NCLEX practice attempt 1

What risk factors should the nurse include when conducting a class about type 2 diabetes mellitus? 1. Fat distribution greater in abdomen than in hips. 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. 5. Polycystic ovary syndrome.

1 - fat distribution greater in abdomen than in hips 5 - polycystic ovary syndrome If the body stores fat primarily in the abdomen, risk of type 2 diabetes is greater than if body stores fat elsewhere, such as hips and thighs. Women with polycystic ovary syndrome have increased risk of diabetes.

A primary healthcare provider informs the nurse to prepare for an amniotomy on a client who's labor has not progressed. What should the nurse assess for prior to the primary healthcare provider performing this procedure? 1. Fetal attitude 2. Fetal engagement 3. Fetal lie 4. Fetal position

2 - fetal engagement Fetal engagement is important prior to rupturing the membranes so that the umbilical cord cannot prolapse. Fetal engagement is when the fetus is at station 0 (level of mom's ischial spines).

The nurse is caring for a client who has taken an acetaminophen overdose. Which symptom is the client most likely to exhibit? 1. Expectorating pink frothy sputum 2. Sudden onset of mid-sternal chest pain 3. Jaundiced conjunctiva 4. Diaphoresis and fever

3 - jaundiced conjunctiva This is a sign of liver damage, which is caused by an overdose of acetaminophen.

A home health nurse is assessing the home environment for safety issues concerning ambulation. Which finding would require the nurse to counsel the client and family? 1. Dim hall lighting 2. Grab bar in bath tub 3. Nonskid strips on outside steps 4. Throw rug at front entrance to home 5. Waxed linoleum kitchen floor

1 - dim lighting 4 - throw rug at front entrance to home 5 - waxed linoleum kitchen floor Rooms and hallways should have adequate lighting so client can see while ambulating and see any objects which may be in the way. Throw rugs (rugs that are not secured) can slide and cause a fall. Slippery floors will contribute to falls.

A client is scheduled for plateletpheresis. When taking the client's history, which information is most significant? 1. Allergies to shellfish 2. Date last donated 3. Time of last oral intake 4. Blood type

2 - date last donated platelet donors can have plateletpheresis as often as every 14 days

A nurse is educating the parents of a child with celiac disease. The nurse knows the teaching is successful if the parents choose which food for their child's dinner? 1. Turkey and lettuce sandwich on rye bread 2. Sirloin steak and diced baked potatoes 3. Chicken, vegetables and a whole wheat roll 4. Hotdog and baked beans

2 - steak and baked potatoes Steak and potatoes are gluten free.

A client is hospitalized for chronic renal failure. The nurse will need to notify the primary healthcare provider concerning which findings? 1. Sodium 135 mEq/L 2. Potassium 5.8 mEq/L 3. BP 100/70 4. No weight loss 5. Ionized Calcium 4.0 mg/dL

2 - potassium 5.8 5 - calcium 4.0 Normal K 3.5-5.0 mEq/L; Normal ionized serum Ca 4.5-5.5 mg/dL. The abnormal lab results need to be reported.

The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice for the nurse to place the client in until full consciousness is regained? 1. Supine 2. Fowler's 3. Lateral 4. High Fowler's

3 - lateral When someone is very sedated and not fully conscious, we want them on their side so the airway remains open and the secretions can drain.

The clinical specialist is teaching a group of new staff nurses about therapeutic communication. Which statement by one of the staff nurses indicates to the clinical specialist that further teaching is needed? 1. Effective communication involves feedback to let the sender know that the message was understood by the receiver. 2. An effective message should be clear and complete. 3. Therapeutic communication does not include the use of gestures. 4. I must listen with a "third ear" to be aware of what the client is not saying.

3 - therapeutic communication does not include the use of gestures gestures are a type of nonverbal communication which can provide assistance in communicating therapeutically with a client. Other forms of nonverbal communication include facial expression, touch, mannerisms, posture, position, and personal space.

the nurse is caring for a client who has been diagnosed with dissociative identity disorder. What is the most appropriate short term goal? 1. Recovery of memory deficits. 2. Demonstration of the ability to perceive stimuli correctly. 3. Elimination of causative phobia. 4. Verbal recognition of the existence of multiple personalities.

4 - verbal recognition of the existence of multiple personalities

The nurse is caring for a client following spinal surgery. The client is placed on methylprednisolone. What additional drug therapy would the nurse expect to be prescribed with methylprednisolone? 1. Pantoprazole 2. Phenytoin 3. Imipramine HCI 4. Aminocaproic acid

1 - pantoprazole A potential side effect of methylprednisolone is a peptic ulcer. The primary healthcare provider will prescribe a proton pump inhibitor or H2 blocker to prevent this side effect.

The client had a thoracentesis with removal of 2500 mL of fluid from the chest cavity. What is the priority nursing assessment for this client? 1. Vital signs 2. Pain 3. O2 sat 4. Signs of infection

1 - vital signs Should be watching the vital signs for shock, tachycardia, and hypotension because a lot of fluid has just been removed from the body.

The nurse is providing post-operative care to the craniotomy client. Hourly urinary output increases from 100 mL last hour to 500 mL this hour. What action by the nurse takes priority? 1. Elevate HOB 90 degrees 2. Auscultate apical pulse 3. Obtain a blood pressure 4. Assess Glasgow Coma Score

3 - obtain a BP This is the best answer because we are "worried" this client is going into SHOCK due to diabetes insipidus. So, you better be checking a BP. This is a time where checking the BP is appropriate. If we "assume the worst" I better check a blood pressure. It could have dropped out the bottom.

Which task should the nurse perform first? 1. Suctioning the tracheostomy. 2. Changing a colostomy bag that is leaking. 3. Performing an admission assessment on a client. 4. Administering pain medication to a postoperative client.

1 - suction the trach The tracheostomy tube must be suctioned to keep the client's airway open. Suctioning the tracheostomy should take priority. Remember, airway first.

A client is diagnosed with new onset grand mal seizures. Which nursing interventions should the nurse implement for this client? 1. Have an unlicensed assisitve personnel stay with the client. 2. Pad the side rails with blankets. 3. Place the bed in low position. 4. Keep a padded tongue blade at the bedside. 5. Instruct client to call for help when ambulating.

2 - pad side rails 3 - place bed in low position 5 - instruct client to call for help when ambulating During a seizure these interventions will help to protect the client from injury. The client may strike the side rails. The bed should be placed in the low position in case the client falls out of the bed. The client would need assistance to the floor if a seizure starts while ambulating.

What should the nurse document after a client has died? 1. Time of death 2. Who pronounced the death 3. Disposition of personal articles 4. Destination of body 5. Primary healthcare provider's prescriptions 6. Time body left facility

1 - time of death 2 - who pronounced death 3 - disposition of personal articles 4 - destination of body 6 - time body left facility All of these should be documented. Also document consideration of and preparation for organ donation; family notified and decisions made; location of identification tags.

the nurse is preparing to administer iron dextran IM. Which injection site would be best for administration? 1. Ventrogluteal site 2. Vastus lateralis site 3. Rectus Femoris site 4. Deltoid site

1 - ventrogluteal site This site would be used for Z track IM injections. Iron preparations are administered by the Z track technique, preferably in a large, deep muscle such as the ventrogluteal muscle.

Which electrolyte imbalance would be the nurse's priority concern in the burn client? 1. Hypernatremia 2. Hyperkalemia 3. Hypoalbuminemia 4. Hypermagnesemia

2 - hyperkalemia When the cells lyse they release potassium, and then the serum potassium goes up. And if the kidneys stop, we are in real trouble.

The charge nurse was notified that a client with 2nd degree burns is being admitted to the floor. Which nurse should be assigned this client? 1. A nurse caring for clients with spina bifida and acute gastroenteritis. 2. The new nurse, out of orientation for 2 months, caring for clients diagnosed with tonsillitis and anorexia nervosa. 3. The pregnant nurse caring for clients with cystic fibrosis and staph infection. 4. A nurse caring for clients with irritable bowel syndrome and post op appendectomy.

4 - IBS and post op appendectomy It would be best to assign the client to this nurse because the clients this nurse is caring for do not have anything contagious, which will decrease the risk of the burn client becoming infected.

A client with gestational diabetes delivers an infant with macrosomia. What is the most vital component of the infant's assessment for the nurse to perform? 1. Evaluation of the infant for cephalhematoma. 2. Determining if the infant sustained a clavicle fracture. 3. Observing for arm movement to evaluate for facial palsy. 4. Frequent blood glucose monitoring to ensure stable values.

4 - frequent blood glucose monitoring Infants of diabetic mothers are at risk for hypoglycemia following birth. Hypoglycemia can trigger seizures and cognitive deficits.

Upon receiving a diagnosis of Stage 4 lung cancer, an elderly client expresses regret for having chosen to smoke. Which response by the nurse would best help the client cope at this time? 1. "You are lucky to have lived a very long life." 2. "We have younger clients in worse shape than you." 3. "The doctor will make sure to treat any pain." 4. "You are regretting your decision to smoke."

4 - you are regretting your decision to smoke The nurse responds with an open-ended statement that reflects back what the client has stated. This allows the client to continue expressing concerns and feelings about the diagnosis or past choices. At this time, encouraging the client to verbalize is the best choice to help with coping.

A nurse is teaching a group of small farm owners how to prevent pesticide exposure for field workers. What points should the nurse include? 1. Importance of hand washing before eating. 2. Wearing protective clothing while working in the field and at home. 3. Removing clothing and shoes worn in the field before entering the home. 4. Washing fruit and vegetables prior to eating. 5. Boiling all vegetables for a minimum of 5 minutes prior to eating.

1 - hand washing before eating 2 - protective clothing in the field 3 - remove clothing before going inside 4 - washing fruit and veggies before eating he standard precautions of hand hygiene is recommended prior to eating. This will reduce the transmission of pathogens and possible pesticides. The pesticides may be present on their clothing, so the clothing and shoes should be removed. Fruits and vegetables should be washed to remove pathogens and pesticides. All points are important to include when teaching prevention of pesticide exposure.

A staff nurse decides to go to lunch with a friend instead of meeting with a study group for a certification exam. The staff nurse informs the clinical specialist, "Studying more will not do any good anyway." What defense mechanism does the clinical specialist understand that the staff nurse is exhibiting? 1. Rationalization 2. Denial 3. Regression 4. Reaction formation

1 - rationalization Rationalization is the mind's way of justifying behavior by offering an explanation other than a truthful response. This is often used to avoid embarrassment.

What precautions should be taken with computer monitors that display client health information to ensure client's confidentiality? 1. Orient the screen facing the client rooms so that healthcare personnel can access the information easily. 2. Have the screen placed facing away from any visitor or client care area where information could be viewed by unauthorized persons. 3. Turn the computer monitors off when the computer is not in use. 4. The computer should be kept in a secured, locked area.

2 - have screen facing away from visitor and client care areas

A client received 2nd and 3rd degree burns on both arms and the anterior trunk when pouring gas on a burning trash pile. With the percentage of burns indicated, what should the nurse anticipate? 1. Movement of fluid out of the cells into the vascular space. 2. Increased capillary permeability and 3rd spacing of fluids. 3. Rapid fluid shift out of the vascular bed 48 hours after the burn. 4. Severe fluid volume excess in the first 24 hours after the burn.

2 - increased cap permeability and 3rd spacing Using the Rule of Nines, the client would have burned approximately 36% of the body. For burns greater than 20-25% of the total body surface area, the nurse should recognize that significant vascular damage occurs which causes increased permeability. The fluid leaks out of the vascular space and out into the tissues (3rd spacing). The client can go into a severe fluid volume deficit and shock.

A school nurse educates a group of teachers how to extinguish a fire involving a child whose clothes are on fire. Which statement by the teachers would indicate to the school nurse that the teachers understand what should be done first? 1. "Someone should be assigned to call 911." 2. "Lay child flat and roll in a blanket." 3. "A blanket should be thrown over the child's head and body." 4. "Use a fire extinguisher to put out the flames."

2 - lay child flat and roll in a blanket The flames should be extinguished first. The best way to accomplish this it to lay the child flat and roll in a blanket. This is referred to as the drop and roll method, when a blanket is available.

A client diagnosed with arachnophobia is prescribed alprazolam 0.5 mg orally three times daily. The nurse knows that teaching about this medication is successful when the client makes what statement? 1. Alprazolam will take up to two weeks to start working. 2. The drug does not cause drowsiness, so my daily activities will not suffer. 3. This medication cannot be taken with food. 4. I should not stop taking alprazolam suddenly.

4 - I should not stop taking this med suddenly Suddenly stopping could produce serious withdrawal symptoms, such as depression, insomnia, anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, and delirium.

Which symptoms would the nurse be likely to observe in the client who overdosed on diazepam? 1. Bradypnea 2. Bradycardia 3. Hyperthermia 4. Somnolence 5. Hyperreflexia 6. Psychosis

1 - bradypnea 2 - bradycardia 4 - somnolence Benzodiazepines are central nervous system (CNS) depressants. Diazepam is a benzodiazepine. They will slow respirations (bradypnea) and the heart rate (bradycardia). Somnolence (extreme, prolonged drowsiness) would be seen.

The six bed Labor and Delivery area is full when the Emergency Department nurse calls for a bed for a woman reporting low back pain, pelvic pressure and increased vaginal discharge at 36 weeks gestation. Which would be the most appropriate action for the charge nurse? 1. Transfer a G4P4 who delivered full-term twins one hour ago to the antepartum/postpartum floor. 2. Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the antepartum/postpartum floor. 3. Transfer an 8 hour postpartum G1P1 on Magnesium Sulfate for eclampsia from the LDR unit to the ante/postpartum unit. 4. Request that the new client be admitted to the antepartum/postpartum floor.

2 - G3P3 who delivered an 8 pound newborn 3 hours ago The client and newborn are not in any present distress. Also the delivery occurred 3 hours ago. This client would not be a risk and could be cared for on the antepartum/postpartum floor.

A client, who is having difficulty falling asleep, asks the nurse for a sleeping aid. What is the first action the nurse should provide to the client? 1. Assist client to take a cool bath. 2. Provide a back massage. 3. Administer prescribed triazolam. 4. Give client a crossword puzzle to work.

2 - provide a back massage

Two days after a myocardial infarction, a client begins reporting orthopnea and dyspnea. Further assessment reveals bi-basilar crackles, jugular venous distension, an S3 heart sound, a BP of 100/60 mm Hg, and apical pulse of 90 beats per minute. The urine output has steadily declined over the past 12 hours. What should the nurse do first? 1. Notify the primary healthcare provider. 2. Increase the IV rate. 3. Elevate the head of the bed. 4. Observe for cardiac arrhythmias.

3 - elevate the hob The client is reporting inability to breathe. (Orthopnea means the client needs to sit up to breathe better.) With ANY client having difficulty breathing, the first intervention for the nurse is to sit the client up. This client is showing s/s of heart failure.

A clinic nurse is educating a client diagnosed with Bell's Palsy. What is the most important educational point the nurse must emphasize to the client? 1. Physical therapy will be needed to maintain muscle tone of the face. 2. Massaging the face several times daily using a gentle upward motion. 3. Proper methods of closing eyelids and eye patching. 4. Non-steroidal anti-inflammatory medications are used to alleviate painful muscles.

3 - proper methods of closing eyelids and eye patching Even though all are educational points that need to be provided to the client, this is the most important educational point to make. Keratitis, or the inflammation of the cornea, is one of the most dangerous complications for a client with Bell's palsy. As a precautionary measure, the nurse must ensure that the cornea is protected even if the eyelids will not close.

The nurse is caring for a 5-year old child brought to the Emergency Department by the parents for pain and swelling in the left arm. An x-ray of the arm confirmed a fracture. The parents give conflicting stories about the accident. What action by the nurse is most appropriate? 1. Prepare the child for casting of the arm. 2. Ask the primary healthcare provider to order bone series film. 3. Consult social services. 4. Obtain a history as to how the accident happened.

3 - social services

The nurse is teaching a client who has been prescribed daily glucocorticoids for the treatment of Addison's disease. What teaching points should the nurse emphasize? 1. Be aware of the development of hypoglycemia. 2. Test the urine for albumin or other proteins. 3. Take the medication 30 minutes prior to bedtime. 4. Maintain the prescribed dose without interruption in therapy.

4 - maintain the prescribed dose without interruption in therapy Glucocorticoids should not be abruptly discontinued due to the risk of adrenal suppression with prolonged use. Doses should be tapered before being discontinued.

Which foods should the nurse teach a client to avoid when prescribed a diet limiting purine rich foods? 1. Peanut butter 2. Potatoes 3. Apples 4. Venison 5. Scallops

1 - PB 4 - venison 5 - scallops Meats such as liver, bacon, veal, and venison are high in purine and should be avoided. Seafood such as sardines, mussels, codfish, scallops, trout, and haddock are high in purine and should be avoided.

Which prescriptions are appropriate for the nursery nurse to initiate on a newborn prior to discharge home? 1. Hepatitis B vaccine 2. Erythromycin Ointment 3. Vitamin K 4. Lanolin 5. PKU Screening

1 - hep B 2 - erythromycin ointment 3 - vitamin K 5 - PKU screening

The nurse makes selections from the hospital menu for a client who is confused and suspicious of others. Which menu choice is best? 1. Ham and vegetable casserole 2. Cheese and crackers 3. Caffeine free tea 4. Packaged sugar free Jell-O

4 - packaged sugar free jell-o A client who is suspicious of others needs foods that are packaged and can see them opened.

The nurse is searching for information about the nursing care of a client receiving an experimental drug for the treatment of obesity. Which database is most likely to address this issue? 1. Cumulative Index for Nursing and Allied Health Literature (CINAHL) 2. Cochrane Library 3. Health and Wellness Resource Center 4. MEDLINE

1 - CINAHL

The nurse educator is teaching a group of nursing students about client advocacy. What should the educator tell the students are the consequences of failure to act as a client advocate? 1. Life-threatening complications for the client. 2. Legal action against the nurse and/or healthcare facility. 3. Suspension or loss of license to practice nursing. 4. Suspension or loss of license to practice medicine. 5. Loss of client autonomy and right to make decisions.

1 - life threatening complications 2 - legal action 3 - suspension or loss of license 5 - loss of client autonomy

Following a total hip replacement, the nurse provides discharge teaching to the client. The nurse knows that teaching was effective when the client states which activities are safe to perform? 1. Using an abduction pillow while sleeping 2. Crossing the legs 3. Using a toilet extender 4. Showering rather than taking a bath 5. Tying shoes

1 - abduction pillow 3 - toilet extender 4 - shower instead of bath The client should use an abduction pillow to keep hip in proper alignment and prevent hip dislocation. A toilet extender keeps the hip in proper alignment and prevents hip dislocation. Showering rather than sitting in a tub will prevent flexion of the hip.

A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most important nursing measure to include in the nursing care plan for this client? 1. Observation and support of ventilation 2. Insertion of indwelling urinary catheter 3. Nasogastric suctioning 4. Frequent assessments of level of consciousness

1 - observe and support ventilation Guillain-Barre syndrome is an acquired inflammatory disease that results in demyelinization of the peripheral nerves. It is usually ascending in nature and can lead to respiratory paresis or paralysis.

Which nursing task would be appropriate to delegate to an LPN/VN? 1. Obtain a wound culture from a client. 2. Administer regular insulin IV to a client in diabetic ketoacidosis. 3. Monitor a client's closed drainage unit (CDU) for tidaling. 4. Assess a client for tactile fremitus.

1 - obtain a wound culture from a client

A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who will need assistive devices upon discharge. Which devices should the case manager include for this client? 1. Dinner plate food guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip eating utensils 6. Button closures on clothes

1-5 The goal is to promote self-care by the client as much as possible. The case manager should evaluate the need for assistive devices to help with eating, bathing, dressing, and ambulating. The dinner plate food guard will prevent food from being pushed off the plate. The transfer belt will provide safety for the client to get into a chair or back in bed. A raised toilet seat makes it easier for the client to sit on the toilet without falling. The long-handled shoe horn allows the client to put on shoes without assistance. Wide grip utensils accommodate a weak grip.

When assessing a client, the nurse finds that in response to painful stimuli the upper extremities exhibit flexion of the arm, wrist, and fingers with adduction of the limb, while the lower extremity exhibits extension, internal rotation, and plantar flexion. How would the nurse accurately document this finding? 1. Decerebrate posturing 2. Decorticate posturing 3. Reflex posturing 4. Superficial posturing

2 - decorticate posturing This describes decorticate posturing because they are moving towards the core of the body.

A 68 year old client was admitted two days ago to a long-term care facility. The client has chronic kidney disease, coronary artery disease and chronic obstructive pulmonary disease. Oxygen 2 L/per nasal cannula is being administered. Assistance is needed with activities of daily living. The primary healthcare provider visits today and writes new prescriptions. Who is the best person for the charge nurse to delegate carrying out these prescriptions? 1. Unlicensed assistive personnel (UAP) 2. LPN/LVN 3. RN 4. Charge Nurse

2 - LPN/LVN

The nurse's goal is to reduce the risk of flu and its complications by offering a class at the local high school. Which groups of people should be included in the nurse's teaching plan as needing the flu shot? 1. Babies less than 6 months old 2. Any child older than 6 months 3. Pregnant women 4. Parents of young children 5. People with a chronic illness

2 - any child older than 6 months 3 - pregnant women 4 - parents of young children 5 - people with chronic illness All people greater than 6 months of age should get a flu shot, unless allergic to eggs, or if there has been an adverse reaction in the past. Pregnant women should receive the flu shot. Parents of young children may be exposed to the flu and should get the vaccine. People with a chronic illness are more susceptible to flu and its complications.

The nurse is planning health promotion strategies for an older client on a limited, fixed income who is trying to increase activity. The client has been cleared for moderate physical activity by the primary healthcare provider. Which strategies would be appropriate for this client? 1. Suggest that the client join a local gym for access to equipment and support. 2. Suggest contacting a neighbor so that they can walk each day in the neighborhood. 3. Encourage client to get up and walk around the house during each TV commercial break. 4. Suggest the client go to the community senior center for daily strengthening exercises. 5. Encourage client to use one-pound soup cans for muscle toning.

2 - contact neighbor to go for walks 3 - walk during commercial breaks on TV 4 - go to community senior center for daily exercises 5 - use soup cans for muscle toning

Which action by a nurse indicates to the charge nurse that the sterile field has been contaminated? 1. The sterile field is above the level of the waist. 2. Sterile gauze dressing within the one inch border of sterile field. 3. Remains facing the sterile field throughout procedure. 4. Inspects sterile wrapped instruments for tears.

2 - sterile dressing within the one inch border of the sterile field No sterile object should be within the one inch border of the sterile field as the object is no longer considered sterile.

The nurse is assessing pain after surgery in a 3 year old client with a known developmental delay. Which pain scale should the nurse use to assess this client's pain level? 1. CRIES scale 2. Numeric scale 3. FLACC scale 4. FACES scale

3 - FLACC scale The FLACC scale can be used for pediatric clients from age 2 months to 7 years and is appropriate when clients cannot communicate their pain.

The home health nurse is caring for a client with a neurological urinary tract dysfunction. What information should be included when teaching the client how to perform intermittent self catheterization? 1. Performed in an emergency department (ED). 2. Prevents urinary catheter infections. 3. Perform as a clean procedure. 4. Requires using sterile gloves.

3 - perform as a clean procedure Home intermittent catheterization is a clean, not sterile technique when performed in the home environment. Home intermittent catheterization is preferred over continuous use of an indwelling catheter, as an indwelling catheter increases client risk of urinary tract infection (UTI).

The nurse is caring for a Native American client who has returned to the surgical floor following abdominal surgery. The nurse is concerned about the level of discomfort that the client is experiencing. Which comment is the nurse likely to hear upon assessment? 1. "The pain is getting worse. I can't stand it." 2. "I need something for pain as soon as possible." 3. "I hope that the pain will go away soon." 4. "I am doing okay. The pain is not bad."

4 - I am doing okay, the pain is not bad The Native American client is likely to be quiet and less expressive of pain. Native Americans tend to tolerate high levels of pain.

Which instructions should the nurse give the unlicensed assistive personnel (UAP) about care needed to reduce the risk of infection when a client has an indwelling catheter? 1. Check catheter for kinks in the tubing when the client is in the bed or chair. 2. Instruct the UAP to disconnect the catheter from the bag when measuring output. 3. Wash hands before providing personal care to the client. 4. Ensure that catheter remains secured to the thigh. 5. Make sure that the drainage bag is always below the level of the bladder.

1 - check catheter for kinks 3 - wash hands before providing care 4 - ensure catheter remains secured to thigh 5 - keep drainage bag below bladder level Tubing that becomes obstructed cannot allow adequate urine flow. The urine flow occurs by gravity. Adequate handwashing before providing care is one defense against infection. Tension on the tubing may cause irritation and subsequent infection. The bag should be below the level of the bladder so that urine flows appropriately.

Which signs and symptoms, if noted by the nurse, would indicate that the client with hyperthyroidism is experiencing thyroid crisis? 1. Hyperkinesis 2. Bradycardia 3. Hypertension 4. Restlessness 5. Confusion

1 - hyperkinesis 3 - hypertension 4 - restlessness 5 - confusion

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Check client for signs of skin breakdown. 2. Check client's vital signs after ambulating. 3. Administer 8 ounces of polyethylene glycol electrolyte solution every 10 minutes. 4. Obtain a stool specimen. 5. Determine what activities the client can do independently

2 - check vital signs 4 - obtain a stool specimen

In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last.

Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. Clean around Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's over surgical wound and Penrose drain. Apply abdominal dressing pad.

A client who has been on bed rest for several days is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last.

Assess the client's orientation. Assist the client to sit on the side of the bed for 1-2 minutes. Apply a gait belt to the client's waist. Have the client stand by the side of the bed for a few seconds. Ambulate in the room.

What discharge instructions should the nurse provide to the client post abdominal hysterectomy? 1. Ambulate at least 3-4 times per day. 2. Notify the primary healthcare provider if there is a yellow discharge from the surgical wound. 3. Swimming is allowed if staples were used to close the skin. 4. Press a pillow over incision when coughing to ease discomfort. 5. Apply moist heat to surgical site the first couple of days for pain relief.

1 - ambulate 3-4 times per day 2 - notify doctor if there is yellow discharge from the surgical wound 4 - press a pillow over incision when coughing to help with pain The client should get up and move to prevent complications such as deep vein thrombosis (DVT), pneumonia, constipation, etc. The healthcare provider should be notified if the surgical wound is bleeding, red and warm to touch or has a thick, yellow, or green drainage. Pressing a pillow over incision when coughing or sneezing will ease discomfort and protect the incision.

What should a community health nurse include when planning a presentation on prevention and early detection of colon cancer? 1. Maintain a diet high in fruits, vegetables, and whole grains. 2. Exercise regularly. 3. Regular screening should begin at age 30. 4. Yearly guaiac-based fecal occult blood test. 5. Flexible esophagogastroduodenoscopy every 5 years.

1 - maintain a diet high in fruits, veggies, and whole grains 2 - exercise regularly 4 - yearly guaiac based fecal occult blood test A diet high in vegetables, fruits, and whole grains has been linked with a decreased risk of colorectal cancer; whereas, a diet high in red meats, processed meats, and cooking meats at very high temperature (frying, broiling or grilling) creates chemicals that may increase the risk for colorectal cancer. There is a greater risk of developing colorectal cancer in individuals who live a sedentary life style. The guaiac-based fecal occult blood test detects blood in the stool through a chemical reaction. This test is done yearly.

A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client? 1. "Do you take metronidazole on an empty stomach?" 2. "Are you using any products that contain alcohol?" 3. "How long have you had these symptoms?" 4. "What other medications are you currently taking?"

2 - are you using any products that contain alcohol Flushing, nausea and vomiting, palpitations, tachycardia, psychosis are signs of disulfiram-type reaction seen when using products containing alcohol (cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking metronidazole.

A nurse is caring for a client in an outpatient clinic. The client lost her husband of 51 years three months ago. Which findings support that the client is experiencing normal grief reactions rather than clinical depression? 1. The client is experiencing anhedonia. 2. The client states, "I have good and bad days." 3. The client smiles at the nurse while talking about her grandchild. 4. The client has a persistent state of dysphoria. 5. The client states, "I am having fewer crying spells."

2 - client states "i have good and bad days" 3 - client smiles when talking about their grandchild 5 - client states "i am having fewer crying spells"

Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching of proper diet was understood? 1. Pancakes with whipped butter, syrup, bacon, apple juice 2. Scrambled eggs, sliced turkey, biscuit, whole milk 3. Grits, fresh fruit, toast, coffee 4. Bagel with jelly, hash browns, tea

2 - scrambled eggs, sliced turkey, biscuit, whole milk Client needs low sodium and increased proteins.

When caring for a client with hepatitis A, the nurse should take what special precaution 1. Wear gloves when handling blood and body fluids. 2. Wear a mask and gown before entering the room. 3. Use gloves when removing the client's bedpan. 4. Use caution when bringing food to the client.

3 - wear globes when removing the clients bedpan Hepatitis A is transmitted by the fecal/oral route

A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis. What interventions should the nurse initiate? 1. Wear an N95 respirator when caring for client. 2. Restrict fluid intake to 500 mL per day. 3. Position client in semi-Fowler's position. 4. Place client in a negative pressure airflow room. 5. Do not allow visitors for 48 hours.

1 - N95 respirator 3 - position client in semi fowlers 4 - place client in a negative airflow room The nurse should suspect that the client is suffering from tuberculosis. Early pulmonary TB is asymptomatic. When the bacterial load increases, nonspecific symptoms of fatigue, weight loss, afternoon fevers, and night sweats may set in. As disease advances, cough, sputum production, and hemoptysis may appear. This client has the classic symptoms of TB and should be placed on airborne precautions. N95 respirator ensures that the nurse does not inhale the TB organism. Placing in a semi-Fowler's position reduces the work of breathing.

A long-term care nurse is planning care for a newly admitted client diagnosed with Alzheimer's disease. What should the nurse include in the plan of care? 1. Assess client's ability to perform activities of daily living. 2. Perform activities of daily living for the client. 3. Place a clock and calendar in client's room. 4. Encourage family to visit client often. 5. Have nursing staff spend time talking and listening to client.

1 - assess ability to perform ADLs 3 - place a clock and calendar in clients room 4 - encourage family to visit client often 5 - have nursing staff spend time talking and listening to client

Which assessment findings would be of concern to the nurse who is caring for a client who has an arterial line to the radial artery? 1. Capillary refill: Left hand-2 seconds; Right hand- 4 seconds. 2. Blue tinged color to finger tips of right hand. 3. Warm skin to right and left hand. 4. Left radial pulse-88/min; Right radial pulse-82/min 5. Blanching to right hand.

1 - cap refill different 2 - blue tinged color 4 - radial pulses different 5 - blanching on right hand These are all signs of poor circulation to the right hand. The arterial line could be occluding circulation and needs to be removed.

The nurse is performing CPR on an adult client with facial and neck trauma. Following the administration of rescue breaths, where is the best location for the nurse to assess for a pulse in this client? 1. Apical area 2. Carotid artery 3. Femoral artery 4. Radial artery

3 - femoral artery Pulses that are best palpated are large and close to the trunk of the body. The femoral artery is large and at the trunk (proximal) of the body.

The nurse is caring for a client admitted to the emergency department with a history of asthma. Which assessment findings would the nurse anticipate? 1. Coughing 2. Chest tightness 3. 3 + pitting edema to ankles 4. Kussmaul respirations 5. Increased respiratory rate

1 - coughing 2 - chest tightness 5 - increased resp rate

A client is reporting pain rated an 8 out of 10 on the numeric pain scale. The nurse administers an oral pain medication to the client and starts a CD of the client's favorite relaxing music. Fifteen minutes later, the client rates the pain as 2 out of 10 on the numeric pain scale. What type of nonpharmacologic pain relief intervention has the nurse used? 1. Distraction 2. Biofeedback 3. Progressive relaxation 4. Cutaneous stimulation

1 - distraction The nurse uses distraction in the form of music while the oral analgesic takes effect.

The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client? 1. Document the client's statement in the client's own words. 2. Provide information on advance directives to the client. 3. Inform the client that personnel are available to assist with completing an advance directive. 4. Avoid inquiring about a client's advance directive as this could cause the client anxiety and concern. 5. Ask the daughter if she agrees with her mother's decision.

1 - document the clients statement in the clients own words 2 - provide info on advance directives 3 - inform the client that personnel are available to assist with completing an advance directive The nurse should document the client's statement in the client's own words. The nurse should provide the client with information on advance directives and assurance that there are hospital personnel to assist with completing the advance directive.

A nurse is preparing a lecture about suicide. Which target audience would be most appropriate? 1. High school teachers 2. Girl Scout leaders 3. Support group of divorced parents 4. Hispanic immigrant farm workers

1 - high school teachers Among those who commit suicide, young men between the ages of 15-24 are more likely to commit suicide than young girls and women. The best line of defense is to teach about the warning signs of suicide to high school teachers, students, and parents of teens and young adults, particularly male

A client has been on the mental health unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do? 1. Inform the primary healthcare provider that the client wishes to leave. 2. Make arrangements for a commitment hearing, as soon as possible. 3. Tell the client the primary healthcare provider must discharge the client prior to leaving. 4. Call the primary healthcare provider and request a discharge order.

1 - inform the primary healthcare provider Protocols on the unit must be followed when someone is requesting to leave AMA. The first step is to call the primary healthcare provider about the client's desire to leave AMA.

A nurse who has never had varicella has been exposed to a client diagnosed with herpes zoster. What actions should the nurse take? 1. Notify the infection control nurse. 2. Continue to care for client as varicella and herpes zoster are not related. 3. Go to the lab to have a Tzanck smear performed. 4. Obtain herpes zoster vaccine for protection from this exposure. 5. Receive the varicella-zoster immune globulin within 96 hours of exposure.

1 - notify infection control nurse 5 - receive the varicella zoster immune globulin within 96 hours Notify the person responsible for infection control to get post-exposure treatment initiated within a timely manner. For persons who are susceptible, the varicella-zoster immune globulin should be given within 96 hours of exposure. The infection of herpes zoster is contagious until the crusts have dried and fallen off the skin.

The nurse notes that a client has impaired swallowing as a result of a cerebrovascular accident (CVA). Which interventions are appropriate for the nurse to include in the plan of care? 1. Sit the client up at a 90° angle during meals. 2. Assist the client to hyperextend the head when preparing to swallow. 3. Encourage the client to sit up for 30 minutes after eating. 4. Educate a family member on the Heimlich maneuver. 5. Start the client on a thin liquid diet.

1 - sit the client up at 90 for meals 3 - encourage the client to sit up for 30 min after eating 4 - educate a family member on the heimlich maneuver This is the optimal position for chewing and swallowing without aspirating. Sitting up 30 minutes after completing a meal will prevent regurgitation of food. In case of choking, family members should know how to perform emergency measures such as the Heimlich maneuver.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which clients should the charge nurse assign to the medical-surgical nurse? 1. Total abdominal hysterectomy 2. Breast reduction 3. Vaginal delivery with fetal demise 4. 32 week gestation with lymphoma 5. Post-partal with HELLP syndrome

1 - total abdominal hysterectomy 2 - breast reduction

What should the nurse include when providing education to a client receiving tetracycline? 1. Wear long sleeves when going outside. 2. Take tetracycline on a full stomach. 3. Wait at least two hours after taking tetracycline prior to taking iron supplements. 4. Tetracycline can decrease the effectiveness of birth control pills. 5. Do not take this medicine after the expiration date on the label has passed.

1 - wear long sleeves when going outside 3 - wait at least two hours after taking tetracycline prior to taking iron supplements 4 - tetra can decrease the effectiveness of birth control pills 5 - do not take this medication after the expiration date on the label has passed Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Tetracycline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun. Take tetracycline on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective. Tetracycline can make birth control pills less effective. Use a second method of birth control while you are taking this medicine to keep from getting pregnant. Throw away any unused tetracycline when it expires or when it is no longer needed. Do not take this medicine after the expiration date on the label has passed. Expired tetracycline can cause a dangerous syndrome resulting in damage to the kidneys.

The nurse receives new healthcare provider prescriptions on a client diagnosed with Addison's disease. Which prescriptions should the nurse recognize as being inappropriately written and requiring clarification from the prescriber? 1. Weigh QD 2. IV of normal saline at 125 mL/hr 3. MRI of pituitary gland 4. Fludrocortisone acetate 0.1 mg by mouth T.I.W. 5. Dehydroepiandrosterone DHEA sulfate 5 mg by mouth every other day

1 - weigh QD 4 - fludrocortisone acetate 0.1 mg by mouth TIW Use "daily" or "every day". QD is an unapproved abbreviation. T.I.W. stands for three times a week; however, it is an unapproved abbreviation. Use "three times a week".

The home health nurse is assessing the home environment for possible irritants that could increase/precipitate symptoms of respiratory problems. Which assessment questions would be important to determine level of risk? 1. What type of heat do you use in the home? 2. Does anyone in the home have hobbies that involve sanding of wood or use of chemicals? 3. Is there anyone in the home who smokes? 4. Do you routinely use aerosol sprays for personal care or cleaning? 5. Is your water supply treated by a municipal agency?

1 - what type of heat 2 - wood sanding/use of chemicals 3 - smoking in the home 4 - aerosol sprays

The charge nurse on the pediatric unit is reviewing the protocol for blood administration with a staff nurse. Which actions by the staff nurse indicate understanding of blood administration? 1. The blood infusion time was within 6 hours. 2. A filter was used when administering the blood. 3. A second nurse checked the blood compatibility. 4. A set of vital signs was taken 5 minutes after the blood infusion started. 5. One form of client identification were obtained prior to infusion.

2 - a filter was used 3 - a second nurse checked the blood 4 - a set of vital signs was taken 5 min after blood infusion started Filters are used when infusing blood. Two nurses must check the blood product label and blood group. Vital signs are checked frequently during a blood transfusion. For example: A baseline set of vital signs are taken, then again 5 minutes after the initiation of the transfusion, then 15 minutes after transfusion started and every 15 minutes for one hour, then every 30 minutes for one hour, then hourly until infusion is complete.

The client in the manic phase of bipolar disorder begins climbing onto a table in the dayroom and shouts, "I can fly! I can fly! Watch me fly!" What should be the initial intervention by the nurse? 1. Leave the client alone and remove clients from the dayroom. 2. Call for personnel to escort the client out of the day room. 3. Restrain the client, and notify the primary healthcare provider. 4. Tell the client that there is no way that a person can fly.

2 - call for personnel to escort the client out of the room The first priority is the safety of the client. If the client jumps off the table, this action may cause an injury to the client. The nurse may need extra help in case the client becomes violent.

A primary healthcare provider prescribed KCL 40 mEq in 100 mL NS to infuse over 30 minutes. What action should the nurse take? 1. Administer the KCL through the lowest IV line port. 2. Clarify the prescription with the primary healthcare provider. 3. Mix KCL 40 mEq into the present infusing bag of NS when it reaches 100 mL. 4. Set the infusion pump to 100 mL / hour.

2 - clarify with provider Potassium chloride should be diluted and administered to infuse no faster than 40 mEq per hour. So this prescription would infuse too quickly and may lead to life threatening arrhythmias.

The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. Which signs/symptoms are an indication to the nurse that treatment goals have not been met? 1. Diuresis 2. Dyspnea on exertion 3. Persistent cough 4. Warm, dry skin 5. Heart rate irregular at 118/min 6. Alert and oriented

2 - dyspnea on exertion 3 - persistant cough 5 - heart rate irregular at 118/min When the cardiac output decreases, renal perfusion decreases, which leads to decreased urine output and fluid retention. This leads to difficulty breathing. Tachycardiac and rhythm irregularity are signs of fluid volume excess (FVE) and decreased output. Persistent cough, wheezing, and pink blood tinged sputum are all signs that the client is still sick.

An emergency department (ED) nurse working triage has assessed four clients. Which client should receive the highest priority? 1. Alert client who fell on the side walk. Skin warm and dry to the touch, with a three inch laceration on the right knee continuously oozing dark red liquid. 2. Elderly client who moans when the nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds. 3. A client who "passed out" but regained consciousness when feet were elevated. Awake and confused, with warm and dry skin. 4. An alert, responsive client who reports severe abdominal and shoulder pain that began two hours after eating at a local fast food restaurant. Skin is warm and dry.

2 - elderly client who moans when the nurse asks "can you hear me?" respirations even/nonlabored. skin slightly cool to touch with pale nailbeds This client is responding to verbal stimuli by moaning and has an open airway; but any client with an altered level of consciousness is at risk for airway obstruction. The skin assessment indicates a circulation problem.

Which nursing intervention should receive priority after a client has returned from having had eye surgery? 1. Administer pain medication around the clock. 2. Maintain head of bed at 35°. 3. Apply warm compresses. 4. Instruct on importance of turning, coughing, and deep breathing.

2 - maintan HOB at 35 degrees Maintaining head of bed in an elevated position will help to decrease intraocular pressure. Do not lie the client supine as this will increase intraocular pressure. If the intraocular pressure increases too much, damage to the eye structures, including the retina and optic nerve, with resulting loss of vision, may result.

The oncoming nurse has just received report and is preparing to make initial rounds. Which postpartum client should the nurse see first? 1. A primipara 6 hours postpartum saturating one peripad every two hours 2. A multigravida 1 hour postpartum and reporting intense perineal pain 3. A primigravida 12 hours postpartum with the uterine fundus at the umbilicus 4. A multigravida 72 hours postpartum with a brownish pink lochia discharge.

2 - multigravida 1 hr postpartum and reporting intense perineal pain Intense perineal pain is a symptom of a perineal hematoma which is a medical emergency.

What symptoms would the nurse anticipate in a client being admitted to the hospital with a calcium level of 3.2 mg/dL (0.80 mmol/L)? 1. Slowed deep tendon reflexes. 2. Muscle rigidity and cramping. 3. Hypoactive bowel sounds. 4. Positive Chvostek's sign. 5. Seizures 6. Laryngospasms

2 - muscle rigidity/cramping 4 - pos chvosteks sign 5 - seizures 6 - laryngospasms Normal serum calcium is 8.7 - 10.3 mg/dL (2.18 - 2.58 mmol/L). The client with a calcium level of 3.2 mg/dL (0.80 mmol/L) is hypocalcemic. With hypocalcemia, the muscle tone is rigid and tight. Therefore, the client may report muscle cramping. A hallmark sign of hypocalcemia is a positive Chvostek's sign, which is a twitching of facial muscles following tapping in the area of the cheekbone, indicative of hyperirritability. The client may be at risk of having seizures due to the neuromuscular irritability. Prolonged contraction of the respiratory and laryngeal muscles causes laryngospasm and stridor and may result in cyanosis.

A nurse drops a bottle of IV fluid, which shatters on the floor in the hallway. What action should the nurse take? 1. Notify housekeeping to clean up the spill. 2. Pick up glass with a broom and dustpan and dispose into a puncture resistant sharps container. 3. Pick up the glass with gloved hands and dispose into a puncture resistant sharps container. 4. Use a wet mop to collect the glass and dispose of it in the garbage can.

2 - pick up glass with broom and dustpan and dispose of in a puncture resistant sharps container The nurse must not be cut by the broken glass. Proper removal of glass includes using a dustpan and broom to collect the glass and disposing of it into a puncture resistant sharps container.

Which assignments would be most appropriate for the RN to delegate to an LPN/VN? 1. Six year old with new onset diabetes. 2. Ten year old with pneumonia admitted two days ago. 3. Three month old admitted with severe dehydration. 4. Four year old admitted for developmental studies. 5. Twelve year old with post op wound infection taking oral antibiotics.

2 - ten year old with pneumonia admitted two days ago 4 - four year old admitted for developmental studies 5 - 12 year old with post op wound infection on antibiotics

What should the nurse include when providing teaching to a female client prescribed doxycycline for the treatment of acne? 1. Take this medication with food to maximize absorption. 2. Use a non-hormone method of birth control while taking this medication. 3. Wear protective clothing when outside. 4. Drink plenty of fluids while taking this medication. 5. Iron and calcium supplements can be taken with this medication.

2 - use non-hormone method of birth control 3 - wear protective clothing outside 4 - drink plenty of fluids Doxycycline is a tetracycline antibiotic. Doxycycline can make birth control pills less effective. A non-hormone method of birth control (such as a condom, diaphragm, spermicide) should be used to prevent pregnancy while using doxycycline. Avoid exposure to sunlight or tanning beds. Doxycycline can make you sunburn more easily. Wear protective clothing and use sunscreen (SPF 30 or higher) when outdoors. Take doxycycline with a full glass of water. Drink plenty of liquids while taking this medicine.

A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What should the nurse suggest to reduce this side effect? 1. Stop taking the medication and call the primary healthcare provider. 2. Drink plenty of water with the medication. 3. Take the medication before bedtime. 4. Take antacids when taking the medication.

2- drink plenty of water with the med Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet.

The nurse is caring for a client who is to receive an IV infusion of heparin. The client's dose is based on a sliding scale prescription. What is the priority lab value to check before initiating the heparin infusion? 1. PT and/or INR 2. aPTT 3. Platelet count 4. WBC count

2. aPTT The activated partial thromboplastin time (aPTT) is a lab value used to assess pathways in the clotting cascade and is used to monitor Heparin therapy in clients. To maintain a therapeutic level of Heparin, the aPTT should be maintained at 1.5-2.5 times the normal range.

The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider? 1. BP 150/108 decreases to 138/86 2. Weight gain of 5 pounds (2.27 kg) in one week 3. Serum sodium level of 139 mmol/L 4. Angioedema 5. Serum potassium of 5.8 mEq

2. weight gain of 5 pounds in one week 4. angioedema 5. serum potassium of 5.8 Weight gain of 5 pounds in one week is a s/s of an adverse effect of ACE inhibitor use. Weight gain is a sign of fluid retention. Angioedema is an adverse effect of ACE inhibitors and can be life threatening. This should be reported immediately to the healthcare provider. The potassium level is too high. Hyperkalemia is an adverse effect of an ACE inhibitor and needs to be reported.

A client is hospitalized because of severe malnutrition related to anorexia nervosa. What is the most important goal for this client? 1. Verbalize understanding that eating behaviors are maladaptive. 2. Verbalize the importance of adequate nutrition. 3. Achieve at least 80% of expected body weight. 4. Acknowledge misperception of body image as fat.

3 - achieve at least 80% of expected body weight Until appropriate weight is gained, the client continues to be at risk for major health complications including hypotension, cardiac arrhythmias, poor muscle tone, increased risk for infection, abnormal liver function, and damaged kidneys.

A small community has experienced a severe tornado that hit a shopping mall and caused extreme damage and suspected mass casualties and injuries. Which intervention takes priority? 1. Triage victims and tag according to injury. 2. Assess the immediate area for electrical wires on the ground and in vicinity of victims. 3. Activate the community emergency response team. 4. Begin attending to injuries as they are encountered.

3 - activate the community emergency response team With mass casualties, community response teams are needed.

A client with a history of congestive heart failure has an implantable cardioverter defibrillator (ICD) surgically implanted. What teaching points should the nurse provide the client prior to discharge? 1. Avoid hot baths and showers. 2. Increase intake of leafy green vegetable products. 3. Avoid magnets directly over the site. 4. Notify primary healthcare provider whenever a shock is delivered by the ICD. 5. Driving is not recommended for 1 year after placement of an ICD.

3 - avoid magnets directly over site 4 - notify healthcare provider whenever a shock is delivered Magnets can deactivate the defibrillator. Other transmitter devices should also be avoided. Most arrhythmias need only one shock, but the healthcare provider should be notified when a shock is delivered so that monitoring can increase. The client cannot drive for 6 months after implantation of an ICD and cannot drive for 6 months after any shock therapy from the ICD

The nurse is caring for a client taking spironolactone. Which dietary change should the nurse teach the client to make when starting treatment with this medication? 1. Eat extra helpings of bananas. 2. Increase intake of water. 3. Avoid salt substitutes. 4. Increase intake of green leafy vegetables.

3 - avoid salt substitutes Spironolactone is a potassium sparing diuretic. Salt substitutes have potassium instead of sodium and should be avoided.

A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops slurred speech, shuffling gait and drooling. Which prescribed PRN medication would the nurse administer? 1. Lorazepam 2. Atropine 3. Benztropine 4. Chlorpromazine

3 - benzotropine These signs and symptoms are reflective of pseudoparkinsonism, a form of extrapyramidal side effects which are side effects of the haloperidol. An anticholinergic agent maybe used for treatment. This is an anticholinergic agent that may be used for extrapyramidal side effects.

A client has been prescribed vancomycin 1 gram IV every 12 hours for the treatment of methicillin-resistant staphylococcus aureus (MRSA). Which action by a new nurse when administering this medication would require intervention by the charge nurse? 1. Dilutes medication in NS 100 mL. 2. Delivers medication via an IV pump. 3. Calculates infusion rate at 30 minutes. 4. Monitors IV site every 30 minutes during infusion.

3 - calculates infusion rate at 30 min This dose of medication should be delivered over at least 60 minutes to prevent hypotension and ototoxicity.

The nurse recognizes that treatment has been successful in resolving fluid volume excess based on which assessment findings? 1. Continued lethargy 2. Heart rate 112/min 3. Decreasing shortness of breath 4. BP 114/78 5. Increased thirst

3 - decreased SOB 4 - BP 114/78 Urinary output should increase with decreasing shortness of breath as hydration is corrected, and BP should be normal.

What should the nurse do first when caring for a client who is being admitted with a diagnosis of meningococcal meningitis? 1. Assess neuro status. 2. Obtain health history. 3. Institute droplet precautions. 4. Orient client to the room and procedures.

3 - droplet precautions Although all the options are appropriate, the priority is to place the client on droplet precaution to prevent the spread of meningococcal meningitis

Following surgery, a client refuses to ambulate as prescribed. What action should the nurse take? 1. Notify the primary health care provider of client's refusal to ambulate. 2. Offer the client pain medication. 3. Explain complications associated with bed rest. 4. Perform passive range of motion exercises.

3 - explain complications associated with bed rest The nurse should educate the client about complications that can be prevented with ambulation, such as constipation, pneumonia, or deep vein thrombosis (DVT).

A home health nurse has taught a client about home dressing changes using a clean technique. Which statement made by a client indicates to the nurse that the client understands this technique? 1. "The wound should be cleaned using a washcloth, soap, and water." 2. "Povidone-iodine should be applied to the wound with each dressing change." 3. "It is important that I wash my hands using soap and water before removing my dressing." 4. "I will use sterile gloves to clean my wound and change the dressings."

3 - it is important that i wash my hands using soap and water before removing my dressing Clean technique requires washing hands with soap and water prior to removing the dressing

The nurse is caring for a client diagnosed with type 2 diabetes who was brought to the emergency department in an unresponsive state. A diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is made. The nurse prepares for the administration of which initial therapy? 1. Oxygen by nasal cannula 2. Long-acting IV insulin 3. Normal saline 4. IV dextran

3 - normal saline Clients in HHNS diurese due to a high glucose load in the vascular space. The client becomes severely volume depleted and is at risk for developing shock. Therapy is focused on combating shock.

A new admit arrives to the nursing unit with one thousand dollars in cash. What would be the best action by the nurse to safeguard the client's money? 1. Insist the money go home with the client's visitor. 2. Place the money in the client's bedside table drawer. 3. Put itemized cash in envelope and place in hospital safe. 4. Lock money up in narcotic cabinet with client's identity and room number.

3 - put itemized cash in envelope and place in hospital safe

A nurse invites a friend home one evening. On arrival, the friend sees the nurse's large, white, long-haired cat sitting on the couch and begins to experience palpitations, trembling, nausea, shortness of breath, and a feeling of losing control. What should the nurse do first? 1. Stay with the friend until the friend feels better. 2. Have the friend breathe into a paper bag. 3. Remove the cat from the room. 4. Dim the lights in the room.

3 - remove the cat from the room Remove the source of the panic attack first, then continue to assess the person for symptoms. Removing the cat "fixes" the problem

Which statement by a student nurse indicates to the nurse educator that teaching regarding witnessing consent signatures has been successful? 1. "Two people must witness a consent signature." 2. "A RN must witness a consent signature." 3. "Signing as a witness implies that the client willingly signed the consent." 4. "A witness must be over the age of 21."

3 - signing as a witness implies that the client willingly signed the contract Signing as a witness implies that the witness has observed the client personally signing the consent form with no coercion.

The nurse is evaluating dietary education provided to a client diagnosed with cholecystitis. The nurse determines that further teaching is necessary when the client chooses which meal to consume? 1. Cup of oatmeal, blueberries, soymilk 2. Whole grain pasta, marinara sauce, baked fish, coffee 3. Spaghetti with meat sauce, peas, garlic French bread, tea 4. Lentil soup, vegetable medley, fruit salad, water

3 - spaghetti with meat sauce, peas, garlic french bread, tea meat is high in fat, french bread is low in fiber and high in fat

The nurse is working with the parents of a preschooler to help promote healthy sleep patterns of approximately 8-12 hours per night. Which intervention should assist the parents to achieve adequate sleep for their preschooler? 1. Offer a time of exercise prior to bedtime. 2. Follow a bedtime routine at least three or four nights per week. 3. Spend about 30 minutes with the preschooler prior to bedtime for stories, prayers, etc. 4. Do not encourage your preschooler to take a toy to bed

3 - spend 30 min with them before bed Rituals help the preschooler to feel secure. Quiet time to read, tell stories, and say prayers prepares the child for sleep.

Which assignment would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Obtaining a sterile urine specimen from an indwelling catheter. 2. Inserting an in-and-out catheter on a client postpartum. 3. Taking vital signs on a client 12 hours postpartum. 4. Removing an indwelling catheter on a client postpartum. 5. Perform perineal care on a client with an episiotomy.

3 - taking vital signs on a client 12 hours postpartum 5 - perform perineal care on a client with an episiotomy Taking vital signs is within the scope of practice for the UAP, but the nurse is responsible for evaluating the vital signs. Performing perineal care is within the scope of practice for the UAP. The nurse is responsible for assessing the episiotomy and confirming that perineal care is done properly.

The nurse is caring for a depressed client. The client has a flat affect, apathy, and slowed physical movement. The client has not bathed in several days and there is a malodorous odor noted. Which intervention would be most appropriate at this time 1. Explain the rules about daily showers. 2. Leave the client alone since there is slowed movement. 3. Tell the client it is time to take a shower. 4. Ask when he or she would like to take a shower.

3 - tell them its time to take a shower Depressed clients often have little energy to do or think. Give short, simple commands during this time.

The nurse assesses a multigravida who is four hours postpartum. Findings include that fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The lochia is moderately heavy and bright red. Which nursing intervention has priority? 1. Massage the fundus. 2. Administer intravenous oxytocin. 3. Document these normal findings. 4. Assist the client up to void.

4 - assist the client up to void These findings are caused by a full bladder, which prevents the uterus from contracting down and achieving homeostasis. Once the bladder is empty, the fundus will contract adequately and return to its normal location at level of umbilicus or 1 finger breadth below the umbilicus and in the midline. A distended bladder will displace the uterus, usually to the right.

The nurse is caring for a client with possible hepatic failure. The nurse asks the client to sign a permit for a procedure. The nurse recalls the client's admission signature as legible, but, now observes a jerky, illegible signature. What should the nurse suspect is the cause of this handwriting change? 1. Fetor 2. Ataxia 3. Apraxia 4. Asterixis

4 - asterixis Yes, the liver flap, which is an abnormal muscle tremor, is usually found in clients with diseases of the liver. This is an indication that the hepatic failure is worsening and needs to be documented.

The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given? 1. "The action of the medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you do not break a bone." 4. "Glycopyrrolate will decrease stomach secretions."

4 - decreases stomach secretions Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease the risk of aspiration.

A hysterical college student arrives in the emergency department in bloody soiled clothing. The nursing assessment reveals facial bruising and multiple contusions consistent with the client's report of being raped. Which initial nursing intervention takes priority at this time? 1. Notify police of the alleged rape. 2. Allow the client privacy to wash self. 3. Remove clothing and bag for evidence. 4. Encourage client to express fears and anxiety.

4 - encourage client to express fears and anxiety Although there are specific protocols that must be followed when dealing with rape clients, it is important to remember that this client had all control taken away during the attack. The emotional effects of rape are as traumatizing as the physical injuries. Allowing the client to first express emotions, such as fear or anxiety, returns a small amount of control to a situation in which the client has little or none.

Family members have been asking triage nurses if loved ones were admitted to the hospital during a national emergency situation with massive casualties. What response should be made by the nurses? 1. Tell the family members that information about clients cannot be provided. 2. Ask for the victims' permission before talking with the family members. 3. Instruct the family to wait for public announcements about victims. 4. Inform them if their family members have been admitted.

4 - inform them their family members have been admitted The national emergency situation allows waivers for the Health Insurance Portability and Accountability Act (HIPAA) provisions. Due to the emergency situation, the nurse may inform the family members about the status of their loved ones.

A client with heart failure and pulmonary edema is given furosemide intravenously. Which assessment indicates that 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 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 HF. The number one thing to worry about in clients with HF is pulmonary edema, because this is what can kill the client.

The nurse is assigned to care for a client who has developed intestinal obstruction and has had an NG tube inserted to low suction. Blood gases are pH 7.54, pCO2 52, HCO3 35. Assessment of the client by the nurse reveals that the client is weak, shaky, and reporting tingling of the fingers. The nurse determines that this client is in which acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4 - metabolic alkalosis Metabolic alkalosis occurs from gastric losses via vomiting, NG tubes to suction, or lavage, and potent diuretics. Signs and symptoms include n/v, sensorium changes, tremors, convulsions. pH > 7.45, pCO2 > 45, HCO3 > 27

A client, admitted to the medical unit with persistent vomiting, reports weakness and leg cramps. The spouse states that the client is irritable. The primary healthcare provider has prescribed lab work and blood gases. Based on this assessment, the nurse anticipates which acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4 - metabolic alkalosis Symptoms of alkalosis are often due to associated potassium loss and may include irritability, weakness, and cramping. Excessive vomiting eliminates gastric acid and potassium, leading to metabolic alkalosis.

Post cataract removal a client reports nausea and severe pain in the operative eye. Which nursing intervention takes priority? 1. Administer morphine and ondansetron. 2. Reposition client to non-operative side. 3. Massage the canthus to unblock the lacrimal duct. 4. Notify the primary healthcare provider.

4 - notify healthcare provider Severe pain with nausea indicates an increase in intraocular pressure and needs to be reported at once. Eye damage can result if not resolved quickly. The primary healthcare provider may prescribe medications or take the client back to surgery.

A nurse attaches a client to continuous cardiac monitoring due to a potassium level of 2.8 mEq (2.8 mmol). The nurse should monitor for which dysrhythmia? 1. Third degree heart block 2. Atrial fibrillation 3. Premature atrial contractions 4. Premature ventricular contractions

4 - premature ventricular contractions Hypokalemia is reflected by the EKG. The earliest EKG change is often premature ventricular contractions (PVCs) which can deteriorate into ventricular tachycardia or fibrillation (VT/VF) without appropriate potassium replacement.

Which nursing action is likely to improve client satisfaction and demonstrate acts of beneficence? 1. Allowing clients to make their own decisions about care 2. Answering all questions posed by client in an honest manner 3. Reporting faulty equipment to the proper departments 4. Sitting at the bedside and listening to an elderly client

4 - sitting at the bedside and listening to an elderly client Sitting and listening demonstrates kindness and compassion that are consistent with the ethical term "beneficence." Beneficence is taking positive action to help others and a desire to do good which is the core principle of client advocacy.

The nurse is teaching a diabetic client who has been prescribed Lispro insulin about avoiding hypoglycemia. What administration teaching is priority? 1. Take insulin 30 minutes before bedtime 2. Take insulin twice daily in AM and PM 3. Take insulin one hour before meals 4. Take insulin with meals

4 - take insulin with meals Lispro is a rapid-acting insulin that should only be taken with food or within 15 minutes of a meal.