as much as possible.​ 5. Incorrect: This is not a primary preventive measure but a secondary preventive measure. Removing the victim is not preventing primary violence but additional violence. Secondary prevention aims to reduce the impact of a disease or injury that has already occurred. This is done by detecting and treating disease or injury as soon as possible to halt or slow its progress, encouraging personal strategies to prevent re-injury or recurrence, and implementing programs to return people to their original health and function to prevent long-term problems. Examples include: regular exams and screening tests to detect disease in its earliest stages (e.g. mammograms to detect breast cancer); daily, low-dose aspirins and/or diet and exercise programs to prevent further heart attacks or strokes; suitably modified work so injured or ill workers can return safely to their jobs.​​

What interventions should the LPN/VN include when reinforcing teaching with a client on how to prevent and treat fungal infections of the feet? 1. Apply cornstarch to the feet after bathing. 2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 3. Wear socks at all times until infection has cleared up. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe.

2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe. Athlete's foot is treated with topical antifungal in most cases. Severe cases may require oral drugs. The feet must be washed daily with soap and water and dried thoroughly since the fungus thrives in moist environments. Steps to prevent athlete's foot include wearing shower sandals in public showering areas and wearing shoes that allow the feet to breathe.

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

2. The client should notify their primary healthcare provider if urinary retention develops. 3. Benztropine can reduce the ability to sweat, so do not become overheated. 5. Sit up or stand up slowly to prevent lightheadedness. Rationale: Urinary retention is a side effect of benztropine. Benztropine can reduce the ability to sweat and cause the body to overheat. Do not become overheated in hot weather or while you are being active because heatstroke may occur. Benztropine may cause dizziness, lightheadedness, or fainting. Alcohol, hot weather, exercise, or fever may increase these effects. To prevent these negative effects, sit up or stand slowly, especially in the morning. Sit or lie down at the first sign of any of these effects.

A client with a history of adrenal insufficiency is placed on fludrocortisone. Which value is most important for the nurse to monitor? 1. Magnesium 2. Weight 3. Pain 4. Glucose

2. Weight Rationale: Weight is monitored daily to check for sudden increases which would indicate fluid retention. Fludrocortisone is a man made glococorticoid and is used to treat low gloucocorticoid levels caused by diseases of the adrenal gland. Glucocorticoids are important in maintaining salt and water balance in the body and normalizing blood pressure.

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

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

The nurse is caring for a client admitted with an episode of bleeding esophogeal varices. What should the nurse monitor for after administering propranolol to this client? 1. Increased systolic BP 2. Hypokalemia 3. Bradycardia 4. Wheezing 5. Decreased hematemesis

3. Bradycardia 4. Wheezing 5. Decreased hematemesis Rationale: Propranolol is a beta blocker that affects the heart and circulation. It is used in the treatment of high blood pressure, irregular heartbeats and in the prevention of angina and headaches. This medication works by blocking epinephrine and reduces heart rate, blood pressure and strain on the heart. Decreasing the heart rate should decrease bleeding. Wheezing is an adverse reaction from propranolol and should be monitored for after administration. A decreased in heart rate and blood pressure will help to decrease bleeding. Hematemesis is vomiting blood.

What information should be reinforced when a LPN/VN is talking with a group of college students about the transmission of hepatitis B and human immunodeficiency virus (HIV)? 1. HIV is transmitted via toilet seats whereas hepatitis B is not. 2. HIV is transmitted by sexual contact whereas hepatitis B is not. 3. Hepatitis B is more readily transmitted via needle sticks than HIV. 4. Neither virus is transmitted via body fluids.

3. Hepatitis B is more readily transmitted via needle sticks than HIV. Hepatitis B virus (HBV) and HIV can be transmitted in similar ways, but hepatitis B is more infectious. Studies show hepatitis B is more readily transmitted via needle sticks than HIV. More than 1 million people currently have HIV in the United States. Hepatitis B is 50-100 times more infectious then HIV. Both hepatitis B and HIV are transmitted via body fluids through sexual contact. Therefore, condoms should be used during sexual contact. Using a latex condom reduces the chances of hepatitis B and HIV being passed on during sex. Syringes and other injecting drug equipment should never be shared.

One hour after administering pyridostigmine, the nurse notes increased salivation, lacrimation, and urination in the client. What initial action should the nurse take? 1. Administer a second dose of pyridostigmine. 2. Place client in side lying position. 3. Notify the primary healthcare provider. 4. Prepare for intubation and mechanical ventilation.

3. Notify the primary healthcare provider. Rationale: These are signs and symptoms of cholinergic crisis. The client can get increasingly worse. The primary healthcare provider can prescribe atropine as treatment of overdose.

Which side effect of chemo should the nurse immediately report to the primary healthcare provider? 1. Nausea 2. Fatigue 3. Paresthesia 4. Anorexia

3. Paresthesia Rationale: Paresthesia is a side effect of some chemotherapeutic medications and if it occurs, the primary healthcare provider needs to modify the dosage or discontinue.

A client in the manic phase of bipolar disorder is constantly walking around the day room and refuses to sit down to eat the spaghetti and meatballs sent by the kitchen. Which food should the nurse request from dietary? 1. Carrots and apples 2. Donuts 3. Pepperoni pizza sticks 4. Strawberry pastry

3. Pepperoni pizza sticks High protein, high calorie, nutritious finger foods are required when the client will not sit down to eat. This client needs food they can eat "on the go" because they are burning more calories in this phase of bipolar disorder.

The nurse is caring for a preoperative client who received intramuscular lorazepam 5 minutes ago and is now requesting to void. What is the appropriate nursing action? 1. Ask the unlicensed assistive personnel to assist the client to the bathroom. 2. Insert a indwelling urinary catheter since the client is going to surgery. 3. Place the client on a bedpan. 4. Allow the client to go to the bathroom.

3. Place the client on a bedpan. Rationale: Placing the client on a bedpan is the safest and least invasive choice. Lorazepam can cause drowsiness and the client should not be allowed to ambulate. The client does not need to get up after receiving lorazepam because it can cause drowsiness. The client might fall. Think safety.

What is the nurse's most important role in the care of the family when a client's death is imminent? 1. Providing temporary relief of care giving duties to allow the family to rest. 2. Providing education regarding the symptoms the client will likely experience. 3. Coordinating a visiting schedule for the family that is approved by everyone. 4. Communicating news of the client's impending death to the family while they are together.

4. Communicating news of the client's impending death to the family while they are together. Communicating news of the client's impending death to the family while they are together. The nurse's most important role in the care of the family is compassionate communication. The family needs to be informed about the situation so that they are prepared for the client's death and can provide support to one another.

The nurse, caring for a 70 year-old client whose spouse died 1 year ago, cries often and states, "I wish I had done more with my life". The nurse recognizes that this client is experiencing difficulty in which of Erikson's developmental stages? 1. Identity vs. Role Confusion 2. Intimacy vs. Isolation 3. Generativity vs. Stagnation 4. Ego Integrity vs. Despair

4. Ego Integrity vs. Despair Age 65 years to death is where a person reflects on life. Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and despair. 2. Incorrect: This is the stage for young adults, age 19 to 40 years. Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation.

A client with heart failure and pulmonary edema is given furosemide IM. Which data indicates the furosemide has achieved the desired effect? 1. Weight has decreased 2 pounds 2. Systolic blood pressure has decreased 3. Urinary output has increased 4. Lungs have fewer rales on auscultation.

4. Lungs have fewer rales on auscultation. Rationale: The goal for diuretic therapy in this client is to prevent/relieve fluid accumulation in the lungs. This answer addresses the most life threatening sequelae with heart failure (HF). The number one thing to "worry" about in clients with HF is pulmonary edema because this is what can kill the client. Increased urinary output is an expected finding, but prevention of pulmonary edema is the primary goal.

An unlicensed assistive personnel (UAP) is asked to transfer a client with left hemiplegia from the bed to a wheelchair. The nurse tells the UAP the safest approach for this transfer is what method? 1. Lift client from edge of bed, supporting under arms and pivot to chair. 2. Utilize a slide board to transfer client from bed to the wheelchair. 3. Apply an ambulation belt around client's waist and pull into the chair. 4. Use a mechanical lift to move client from the bed into the wheelchair.

4. Use a mechanical lift to move client from the bed into the wheelchair. Rationale: When transferring a large or physically impaired client out of bed to a wheelchair, safety for both staff and client is most important. The UAP should use a mechanical lift, first rolling the client onto the sling, attaching the lift loops, and allowing the machine to do the work of lifting the client. This provides a safe, gentle lift for the client and protects the UAP from injury. This is not appropriate for a client with hemiplegia. Because the client has no sensation or control over the left side, managing that extra dead weight will be placed on the UAP. Trying to lift the client under the arms and pivot into the chair is extremely risky, putting both the client and UAP in danger of being injured.

The LPN is caring for a four month old infant diagnosed with respiratory syncytial virus (RSV) and placed in contact isolation. What personal protection equipment (PPEs) should the LPN use when providing care to the baby? 1. Double glove when changing the infant's soiled diapers. 2. Place face mask on infant when transported for x-rays. 3. Only gloves are necessary in order to provide infant care. 4. Wear gown and mask during feeding or burping of the baby.

4. Wear gown and mask during feeding or burping of the baby. Rationale: The main concern is to prevent the spread of the infection, which is transmitted by respiratory secretions. This baby would still be bottle fed and require burping. The potential exists for oral secretions from burping, or even spitting up, to contaminate the LPN's uniform. Without a gown or mask, these secretions would be transmitted to other clients to whom the LPN provides care.

HCO3- Normal 21 -28 mEq/L

< 21 = Acidosis >28 = Alkalosis

pH normal 7.35 - 7.45

< 7.35 = acidosis > 7.45 = alkalosis

Phenytoin is an anticonvulsant. It works by slowing down impulses in the brain that cause seizures.

A major side effect is gingival hyperplasia. Oral hygiene is important for decreasing this complication while the client is on phenytoin.

A client with burn injuries has lost a significant amount of body fluid. An IV of lactated Ringer's solution is infusing at 200mL/hr, and the client's urine output for the past 8 hours is 400 mL. Which of these are signs and symptoms of early hypovolemic shock? (select all that apply) A. A change in BP from 118/60 from 102/68 B. A change in level of consciousness from awake to restless C. A decrease in O2 saturation from 98 to 93% D. A decrease in urine output over 8 hours from 400 to 240mL

A. A change in BP from 118/60 from 102/68

The nurse is assigned to receive a client in the emergency department with suspected anthrax exposure pre-decontamination. Which transmission precautions should be most appropriate for the client? (select all that apply) A. Airborne B. Contact C. Aplastic D. Droplet

A. Airborne B. Contact D. Droplet E. Standard

A client with a known cardiac history is admitted to the acute care unit with stable angina. At 7:00 am the client has stable vital signs and was on 2L of oxygen via nasal cannula. At 10:00am the client reports chest pain of 6 on a scale of 1 to 10 is slightly diaphoretic and pale, has a blood pressure (BP) of 100/52mmHg, and has a respiratory rate of 24 breaths/min. Which action should the nurse implement first? A. Apply 4L of oxygen as ordered. B. Encourage fluids C. Administer the prescribed opioid for pain control D. Obtain a full set of vital signs including temperature

A. Apply 4L of oxygen as ordered.

The PN is observing the relationship between a mother and her 4-year old child. Which behaviors would the PN consider indicative of positive parenting? (select all that apply) A. Child maintains eye contact with the parent B. Child is shown how to pet the dog nicely C. Parent asks the child to help with dusting the room D. Parent says "Don't do that, It's wrong" E. Parent asks the child "Do you want me to read to you before you go to bed?"

A. Child maintains eye contact with the parent B. Child is shown how to pet the dog nicely C. Parent asks the child to help with dusting the room E. Parent asks the child "Do you want me to read to you before you go to bed?"

The PN is caring for a postpartum patient with a history of gestational hypertension who delivered 24 hours ago. Which symptoms may alert the PN the patient is exhibiting early symptoms of DIC? (select all that apply) A. Gingival bleeding B. Alterations in mental status C. Unexplained bruising D. Hematuria E. Gangrenous toes F. Increased fibrinogen

A. Gingival bleeding B. Alterations in mental status C. Unexplained bruising D. Hematuria

In the elevator the UAP overhears two nurses talking about a client who will lose her leg because of the negligence of the staff. What federal law has been violated? A. HIPAA B. Americans with Disabilities Act (ADA) C. Nurse Practice Act (NPA) D. Patient Self-Determination Act (PSDA)

A. HIPAA

The PN is caring for a client who is 24 hours postoperative for a hemicolectomy with temporary colostomy placement. On assessment, the PN that the stoma is dry and dark red. Based on this finding, which action should the nurse take? A. Notify the healthcare provider of the finding B. Document the finding in the client's record. C. Replace the pouch system over the stoma D. Place petroleum gauze dressing on the stoma

A. Notify the healthcare provider of the finding

A client expresses anxiety to the PN about an upcoming surgery. Which response by the PN is likely to be most supportive of the client? A. Tell me what has been shared with you about the surgery B. Let me review the postoperative care you'll receive after surgery C. Don't worry. Your surgeon has the best record of success D. I had surgery just like that, and I'm fine

A. Tell me what has been shared with you about the surgery

The UAP reports to the PN that a client who had surgery 4 hours ago has had decrease in blood pressure from 150/80 to 110/70 in the past hour. The PN advises the UAP to check the client's dressing for excess drainage and report the findings to the charge nurse. Which factor is important to consider when assessing the legal ramifications of this situation? A. The parameters of the state's nurse practice act B. The need to complete an adverse occurrence report C. Hospital protocols regarding the frequency of assessing vital signs D. The healthcare provider's prescription for changing the postoperative dressing

A. The parameters of the state's nurse practice act

The PN has UAPs on the team. Which client task(s) could be assigned to the UAP? (select all that apply) A. Transporting a client scheduled for a STAT CT scan B. Bathing a client receiving IV normal saline through a peripherally inserted central catheter (PICC) line C. Removing a Foley catheter in a postpartum client per the HCP's prescription and encouraging voiding in 8 hours D. Reconnecting the prescribed negative-pressure vacuum (wound vac) to a client with a pressure ulcer E. Clearing the alarm on the IV pump and restarting the pump

A. Transporting a client scheduled for a STAT CT scan B. Bathing a client receiving IV normal saline through a peripherally inserted central catheter (PICC) line

A client with pneumonia has impending respiratory failure. Which set of ABGs values demonstrate acute respiratory failure? A. pH-7.30 PCO2-52 PO2-56 HCO2-26 B. pH-7.35 PCO2-44 PO2-86 HCO2-28 C. pH-7.35 PCO2-66 PO2-66 HCO2-31 D. pH-7.30 PCO2-39 PO2-88 HCO2-31

A. pH-7.30 PCO2-52 PO2-56 HCO2-26

hospital acquired infection (nosocomial)

Acquired as a result of exposure to a microorganism in a hospital setting

Pneumonia Risk Factors

Age 65 or older or residents in long-term care Recent surgery (abdominal, thoracic) Altered consciousness, alcoholism, head injury, seizures, smoking, splenic dysfunction, anesthesia, drug overdose, cerebrovascular accident Prolonged immobility Immunosuppression

Hypophosphatemia

Alcohol withdrawal, diabetic ketoacidosis, respiratory alkalosis Phosphate <3.0 mg/dL decreased cardiac output, weak peripheral pulses Skeletal muscle weakness

Hypomagnesemia

Alcoholism, malabsorption, diabetic ketoacidosis, diuretics Mg < 1.3 mEq/L Skeletal muscle weakness hyperactive deep tendon reflexes numbness and tingling painful muscle contractions Decreased gastrointestinal motility, nausea

Four clients arrive in the emergency department after an explosion. In which order should they be assessed? All options must be used A. A 70-year-old who is complaining of pain level 8/10 from a hand burn B. A 35-year-old with partial and full thickness burns to the anterior and posterior chest C. A 25-year-old with a superficial burn to the right anterior arm and lateral chest D. A 42-year-old with a partial-thickness burn to the anterior lower extremity and confusion

B. A 35-year-old with partial and full thickness burns to the anterior and posterior chest D. A 42-year-old with a partial-thickness burn to the anterior lower extremity and confusion A. A 70-year-old who is complaining of pain level 8/10 from a hand burn C. A 25-year-old with a superficial burn to the right anterior arm and lateral chest

A client who is one day postoperative after a left pneumonectomy is lying on his right side with the head of bed elevated 10 degrees. The nurse assesses his respiratory rate at 32 breaths/min. In what order should the nurse perform the following actions? A. Elevate head of bed B. Assist the client into the supine position C. Measure the client's O2 saturation D. Administer IM PRN morphine

B. Assist the client into the supine position A. Elevate head of bed C. Measure the client's O2 saturation D. Administer IM PRN morphine

A 72-year-old client returned from surgery 6 hours ago. The client received hydromorphone 2 mg IV 30 minutes ago for a pain rating of 8/10. The family member requests that her father be checked immediately. On arrival to the room the nurse finds the client difficult to arouse with a respiratory rate of 6. Which is the priority nursing action? A. Elevate the head of the bed and turn the client to side B. Assist with the administration of naloxone 0.4 mg IV C. Assess breath sounds and neurological status D. Check vital signs and pulse oximetry

B. Assist with the administration of naloxone 0.4 mg IV

A client who is receiving chemotherapy has these CBC results: hemoglobin 8.5 g/dL hematocrit 32% and WBC count 6500 cells/mm3. Which meal is the best choice for this client? A. Grilled chicken, rice, fresh fruit salad, and milk B. Broiled steak, whole wheat rolls, spinach salad, and coffee C. Smoked ham, mashed potatoes, applesauce, and iced tea D. Tuna noodle casserole, garden salad, and lemonade

B. Broiled steak, whole wheat rolls, spinach salad, and coffee

A client who is postoperative for a colectomy complains "I just felt a popping right after I coughed." The PN notes a large amount of serosanguineous drainage and the intestines protruding slightly from the incision. The PN should immediately implement which priority intervention(s)? (select all that apply) A. Encourage the client to turn and breathe deeply while splinting the opening B. Cover the wound with a moist, sterile, normal saline dressing C. Document the appearance of loops of bowel through the wound. D. Reinsert the organs and apply a firm pressure dressing E. Place the client in a low Fowler's position with the knees bent F. Contact the charge nurse and call the healthcare provider

B. Cover the wound with a moist, sterile, normal saline dressing E. Place the client in a low Fowler's position with the knees bent F. Contact the charge nurse and call the healthcare provider

The nurse is caring for a client in shock of unknown etiology and observes the following rhythm on the monitor. Which is the nurse's priority intervention? A check for a carotid pulse B. Defibrillate the patient with 360 joules of energy C. Administer an intravenous saline bolus D. Give two breaths via Ambu bag

B. Defibrillate the patient with 360 joules of energy

The nurse finds a client slumped in a chair. Place the nurse's actions in order of priority from first to last for this client A. Activate the code team and obtain defibrillator B. Determine unresponsiveness C. Assess the cardiac rhythm using the quick look paddles D. Assess for a carotid pulse E. Open airway and give two rescue breaths by bag valve mask F. Move the client to a flat position in bed or on the floor G. Begin compressions

B. Determine unresponsiveness A. Activate the code team and obtain defibrillator D. Assess for a carotid pulse F. Move the client to a flat position in bed or on the floor G. Begin compressions E. Open airway and give two rescue breaths by bag valve mask C. Assess the cardiac rhythm using the quick look paddles

A client is admitted with a 2-day history of cough, fever, and fatigue. The medical history is positive for type 1 diabetes and recent upper respiratory infection. Vital signs are heart rate 109, BP 102/58, respiratory rate 24 breaths/min, temperature 104(40C) and SpO2 92% on 2L oxygen via nasal cannula. Which prescription has the highest priority in this client's care? A. Initiate large-bore IV access. B. Draw two sets of blood cultures C. Administer the ordered IV antibiotics D. Draw serum lactate and glucose levels

B. Draw two sets of blood cultures

The nurse is precepting a nurse orientee who's caring for a client with a chest tube. The client is 12 hours postoperative from a left partial pneumonectomy. Which assessment will the nurse advise the orientee to immediately report to the healthcare provider? (select all that apply) A. Pain level of 6 out of 10 on the left side B. Tracheal deviation toward the right side C. Drainage from the chest tube of 50mL in the last hour. D. Oxygen saturation of 90% on 2L/min E. Vigorous bubbling in the suction chamber

B. Tracheal deviation toward the right side D. Oxygen saturation of 90% on 2L/min E. Vigorous bubbling in the suction chamber

Surgery first then radiation for certain cancers

Breast Colon Rectal Brain

Most common cancer in women

Breast, lung, colon, rectum

COPD - ausculation

Bronchitis Crackles Rhonchi Inspiratory/expiratory wheezes Emphysema Distant breath sounds Quiet breath sounds Wheezes

COPD - Inspection

Bronchitis Right sided heart failure cyanosis, distended neck veins Emphysema Purse-lip breathing noncyanotic thin

A 20-year-old client has been receiving chemotherapy for acute lympocytic leukemia. Which statement by the client indicates understanding of the nurse's discharge teaching about leukemia? A. "I'm relieved that I don't have any activity restrictions." B. "I'd better wash my hands carefully because my son can catch leukemia." C. "I should avoid close contact with people who might give me an infection." D. "I need to be careful not to cut myself when shaving because I may not be able to stop the bleeding."

C. "I should avoid close contact with people who might give me an infection."

A new client seen in the prenatal clinic tells the PN she cannot afford to maintain her heart-healthy diabetic diet. What is the most appropriate nursing intervention? A provide an educational film about the value of nutrition in pregnancy B. Inform the mother how inadequate nutrition affects the infant's health C. Assist the client in finding a resource for providing adequate nutrition D. Refer client to a dietician responsible for clients diagnosed with diabetes

C. Assist the client in finding a resource for providing adequate nutrition

What nursing action has the highest priority when admitting a client to a psychiatric unit on an involuntary basis? A. Reassure the client that this admission is only for a limited amount of time. B. Offer the client and family the opportunity to share their feelings about the admission. C. Determine the behaviors that resulted in the need for admission D. Advise the client about the legal rights of all hospitalized clients

C. Determine the behaviors that resulted in the need for admission

A PN is preparing for change of shift. Which action by the nurse is characteristic of ineffective hand-off communication? A. The PN tells the nurse coming on duty that a client is anxious about his pain and needs information about the use of the incentive spirometer reinforced. B. The nurse refers to the electronic medical record (EMR) to review the client's medication administration record. C. During rounds, the nurse talks about the problem the UAP created by not performing a fingerstick blood glucose test on the client D. Before giving the report the nurse performs rounds on the assigned clients so that there is less likelihood of interruption during the hand-off.

C. During rounds, the nurse talks about the problem the UAP created by not performing a fingerstick blood glucose test on the client

In completing a client's preoperative routine, the PN finds that the consent form has not been signed. The client begins to question the surgical procedure. Which action should the PN take next? A. Witness the client's signature on the consent form B. Answer the client's questions about the surgery C. Inform the charge nurse that the client has questions about the surgery D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered

C. Inform the charge nurse that the client has questions about the surgery

A client with COPD is resting in a semi-fowler's position with oxygen at 2 L/min per nasal cannula. The client develops dyspnea. Which action should the PN implement first? A. Call the healthcare provider B. Obtain a bedside pulse oximeter C. Raise the head of the bed further D. Assess the client's vital signs

C. Raise the head of the bed

A client recovering from ARDS is awake and alert but has residual fatigue and generalized weakness. His current vital signs are heart rate 83 beats/min, BP 104/64, respiratory rate 25 breaths/min, SPo2 is 92% on 2L/min oxygen via nasal cannula. Which vital sign finding should the UAP immediately report to the nurse? A. Heart rate of 83 per minute B. Blood pressure of 104/64 C. Respiratory rate of 25 breaths/min D, SpO2 92% on 2L/min O2 via nasal cannula

C. Respiratory rate of 25 breaths/min

Which laboratory result for a preoperative client would prompt the nurse to contact the healthcare provider? A. Platelet count 151X 10/L (151,000/mm3) B. WBC count: 85X10/L (8500/mm3) C. Serum Potassium level: 2.8 mEq/L D. Hematocrit: 54%

C. Serum Potassium level: 2.8 mEq/L

Which assessment should the nurse delegate to a UAP in a long-term acute care setting? (select all that apply) A. Check the blood glucose level before meals for a client with an insulin drip B. Giving PO medication left at the bedside for the client to take after eating C. Taking vital signs for an older client with left humerus and left tibial fractures D. Replacing an abdominal wound dressing that has been soiled by incontinence E. Obtaining a culture and sensitivity sample from a central line catheter

C. Taking vital signs for an older client with left humerus and left tibial fractures A. Check the blood glucose level before meals for a client with an insulin drip - IS INCORRECT - patient isn't stable RN or maybe LPN would need to check

The PN is reviewing the electronic health records of several clients. Which client is at high risk for a potassium deficit? (select all that apply) A. The client with hyperthyroidism B. The client with metabolic acidosis C. The client with intestinal obstruction D. The client receiving nasogastric suction E. The client with watery diarrhea

C. The client with intestinal obstruction D. The client receiving nasogastric suction E. The client with watery diarrhea

The PN is preparing a client for discharge. What method would best show the PN the patient understands self-care regarding the client's ability to perform insulin injections at home? A. View the client reading the information booklet on diabetes B. Have the PN demonstrate the steps of insulin injection C. Use the teach-back and observe the client's self-injection technique D. Provide the client with free access to an online interactive program on injection techniques.

C. Use the teach-back and observe the client's self-injection technique

Cardiac arrest is the most common event requiring CPR

CAB - Chest compressions, airway breathing Adult 100-120 compressions/min

Fluid volume excess

CAUSES HF (most common), renal failure, cirrhosis, overhydration SYMPTOMS Peripheral edema, periorbital edema, elevated BP, dyspnea, altered LOC LABORATORY FINDINGS decreased BUN decreased HGB decreased HCT decreased serum osmolality decreased urine specific gravity TREATMENT - dilution Diuretics, fluid restrictions, weigh daily, monitor potassium

fluid volume deficit

CAUSES Inadequate fluid intake, hemorrhage, vomiting, diarrhea, burns SYMPTOMS weight loss, postural hypotension, tachycardia, dry membrane LABORATORY FINDINGS Increased BUN Increased HCT Increased urine specific gravity TREATMENT - concentration Strict I&O, replace with isotonic fluids, monitor BP, weigh daily

CPR and choking basics Guidelines vary based on age

Check for pulse infant< 1 year: brachial pulse Children 1 year to puberty: carotid or femoral Compressions Infants: compression cover 1/3 anterior/posterior diameter of chest; depth is 1.5inches Children: compressions cover 1/3 of anterior/posterior diameter of chest; depth is 2 inches deliver each breath over 1 second

Delirium - acute state of confusion and difficulty concentrating

Common among elderly, hospitalized clients Risk factors sleep deprivation, advanced age, or vision or hearing impairment Use of opioids and/or corticosteroids Drug or alcohol abuse UTI, Fluid and electrolyte imbalance Postoperative (unscheduled surgery) ICU, emergent delirium TREAT CAUSE

DIC may lead to uncontrollable hemorrhage

D-Dimer assay measures the degree of fibrinolysis (fibrin products in the blood) Appropriate treatment measures can be challenging and sometimes paradoxic Heparin infusion (early in DIC, when clots are forming) Blood FFP (fresh frozen plasm - fast as possible) give blood back 2-4 hrs

The nurse is assessing clients at the site of a community disaster. Using the color-coded system for triage, which client should the nurse tag with a red code? A. A client with a large head injury that is bleeding, an open chest wound, cyanotic skin, no capillary refill, and agonal respirations B. A client with bruising and swelling of the right forearm, assorted lacerations to the face and neck, dry skin, normal capillary refill, and a respiratory rate of 18. C. A client with scratches and scrapes to the head and face who is limping and helping other clients at the scene D. A client with an open wound to the abdomen, and a deformed right femur, pulse 125, delayed capillary refill, respiratory rate 32 who is moaning

D. A client with an open wound to the abdomen, and a deformed right femur, pulse 125, delayed capillary refill, respiratory rate 32 who is moaning

The nurse palpates a crackling sensation around the insertion site of a chest tube in a client who has had thoracic surgery. Which action should the nurse take? A. Return the client to surgery B. Prepare for insertion of a larger chest tube C. Increase the water seal suction pressure D. Continue to monitor the insertion site.

D. Continue to monitor the insertion site.

The nurse is preparing to administer a purified protein derivative (PPD) test to a client who is entering nursing school. Which action is the nurse's highest priority? A. Prepare 0.1-mL for tuberculin syringe B. Assess the skin condition on the forearm C. Teach the client about positive findings D. Inquire about bacillus Calmette-Guerin BCG vaccine history

D. Inquire about bacillus Calmette-Guerin BCG vaccine history Given in foreign countries minimum 10 year positive of a PPD test

A client who is 32 weeks pregnant did not eat prior to her prenatal visit and has a small amount of ketones in her urine specimen. Which should the PN suspect? A. Early-onset gestational diabetes B. A potential preeclampsia condition C. Symptomatic of UTI D. Normal pregnancy changes in carbohydrate metabolism

D. Normal pregnancy changes in carbohydrate metabolism

What should the PN anticipate as the most serious complication for a neonate delivered by a client who is heroin addicted? A. Hyperbilirubinemia B. Postmaturity of the infant C. psychosocial addition to heroin D. Probability of meconium aspiration

D. Probability of meconium aspiration

An 18-year old woman is being discharged after delivering a healthy baby. She has a cousin whose baby died from sudden infant death syndrome (SIDS). The client seems to know many of the precautions to take. Which information does the PN need to correct? A. Always place infants on their backs to sleep B. Room sharing has been shown to decrease SIDS C. Keep the crib free of stuffed animals and crib pads D. Sleeping with the baby can alert the mother to changes

D. Sleeping with the baby can alert the mother to changes

The PN checks a client's abdominal surgical incision for signs of infection. Which sign or symptoms would indicate an infection? (select all that apply) A. The client refuses to cough and breathe deeply as directed B. The client complains of pain level 4 on a scale of 1 to 10 C. A moderate amount of serosanguineous drainage is present on the gauze dressing D. The client complains of chills and tremors E. The client's vital signs are: temperature 100.4 (38C), pulse 106 beats/min, respirations 20 breaths/min

D. The client complains of chills and tremors E. The client's vital signs are: temperature 100.4 (38C), pulse 106 beats/min, respirations 20 breaths/min

The charge nurse is assigning rooms for four new clients. Only one private room is available on the oncology unit. Which client should the PN expect to be placed in the private room? A. The client with ovarian cancer who is receiving chemotherapy B. The client with breast cancer who is receiving external beam radiation C. The client with prostate cancer who has just had a transurethral resection D. The client with cervical cancer who is receiving intracavity radiation

D. The client with cervical cancer who is receiving intracavity radiation

The family member of a client who is in a posey vest restraint asks why the restraint was applied. How should the practical nurse respond? A. The restraint was prescribed by the HCP B. There are not enough staff members to keep the client safe at all the time C. The other clients are upset when another client wanders at night D. The client's actions place the client at risk for self-harm

D. The client's actions place the client at risk for self-harm

Electrolyte imbalance - Potassium

Depolarizes and generates action potentials, regulates protein synthesis, glucose use and storage

Hyponatremia - Addison's

Diuretic, GI fluid loss, hypotonic IC fluids, diaphoresis NA < 135 mEq/L Muscle cramps, confusion, weakness, seizures Check BP frequently Restrict fluids, cautious IV saline replacement as needed

Hypokalemia - Cushing's

Diuretic, vomiting, diarrhea, gastric suction K< 3.5 mEq/L Rapid/thread pulse, flat T waves, fatigue, anorexia, muscle cramps IV potassium Foods high in K (bananas, oranges, spinach)

Dexamethasone is a corticosteroid used short term to treat severe inflammation occurring in rheumatoid arthritis (RA). Expected side effects are associated with the body's response to excessive steroids in the system.

Even short term use of corticosteroids will produce fatigue, secondary to insomnia, truncal obesity accompanied by thin extremities, and an increased appetite resulting in weight gain. Despite the short and intermittent use of corticosteroids for this auto-immune disease, some side effects remain permanently.

Nursing Collaboration Management for HIV

GOAL: Don't let HIV progress - Decrease viral load Nutrition No smoking/alcohol/drugs Exercise Stress reduction Decreased risk of infection Counseling Safe sex Education Safety Pain Management

Hypercalcemia

Hyperparathyroidism, malignant bone disease, excessive supplementation Ca++> 10.5mEq/L Muscle weakness, constipation, N/V, dysrhythmias, behavioral changes Limit vitamin D intake Avoid calcium-based antacids Calcitonin to reduce calcium Renal dialysis

acute respiratory distress syndrome (ARDS): Nursing assessment

Hypoxemia dyspnea scattered crackles ^ work of breathing Intercostal retractions Respiratory acidosis (early) Pleural effusions Decreased cardiac output Cyanosis

Side to monitor for after chemotherapy:

Mucositis Alopecia Anorexia, nausea, and vomiting Diarrhea Anemia, neutropenia Thrombocytopenia Infertility, sexual alterations

Less than 400mL in 24 hrs

Oliguria

Hyperkalemia - Addison's

Oliguria, acidosis, renal failure K> 5mEq/L Tall/tented T wave, bradycardia, muscle weakness 10-20% glucose with regular insulin Kayexelate Renal disease Jello not high in potassium

acute respiratory distress syndrome

Overall goal PaO2 of at least 60mm Hg -- less than 60= respiratory failure Goals for recovering patient PaO2 within normal limits for age and baseline values on room air SaO2> 90% Patient airway Clear lungs on auscultation 50% of patients with ARDS die

Pain Assessment Includes:

P - Precipitating or palliative Q - Quality R - Relief of measures/region (location) S - Severity (using scale appropriate for age and client condition) T - Timing (onset, duration) U - Effect of pain on client

Stage 2 of shock: Moderate

Pallor/Cyanosis of mucosa/nail bed MAP decreased > 20 mm Hg Decreased pH Increased lactate Decreased urine output (oliguria) Rapid weak thready pulse Cool moist skin pulse ox 75-80 Anuria

Whatever, as long as you like me

Passive communication Laissez-faire leader

Donepezil is a cholinesterase inhibitor. It improves the function of nerve cells in the brain. It works by preventing the breakdown of acetylcholine.

People with dementia usually have lower levels of this chemical, which is important for the processes of memory, thinking, and reasoning. Donepezil is used to treat mild to moderate dementia caused by Alzheimer's disease.

Risk factors for VTE leading to PE

Prolonged immobility central venous catheters surgery in the last 3 months obesity malignancy clotting disorders history of thromboembolism smoking, BCP, pregnancy & over 35 HF

cardiogenic shock - High Fowler's

Pump failure Results in decreased cardiac output and MAP Older adult related to diabetes mellitus, cardiomyopathies, cognitive impairment MI is the most common cause

Asthma medication goals

Quick relief medications Albuterol (ProAir HFA, Proventil HFA, Ventolin HFA) Levalbuterol (Xopenex HFA) Metaproterenol Terbutaline Ipratropium (Atrovent) Long-term control medications Montelukast (Singulair) Zafirlukast (Accolate) Zileuton (Zyflo) salmeterol (Serevent)

Stage 3 of shock: irreversible

Rapid LOC change Toxic metabolite release leads to unresponsiveness to shock correction Slow shallow respirations Pulse ox <70% Multiple organ dysfunction syndrome (MODS)

Five rights of delegation

Right task Right circumstance Right person Right direction/communication Right supervision

Electrolyte imbalance - magnesium

Skeletal muscle contraction, carbohydrate metabolism, adenosine triphosphate (ATP) formation, vitamin activation, cell growth

Drug therapy for Asthma and COPD - Bronchodilators

Tachycardia - check pulse

The main goal of herbal therapy is to restore balance within the body by supporting the client's self-healing ability. When teaching clients, the main goal should always be included.

The main goal of herbal therapy is to restore balance and support healing. Many times herbal therapy is considered less toxic but the question is asking for the main goal of herbal therapy.

The healthcare provider prescribes 3000mL of 5% dextrose (D5W) to run over a 24-hour period. The drop factor is 10 gtt/mL. There are 300 ML remaining at 0900. What time should the PN anticipate the next bag of D5W solution to be hung? (round to the nearest half hour)

The next bag of D5W solution will be hung at 11:30

Malpractice is found when:

The nurse owed a duty to the client The nurse did not carry out that duty or breached that duty The client was injured The nurse's failure to carry out that duty caused the client's injury

The client with borderline disorder may exhibit impulsive and dangerous behavior.

This client is more likely to hurt herself, perhaps through self-mutilation.

Asthma - reversible inflammatory disorder of the airway characterized by an exaggerated bronchoconstrictor response to a wide variety of stimuli

Triggers Allergens Environmental irritants Cold air Exercise Beta Blockers Respiratory stress Reflux esophagitis

Postop care Prevent common complications

Urinary retention - check for bladder distention Pulmonary problems - check breath sounds & O2 GI - absent bowel sounds, decreased peristalsis, paralytic ileus Wound Management - Wound dehiscence and evisceration Venous Thromboembolism (VTE)

Prescriptions can mean

X-ray Lab Orders written by licensed health care providers

Electrolyte Imbalance - phosphorous

activates vitamins and enzymes, forms ATP for energy supplies, assists in cell growth and metabolism, maintains acid-base balance and calcium homeostasis

In general, it is best to advise clients who are prescribed MAOIs to avoid any type of food or liquids that is

aged, cured or fermented to avoid a drug interaction resulting in a hypertensive crisis.

Antipsychotics and Benzodiazepines are used for behavioral problems such as

agitation, physical aggression, and disinhibition

Systemic Inflammatory Response Syndrome (SIRS)

assortment of insults including sepsis, ischemia, infarction, and injury

implementation and intervention in NCLEX questions may mean

data and planning - implementation may not be part of the nursing process

Documentation of the use of restraints and follow-up assessments must

detail the attempts to use less restrictive interventions

durable power of attorney for health care

document that designates a health care proxy, who is authorized make health care decisions for a client who is unable

water only no other foods stay up 30 minutes

for thyroid

Remember for NCLEX: When giving PO potassium

give with juice to help with bitter taste

Lung cancer - leading cause of cancer-related death

in both genders

normal stoma

look likes a beefy red tongue

Healthcare provider can mean

physician nurse practitioner physician assistant

HIV Drug therapy goals

reduce viral load Maintain or raise CD4+ T-cell count To delay development of HIV-related symptoms and opportunistic disease Side effects Multiple drug interactions are possible between nucleoside reverse transcriptase (NRTIs) and other drugs HIV Medications NRTIs - N/V insomnia headache - give at morning NNRTIs - depress CNS, confusion, N/V - give at night PIs

DIC (disseminated intravascular coagulation)

serious disorder of homeostasis resulting from overstimulation of clotting factors followed by anticlotting processes in response to diseases or injury

SEPSIS Blood cultures first

serum lactate & glucose IV Antibiotics

Electrolyte imbalances - sodium

skeletal muscle contraction, cardiac contraction, nerve impulse transmission, normal osmolality, and volume of ECF

Pneumonia nursing assessment

tachypnea productive cough pleuritic pain FEVER OF ABRUPT ONSET dyspnea increased tactile fremitus mental status changes Crackles, decreased breath sounds dullness on percussion ABGs indicative of hypoxemia Inspect, palpate, percuss, ausculate