NCLEX readiness

The client is seen in the emergency department with pustules to the left arm. Wound cultures reveal methicillin-resistant Staphylococcus aureus (MRSA). Which action would the nurse take? Select all that apply 1. Place client in a private room. 2. Ask client to stay in hospital room. 3. Have visitors wash hands before entering and after leaving client's room. 4. Wear an N95 mask when entering client's room. 5. Implement airborne precautions.

1, 2, 3

The Emergency department nurse is caring for a client who has sustained a high-voltage electrical injury. Which intervention should the nurse initiate? Select all that apply 1. Initiate continuous cardiac monitoring. 2. Identify entrance and exit wounds. 3. Give analgesic by mouth as needed. 4. Keep burned limbs below the level of the heart. 5. Cover burned areas with clean sheets.

1, 2, 5

The OR nursing supervisor is notified by staff in the sterilization room that a foul odor has been noted. Upon inspecting the room, the nurse notes a small amount of sewage seeping up through the floor drain. What priority actions should the supervisor initiate? Select all that apply 1. Evacuate staff from the room and lock the door. 2. Tell staff to remove any equipment already sterilized. 3. Report the incident to the administrative Chief Executive Officer (CEO). 4. Call maintenance to thoroughly clean the room. 5. Initiate 'internal disaster protocols' immediately.

1, 3 & 5. Correct: Raw sewage could expose staff to potential hepatitis A as well as other severe health problems. Leaking sewage presents the danger of methane gas formation. The nurse's initial action must be to evacuate all personnel from the room and lock, or seal off, the door until the proper authorized personnel are available. Because this situation could impact the functioning of the facility as well as staff/client health, the administrative CEO needs to be notified immediately. Sewage represents the potential for deadly complications, and therefore the situation is classified as an "internal disaster". Appropriate protocols should be initiated. 2. Incorrect: Any equipment in that room, even if sealed in bags, is no longer considered sterile. Nothing should be removed from that room unless ordered so by the hospital CEO. 4. Incorrect: This situation can be hazardous to both staff and clients, depending on the location of sterilization room. Dealing with leaking sewage requires professional cleanup, along with evaluation by governmental or local authorities to locate and repair the source of the leak.

The nurse is caring for a client who has been receiving treatment for systolic heart failure. What assessment findings would indicate to the nurse that further treatment is necessary? Select all that apply 1. 3+ pedal edema 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 4. Purse-lip breathing 5. Pale nail beds 6. Urine output at 50 mL/hr

1, 4, 5 2. Incorrect: Normal CVP is 2-6 mm Hg. This CVP is within normal range so treatment is effective. 3. Incorrect: Weight loss indicates that fluid is being removed 6. Incorrect: A urine output of 50mL/hour indicates that renal perfusion is adequate.

A client arrives at the emergency department after being removed from a burning building. The nurse suspects carbon monoxide poisoning when the client exhibits which signs and symptoms? Select all that apply 1. Dizziness 2. Epigastric pain 3. Excess salivation 4. Premature ventricular contractions 5. Sweet aromatic odor to breath

1. & 4. Correct: Not enough oxygen is getting to the vital organs, such as the brain and heart, so dizziness, blurred vision, a dull headache, cardiac arrhythmias and respiratory depression can occur. 2. Incorrect: Epigastric pain is not a manifestation of carbon monoxide poisoning. The client will typically report nausea and might vomit. 3. Incorrect: Excessive salivation can be seen with ingestion of acids or alkalis. 5. Incorrect: The client will not have a sweet aromatic odor to breath to the breath with carbon monoxide poisioning. This odor occurs with ethylene glycol poisoning.

client has been admitted with a diagnosis of septic shock and has been successfully intubated.The nurse performs and documents a rapid assessment. Which action is most important for the nurse to perform? Vitals: BP 92/54 HR 116 RR: 22 Temp. 103 O2 91% Heart tones irregular, distant. Face flushed and warm. Extremities cool and mottled. Radial pulses faintly palpable. Pedal pulses non-palpable. Denies chest pain. Endotracheal tube taped in place via oropharynx. Right lung sounds clear. Unable to hear L. lung sounds. Grimaces with light abdominal palpation over pelvic bone. Urine amber and cloudy with red streaks. 100 mL urine output in Foley catheter bag. Opens eyes and moves to command. Pupils PERRLA 1. Pull the ET tube back until breath sounds are heard bilaterally. 2. Start an IV of Normal Saline at 125 mL/hr. 3. Administer acetaminaphen 500 mg rectally. 4. Obtain urine for culture and sensitivity.

1. Correct: Look at the clues: Endotracheal tube taped in place via oropharynx. Right anterior and posterior lung sounds clear. Unable to hear left lung sounds. The ET tube is likely down in the right main stem bronchus. This means the left lung is not being oxygenated. The ET tube needs to be pulled back until breath sounds are heard over the left lung.

Based on the results of the arterial blood gases (ABGs), what imbalance does the nurse understand the client to be exhibiting? Test Clients' Value Reference Range pH 7.35 7.35-7.45 PaO2 95 mmHg 80-100 mmHg PaCO2 49 mmHg 35-45 mmHg HCO3 30 mEq/L 22-26 mEq/L 1. Respiratory acidosis compensated 2. Respiratory acidosis partially compensated 3. Metabolic acidosis compensated 4. Metabolic acidosis partially compensated

1. Correct: The pH is normal but is on the acidic side of normal. The PaCO2 is elevated, causing acid formation. The HCO3 is alkalotic and is increased to buffer the acid. The pH and PaCO2 match, so the original problem was respiratory acidosis, but compensation has occurred since the pH is now normal.

A client has been unable to eat due to protracted vomiting. Which alterations in the arterial blood gases would the nurse expect to find? 1. pH: 7.48, PaCO2: 36, HCO3: 29 2. pH: 7.34, PaCO2: 48, HCO3: 29 3. pH: 7.33, PaCO2: 35, HCO3: 18 4. pH: 7.42, PaCO2: 40, HCO3: 24

1. Correct: The stomach as a lot of acid in it. So, if the client is vomiting a lot, then the client is losing acid. This will make the client alkalotic inside. Is this going to be a lung problem? No. So we are looking for ABGs that indicate that this client is in metabolic alkalosis. A pH of 7.48 is higher than the normal pH value of 7.45, which indicates alkalosis. The PaCO2 is 36, which is on the low end of normal (34-45). The HCO3 is 29, which is higher than the normal HCO3 of 26, which indicates alkalosis. So the Bicarb (Kidney chemical) matches the pH. Metabolic alkalosis. 2. Incorrect: This is partially compensated respiratory acidosis. pH: 7.34 (acid), PaCO2: 48 (acid), HCO3: 29 (alkaline) 3. Incorrect: This is metabolic acidosis. pH: 7.33 (acid), PaCO2: 35 (normal), HCO3: 18 (acid) 4. Incorrect: These are normal ABGs. pH: 7.42 (normal), PaCO2: 40 (normal), HCO3: 24 (normal)

A client who was admitted to coronary care unit with a diagnosis of myocardial infarction is on continuous cardiac monitoring. Which cardiac change noted on the monitor would be of greatest concern? 1. Ventricular tachycardia > 100 bpm 2. Atrial fibrillation with atrial rate > 300 per minute 3. Four premature ventricular contractions within one minute 4. ST segment depression of 0.5 mm

1. Correct: Ventricular tachycardia with a ventricular rate greater than 100 per minute can be a precursor to ventricular fibrillation. This rhythm is the most life threatening and would be of greatest concern. 2. Incorrect: Clients diagnosed with atrial fibrillation are at high risk for formation of thrombus. This is a serious concern, but not as great a concern as ventricular tachycardia. 3. Incorrect: Premature ventricular contractions (PVCs) that are less than 6 are worrisome but not considered a precursor to ventricular tachycardia or ventricular fibrillation. 4. Incorrect: ST segment depression of 1 mm or more signifies myocardial ischemia.

What room assignment by the charge nurse is most appropriate for a client who is being admitted with poor appetite, malaise, and temperature of 101.5ºF (38.6ºC)? 1. Private room. 2. Room with a client who has biliary colic. 3. Room with a client who is 3 days post operative hip replacement. 4. Room with a client who is in skeletal traction due to broken femur.

1. Private room.

The community health nurse has been educating a group of college students living in a dormitory about receiving an immune globulin (IG) injection for hepatitis A virus (HAV). Which statement made by the students would indicate to the nurse that further teaching is necessary? Select all that apply 1. Immune globulin contains antibiotics that destroy the HAV, preventing infection. 2. Immune globulin protection is temporary. 3. Common side effects of Immune globulin include soreness and swelling around the injection site. 4. It is important to take IG within four weeks of any exposure to hepatitis A. 5. Crowded living environments such as dormitories place people at risk for HAV.

1., & 4. Correct: Immune globulin contains antibodies that destroy the HAV, preventing infection. It's very important to take IG within two weeks of any exposure to hepatitis A. 2. Incorrect:This is a correct statement about immune globulin for Hepatitis A, indicating that teaching has been effective. 3. Incorrect:This is a correct statement about immune globulin for Hepatitis A, indicating that teaching has been effective. 5. Inorrect: This is a correct statement about immune globulin for Hepatitis A, indicating that teaching has been effective.

A nurse is attempting planning care for a client who has self-care difficulty due to left-sided hemiparesis. Which intervention should the nurse include? Select all that apply 1. Offer to take the client to the toilet every two hours. 2. Instruct client to use disposable razors once to prevent infection. 3. Encourage family members to comb hair for client. 4. Provide the client with a button hook for dressing. 5. Teach the client to rely on furniture for support when walking.

1., & 4. Correct: Offer bedpan or place client on toilet every 1 to 2 hours during the day and three times during the night. The use of a button hook or loop and pile closure on clothes may make it possible for a client to continue independence in this self-care activity. 2. Incorrect: The client can be helped by using an electric razor and toothbrush. These will improve client safety during self care. 3. Incorrect: Having client comb own hair helps maintain autonomy. This is a one handed task that will enable the client to maintain autonomy for as long as possible. 5. Incorrect: The client should use prescribed assistive devices for ambulation. Furniture may move or not be in the correct place for support while walking.

How should the nurse interpret this arterial blood gas (ABG) report? Exhibit You answered this question Correctly pH: 7.32 paO2: 93 paCO2: 33 HCO3: 19 Select all that apply 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

1., & 6. Correct: This set of ABGs reflects partially compensated metabolic acidosis. The pH, bicarb, and carbon dioxide are all abnormal, so compensation is beginning. Since the pH is not normal yet, total compensation has not occurred. There is only partial compensation.

The nurse is working with a group of elderly clients to promote better nutrition. Prior to developing the health promotion plan, the nurse assesses individual members of the group. Which assessment findings are expected as the nurse works with this group? Select all that apply 1. Some clients may have dental issues, making chewing difficult. 2. There may be a decreased appetite in clients. 3. Caloric and nutritional needs may vary somewhat depending on activity levels. 4. Access to fresh foods is adequate. 5. The desire and interest in cooking is increased.

1., 2. & 3. Correct: Many elderly people have dental issues that affect chewing and intake of nutritionally dense foods. Appetite may decrease due to changes in taste, medications, depression or isolation. Many elderly people are active; therefore, it is important to assess each one individually in regard to activity levels. 4. Incorrect: Many elderly clients may not have access to fresh foods due to infrequent grocery shopping, limited budgets, and a desire to not waste good food. 5. Incorrect: Many elderly do not have a desire to cook for one or two. Pain and physical impairment may also decrease desire or interest in cooking.

A client is being treated for fluid volume deficit with D5W, oral hydration, and management of viral symptoms. Which client data would indicate to the nurse that further treatment is needed? Select all that apply 1. BP 120/70 lying; 98/68 standing 2. Bounding pulses 3. One day weight gain of 5 kg 4. Urine specific gravity of 1.010 (Ref range 1.005 to 1.030) 5. Serum sodium 145 mEq (145 mmol/L) (Ref range 135-145 mEq/135-145 mmol/L)

1., 2., & 3. Correct: The systolic BP has dropped more than 20 mm Hg from lying to standing. This is considered orthostatic hypotension and indicates that the client is still in a fluid volume deficit. A bounding pulse is an indication of fluid volume excess. We have given the client too much fluid. This weight gain for one day is way too much. This indicates that we have put the client into fluid volume excess, which is a problem.

A nurse is caring for a client who is on bed rest following admission to the hospital two days ago with a diagnosis of new onset heart failure. While evaluating the client's progress, what assessment findings would indicate to the nurse that treatment has been effective? Select all that apply 1. CVP 6 mmHg 2. 3. 8 kg weight loss in 24 hours 3. Pink, frothy sputum 4. S3 heart sound 5. Urinary output 320 mL/8 hrs 6. Dyspnea on exertion

1., 2., & 5. Correct: These are all signs that the client is getting better. This is a normal CVP value, which would indicate the client is improving. A weight loss of 3.8 kg in 24 hours is a good thing. Excess fluid is being removed from the body. A urinary output of 320 mL in 8 hours is good. That averages out to 40 mL/hr.

The nurse is planning care for a client who has incomplete emptying of the bladder with reports of dribbling, hesitancy, and frequency. Which intervention would the nurse include in this plan? Select all that apply 1. After voiding, instruct client to void a second time. 2. Encourage the client to void every 4 hours. 3. Teach client to perform the Credé method. 4. Pour warm water over perineum. 5. Insert indwelling urinary catheter if client unable to void.

1., 2., 3., & 4. Correct: Have client attempt to void again. This is called double voiding. This can improve bladder emptying. Encourage client to void every 4 hours. We do not want urine to sit in the bladder for long periods of time. Stagnant urine can create infection. Place bedpan, urinal, or bedside commode within reach. Perform Credé method over bladder to increase bladder pressure. Provide privacy. Have client listen to sound of running water or place hands in warm water and/or pour warm water over perineum to stimulate urination. Offer fluids before voiding. 5. Incorrect: If these methods are unsuccessful, the client will need education on intermittent catheterization.

A nurse is caring for a client post heart catheterization with a left femoral stick. What signs and symptoms would indicate to the nurse that the primary healthcare provider should be notified? Select all that apply 1. Capillary refill of 6 seconds to left toes. 2. Epigastric discomfort 3. Paresthesia to left leg 4. Left pedal pulse 0/4; Right pedal pulse 2+/4 5. Temperature of 99.9º F (37.72º C)

1., 2., 3., & 4. Correct: These signs and symptoms indicate an emergency with loss of circulation to the extremity. This is an emergency, and the primary healthcare provider is the only one that can save this foot from ischemia. Don't delay. Epigastric pain could indicate the client is having an MI. Always assume the worse! 5. Incorrect: A temperature of 101º F (38.3º C) or more indicates a problem.

What teaching points should the nurse include when teaching a client how to prevent a venous stasis ulcer? Select all that apply 1. Maintain a healthy weight. 2. Wear compression stockings. 3. Go for a daily walk. 4. Crossing of the legs should be limited to 30 minutes at a time. 5. Elevate legs when resting.

1., 2., 3., & 5. Correct: Excess weight leads to high pressure in the veins of the legs, which can damage the skin. Venous ulcers are much more common among people who are overweight. Compression therapy is the standard of care for venous ulcers and chronic venous insufficiency. Exercise to improve circulation and reduce body fat. Elevating legs above the heart for 30 minutes, three times a day will minimize edema and reduce intra-abdominal pressure. 4. Incorrect: Crossing of the legs causes venous obstruction that can lead to stasis.

Which assessment finding would the nurse expect in a client diagnosed with Paget's disease? Select all that apply 1. Hearing loss 2. Walking with a limp 3. Muscle weakness 4. A shuffled gait 5. Bow-legged 6. Numbness in lower extremities RationaleStrategies

1., 2., 5., & 6. Correct: Paget's disease is a chronic skeletal bone disorder in which there is excessive bone resorption followed by the marrow being replaced by fibrous connective tissue. The new bone is larger, disorganized, and weak. An overgrowth of bone in the skull can cause hearing loss or headaches. These clients have severe pain, may walk with a limp, and may become bow-legged. With the spine affected by Paget's disease the lower extremity may have tingling and numbness from spinal nerve root compression. 3. Incorrect: Muscle weakness is not a symptom. 4. Incorrect: This is a manifestation of Parkinson's disease which is related to brain and nerve signals. It is not related to Paget's disease.

A client was admitted two days ago in the oliguric phase of acute kidney injury (AKI). What evaluation by the nurse would indicate that treatment has been effective? Select all that apply 1. Variable urine specific gravity 2. Serum K+ 5.5 mEq (5.5 mmol/L) 3. Serum Na+ 140 mEq (140 mmol/L) 4. Minimal crackles auscultated in bases of left lung 5. Urine output = 1250 mL/24 hours

1., 3. & 5. Correct: A fixed specific gravity indicates that the kidneys are not working properly. A variable specific gravity changes based on whether the urine is dilute or concentrated. This is a normal sodium level, which indicates that the client is improving. The serum sodium level would be low in the oliguric phase due to increased dilution of the blood. This urine output is adequate to indicate proper kidney perfusion. 2. Incorrect: The serum potassium is high. The serum potassium level is elevated when the client is still in the oliguric phase. 4. Incorrect: The lungs would need to be clear to verify that treatment has been effective.

A client was admitted 48 hours ago in septic shock. Treatment included oxygen at 40% per ventimask, IV therapy of Lactated Ringer's (LR) at 150 mL/hr, vancomycin 1 gram IV every 8 hours, and methylprednisolone 40 mg IVP twice a day. Which clinical data indicates that treatment has been successful? Select all that apply 1. pH- 7.35; pCO2- 44; pO2 -92; HCO3- 22 (Ref. range: pH 7.35-7.45,pCO2 35-45,pO2 80-100, HCO3 22-26) 2. Skin cool, mottled 3. Urinary output of 300 mL/8 hr 4. Vital signs: Blood pressure 90/52; HR 110; RR 22 5. WBC 10,500/mm3 (10.5 x 10^9)/L (Ref range 4,500 to 11,000 WBCs per microliter (4.5 to 11.0 × 10^9/L)

1., 3., & 5. Correct: This ABG result shows not acid/base imbalance. The results are normal. Urinary output should be adequate if treatment is successful. The urinary output should be at least 30 mL/hr for an adult. 300 mL over 8 hours is adequate at an average of 37.5 mL/hr. The white blood cell count is within normal limits.

A nurse, planning an educational seminar on chronic kidney disease, would invite clients with which medical conditions? Select all that apply 1. Diabetes 2. Frequent urinary tract infections (UTI) 3. Hyperlipidemia 4. Hypertension 5. Obesity

1., 3., 4 & 5. Correct: Polycystic kidney disease is a genetic condition that causes damage to the kidneys. Clients with diabetes and hypertension make up more than 67% of clients diagnosed with chronic kidney disease. Glomerulonephritis damages the kidneys and can lead to permanent damage. 2. Incorrect: Cystitis is an inflammation of the bladder. Inflammation is where part of your body becomes irritated, red, or swollen. In most cases, the cause of cystitis is a urinary tract infection (UTI).Acute UTIs do not generally lead to chronic kidney disease.

During the admission examination of a client diagnosed with acute pyelonephritis, what signs or symptoms would the nurse expect to find? Select all that apply 1. Anorexia 2. Bradycardia 3. Chills 4. Fever 5. Hematuria

1., 3., 4., & 5. Correct: The client with acute pyelonephritis, will often exhibit these signs/symptoms due to the kidney infection. 2. Incorrect: Bradycardia is not a symptom of acute pyelonephritis. The client will more likely experience tachycardia due to fever and chills.

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client? Select all that apply 1. Alternating pressure mattress 2. Bath chair 3. Mechanical hoist lift 4. Oxygen 5. Suction equipment 6. Hospital bed

1., 4., 5., & 6 Correct: An alternating pressure mattress will help to prevent pressure ulcers. The client at the end stages of liver disease will be hypoxemic, so oxygen therapy is provided. The client with hepatic encephalopathy is unresponsive and may need suctioning if unable to clear secretions from the oropharynx. A hospital bed is needed so that the head of the client's bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing.

The nurse is caring for a client due for a dose of fluphenazine 10 mg. The drug is available as an elixir: 5 mg / 5 mL. How many mL will the nurse give to the client? ______mL. Round answer to the nearest whole number.

10

What is the nurse's priority when treating a client admitted with a full thickness thermal burn over 30% of the body? 1. Insert a urinary catheter 2. Establish IV access of Normal Saline 3. Administer fentanyl (1 mcg/kg) IV 4. Apply antibiotic ointment and dressing to burns

2

The nurse is caring for a client in the emergency department following an argument with the spouse. The client describes a verbal argument that began to get physical with shoving of the client. There is a history of domestic violence. Which phase of the cycle of violence is the client describing? 1. Honeymoon phase 2. Tension-building phase 3. Acute battering phase 4. Remorse phase

2 2. Correct: In the tension-building phase, minor physical or emotional abuse may occur as well as verbal arguments. The victim feels growing tension and tries to control the situation. 1. Incorrect: The honeymoon phase is characterized by remorse with promises never to hurt the victim again. The abuser is sorry and apologetic. 3. Incorrect: The acute battering phase includes the release of tension through extreme physical violence. This is also called the explosion phase. 4. Incorrect: There is no remorse phase, but remorse is expressed during the honeymoon phase. There are 3 phases: tension building, acute battering (explosion) and honeymoon phase.

The nurse inadvertently administered the wrong medication to a client. Place the tasks to be completed in order of priority. 1. Alert the Unit Manager. 2. Obtain the client's vitals. 3. Complete an incident report. 4. Report what happened to the health care provider.

2, 4, 1, 3

A client is admitted for treatment of fluid volume deficit. The nurse reviews the admitting lab work and the primary healthcare provider's prescriptions. Which prescription would be of concern to the nurse? Exhibit 1. Diet 2. Furosemide 3. IV infusion 4. Potassium Chloride (KCL)

2. Furosemide would make FVD worse

The nurse is planning care for a client diagnosed with pyelonephritis. What interventions should the nurse include? Select all that apply 1. Advise that urine may turn blue with administration of nitrofurantoin. 2. Encourage voiding every 2 hours. 3. Educate the client that phenazopyridine is an antibiotic used to treat pyelonephritis. 4. Palpate the bladder every 4 hours. 5. Provide client with at least 1500 mL of water to drink daily.

2., & 4. Correct: Encourage frequent voiding every 2 to 3 hours to empty the bladder completely because this can significantly lower urine bacterial counts, reduce urinary stasis, and prevent reinfection. Palpate the bladder every 4 hours to determine bladder distention. 1. Incorrect: Nitrofurantoin is an antibiotic used to treat most UTIs. The color of the urine is not changed. 3. Incorrect: Phenazopyridine is an analgesic for urinary pain. 5. Incorrect: Fluid intake should be increased to 2-3 liters a day unless contraindicated, to flush out the kidneys.

What information should a nurse include when preparing discharge education for a client diagnosed with gastroesophageal reflux disease (GERD)? Select all that apply 1. Foods that may trigger an attack include apple juice, cream cheese, and oatmeal. 2. Lose weight slowly at a rate of 1 kilogram per week. 3. Only eat three small meals per day. 4. Avoid tight-fitting clothing. 5. Wait at least 1 hour after eating to lie down. RationaleStrategies

2., & 4. Correct: Excess pounds (kg) put pressure on the abdomen, pushing up the stomach and causing acid to back up into the esophagus. Work to slowly lose weight, no more than 1-2 pounds (0.5-1 kg) per week. Avoid tight-fitting clothing. Clothes that fit tightly around the waist put pressure on the abdomen and the lower esophageal sphincter.

A community health nurse is presenting a seminar to a group of senior citizens on ways to reduce the risks of peripheral artery disease (PAD). What topics should the nurse include? Select all that apply 1. Daily strenuous exercise 2. How to read food labels 3. Maintaining a BMI less than 30 kg/m2 4. Managing diabetes 5. Use of anti-embolic stockings

2., & 4. Correct: Senior clients are at increased risk for peripheral artery disease for a variety of reasons, though many erroneously believe that this process is an unavoidable part of the aging process. Educating clients on preventative activities will help reduce incidence of atherosclerosis and improved mobility along with quality of life. Mantaining a healthy diet is essential. Empower people by helping them understand the food they want to purchase by learning how to read the food label. One way to do this is to follow the DASH diet. Poorly managed diabetes leads to vessel damage. 1. Incorrect: Clients can increase collateral circulation with a moderate exercise program of at least 30 minutes three times a week. 3. Incorrect: Reduce caloric intake to achieve a body mass index of 18.5 to 24.9 kg/m2. 5. Incorrect: Anti-embolic stockings are ordered to improve venous return in clients with restricted or limited mobility.

What potential contributing factors for transient urinary incontinence should a nurse assess in an elderly female client? Select all that apply 1. Chronic urinary retention 2. Fecal impaction 3. Menopause 4. Restricted mobility 5. Stroke

2., & 4. Correct: Transient incontinence: a temporary type of urinary incontinence caused by an illness or a specific medical condition that is short-lived and is, therefore, quickly remedied by appropriate treatment of the condition and a disappearance of symptoms. The potential causes of transient incontinence may be easily remembered by the mnemonic 'delirium, infection, atrophy, pharmaceuticals, excess urine output, restricted mobility, stool impaction' (DIAPERS). Fecal impaction can compress the urethra resulting in urinary incontinence. Use of diuretics can make it difficult to get to the toilet in time to void, thus causing urinary incontinence. Diabetics have polyuria, which can contribute to urinary incontinence. Vaginitis, a condition caused by an infection or inflammation of the vagina, can contribute to urinary incontinence.

A nurse is caring for a client who had a cholecystectomy 4 hours ago. What interpretation should the nurse make based on the results of the client's arterial blood gases (ABGs)? Exhibit pH:7.31 paO2 92 paCO2 49 HCO3 22 Select all that apply 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

2., & 5. Correct: The pH is 7.31 (normal 7.35-7.45) which means acidosis. The paCO2 of 49 (normal 35-45) indicates a respiratory problem. The arterial blood gas results indicate that the client is in respiratory acidosis. The HCO3 is normal. This means that the client is in uncompensated respiratory acidosis.

The nurse is assigned to care for 5 adult clients. In what order should the nurse care for these clients? 1. The client admitted with electrical burns 8 hours ago and has a serum potassium level of 5.2 mEq/L (Ref. range 3.5-5.2 mEq/L) 2. The client with full thickness burns to the posterior chest who has a temperature of 102°F (38.8°C) and a blood pressure of 88/52 3. The client with partial thickness arm burns who has a temperature of 99°F (37.2°C) and a blood pressure of 92/66. 4. The client who is to receive an analgesic 30 minutes prior to wound debridement in 2 hours. 5. The client with facial burns 3 days ago who has been crying since recent visitors left.

2., 1, 3, 5, 4 The nurse should first see is the client with full thickness burns to the posterior chest who has a temperature of 102°F (38.8°C) and a blood pressure of 88/52. This client's vital organs are not going to be perfused properly with this BP and shock is a major concern. The client's temperature is also too high - worry about infection. The nurse should see the client admitted with electrical burns 10 hours ago and has a serum potassium level of 5.2 mEq/L next. The potassium is high normal, placing the client at risk for heart problems (dysrhythmias). The nurse should see the client with the partial thickness arm burns who has a temperature of 99°F (37.2°C) and a blood pressure of 92/66 third. This client has a a low grade fever and a low normal BP. The client needs to be monitored closely for risk of shock. But at present this client is more stable than the client with a high potassium. The fourth client the nurse should see is the client who has been crying. Don't let facial burns throw you. This burn is 3 days old and swelling would be decreasing at this point. Physical problems take priority over psychological problems. This client is the more stable than the first two that should be seen. However, the client scheduled for wound debridement does not need pain medication for 1 1/2 hours and can be the last client seen.

A nurse is assessing a client who is one day post thyroidectomy and identifies an arrhythmia on auscultation. While taking the blood pressure, the nurse notices the client's hand starts to tremble. What interventions should the nurse initiate? Select all that apply 1. Administer magnesium sulfate IV 2. Continuous cardiac monitoring 3. Draw blood for phosphorus level 4. Initiate seizure precautions 5. Prepare to send client to surgery

2., 3., & 4. Correct: The parathyroid glands can accidentally be removed with a thyroidectomy. Low calcium causes rigid and tight muscles. The heart can be affected and life threatening arrhythmias can occur. So the client should be placed on continuous cardiac monitoring. If the some of the parathyroids have been removed, then calcium will be low and phosphorus will be high. They have an inverse relationship to each other. So both values should be monitored. The client is at risk for seizures so seizure precautions are needed. 1. Incorrect: Is this the problem chemical? No, calcium is the problem. Calcium gluconate should be given IV. 5. Incorrect: Surgery will not fix the problem.

The nurse is assessing a male client suspected of having a myocardial infarction (MI). What signs/symptoms would the nurse expect the client to exhibit? Select all that apply 1. Bradycardia 2. Chest pressure 3. Shortness of breath 4. Flu like symptoms 5. Vomiting

2., 3., & 5. Correct: These are symptoms commonly seen in a male client having an MI 1. Incorrect: Tachycardia rather than bradycardia will be noted with an MI 4. Incorrect: A woman, rather than a male, having an MI my exhibit flu like symptoms.

The nurse is caring for a client who is receiving enoxaparin after a diagnosis of deep vein thrombosis of the left leg. Which nursing interventions would be appropriate for this client? Select all that apply 1. Monitor PT and aPTT 2. Initiate bedrest 3. Elevate left leg 4. Monitor closely for bleeding 5. Monitor complete blood count

2., 3., 4. & 5. Correct: The main complication of anticoagulant therapy is bleeding. Periodic complete blood counts, including platelet count, and stool occult blood tests are recommended during the course of treatment with enoxaparin sodium Injection. Bedrest will reduce the risk of a clot dislodging. Elevate left leg to decrease swelling and promote venous return. 1. Incorrect: When administered at recommended prophylaxis doses, routine coagulation tests such as Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) are relatively insensitive measures of enoxaparin

A client is admitted with arterial disease of the lower extremities. Which client teachings would the nurse initiate? Select all that apply 1. Elevate extremities above the level of the heart. 2. Discourage use of caffeine. 3. Protect extremities from cold exposure. 4. Maintain a warm environment at home. 5. Encourage isometric exercise.

2., 3., 4., & 5. Correct: Caffeine, stress, and nicotine cause vasoconstriction and vasospasm, which impedes peripheral circulation. Warmth promotes arterial flow by preventing the vasoconstriction effects of chilling. Vasodilation will be increased by providing warmth in the environment. Cold causes vasoconstriction. Isometric exercise and walking promote the development of collateral circulation. 1. Incorrect: Lower the extremities below the level of the heart for arterial problems. Dependent extremities enhance arterial blood supply.

The nurse is planning to educate a client who has a diagnosis of right sided heart failure? What information should the nurse include? Select all that apply 1. Blood backs up in the left upper chamber of the heart. 2. Your feet, legs, and ankles will likely swell because blood is backing up in your veins. 3. Activity will increase your heart rate. 4. You might find that you go to the bathroom more often at night. 5. Weigh yourself daily to monitor for rapid weight gain.

2., 3., 4., & 5. Correct: Vascular congestion is evident by swelling of the lower extremities. Ascites may increase pressure on the stomach and intestines causing GI upset with nausea and anorexia. The heart rate increases in an attempt to increase cardiac output. Bedrest induces diuresis. The fluid leaves the extremities and goes back into the vascular space where the kidneys get rid of the excess fluid. Daily weights are important to monitor fluid retention. A rapid weight gain is fluid not fat. 1. Incorrect: The blood backs up into the right atrium and venous circulation.

small community has experienced a mudslide that hit a restaurant causing mass casualties. What would the nurse do first? 1. Assess the immediate area for electrical wires on the ground. 2. Attend to victim injuries as they are encountered. 3. Activate the community emergency response team. 4. Triage and tag victims according to injury.

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The nurse is caring for a client with acute renal failure. The morning assessment findings indicate the client has become confused and irritable. Which finding is most likely responsible for the change in behavior? 1. Hyperkalemia 2. Hypernatremia 3. Elevated blood urea nitrogen (BUN) 4. Limited fluid intake

3. Correct: A client with acute renal failure will have an increased blood urea nitrogen (BUN). Significant elevation in BUN may result in nausea, vomiting, lethargy, fatigue, impaired thought processes, and headache. 1. Incorrect: Hyperkalemia can result from acute renal failure. Symptoms of hyperkalemia do not include confusion and irritability. Hyperkalemia may cause muscle weakness, muscle twitching, and flaccid paralysis. 2. Incorrect: Clients with renal failure retain fluid and are at risk for dilutional hyponatremia. Increased or decreased sodium levels can cause confusion, but this client is not at risk for hypernatremia. 4. Incorrect: Clients with acute renal failure should have limited fluid intake. This will not lead to confusion.

The nurse sees the following rhythm on the cardiac monitor for a client recovering from a myocardial infarction. What would be the nurse's first action upon entering the client's room? Exhibit: Strip looks like Vfib 1. Attempt defibrillation 2. Begin CPR 3. Assess for carotid pulse 4. Administer lidocaine

3. Correct: Although the rhythm strip looks like ventricular fibrillation, you must first check the client. Assess for consciousness, airway, breathing, circulation first. 1. Incorrect: Assess the client first. Do not rely on the strip alone. It may be artifact. If there is no pulse, then you defibrillate. 2. Incorrect: Assess the client first. Defibrillate, then CPR. 4. Incorrect: While CPR is in progress after defibrillation, start IV, if one is not available, then give lidocaine.

A client has been admitted with advanced cirrhosis. The nurse's assessment verifies an increase weight of 6 lbs. (2.71 kg) since yesterday's weight and an abdominal girth increase of 5 inches (12.7 cm). What is the priority assessment? 1. Urinary Output 2. Daily weight 3. Blood pressure 4. LOC

3. Correct: Blood Pressure. We said that all of this ascites is coming from the vascular space and it's getting worse, so what could happen to my blood pressure? It will drop! 1. Incorrect: SURE, you are going to watch the urinary output and the daily weight. LOC is very important as well and one of the first assessments we make, BUT if I can only do one of these assessments, I had better take the BP because that is the one that says SHOCK. 2. Incorrect: SURE, you are going to watch the urinary output and the daily weight. LOC is very important as well and one of the first assessments we make, BUT if I can only do one of these assessments, I had better take the BP because that is the one that says SHOCK. 4. Incorrect: SURE, you are going to watch the urinary output and the daily weight. LOC is very important as well and one of the first assessments we make, BUT if I can only do one of these assessments, I had better take the BP because that is the one that says SHOCK.

Which signs and symptoms would concern the nurse if seen in a client post radical neck surgery? Select all that apply 1. Decreased deep tendon reflexes 2. Flaccid muscle tone 3. Laryngeal stridor 4. Muscle cramps 5. Negative Trousseau's sign

3., & 4. Correct: Laryngeal stridor and muscle cramps are signs indicating that muscles are rigid and tight due to a low calcium level. Some of the parathyroids could have been removed resulting in hypocalcemia. 1. Incorrect: Decreased deep tendon reflexes would be seen with hypermagnesemia and hypercalcemia because they act like sedatives. 2. Incorrect: Flaccid muscle tone is seen with hypermagnesemia and hypercalcemia because they act like sedatives. 5. Incorrect: A negative Trousseau's sign is a good thing. It would be positive if the calcium level is low.

A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client? Exhibit Test Clients' Value Reference Range pH 7.46 7.35-7.45 PaO2 97 mmHg 80-100 mmHg PaCO2 47 mmHg 35-45 mmHg HCO3 28 mEq/L 22-26 mEq/L Select all that apply 1. Metabolic acidosis 2. Respiratory alkalosis 3. Metabolic alkalosis 4. Respiratory acidosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

3., & 6. Correct: Partially compensated metabolic alkalosis is indicated by these ABGs. The pH is 7.46 (normal 7.35-7.45) which is high, which means alkalosis. The PaCO2 is 47 (normal 35-45) which is high. Greater than 45 is acidosis from too much CO2. The HCO3 is 28 (normal 22-26) which is high. A high bicarb level equals alkalosis. The HCO3 matches the pH as both indicate alkalosis. The initial problem was a kidney problem or metabolic alkalosis. The lungs are trying to compensate by holding on to more acid. So the correct answer is partially compensated metabolic alkalosis. 1. Incorrect: A pH of greater than 7.45 indicates alkalosis rather than acidosis. So this option is incorrect. 2. Incorrect: The PaCO2 would be low rather than high if the problem was respiratory alkalosis. 4. Incorrect: A pH of greater than 7.45 indicates alkalosis rather than acidosis. So this option is incorrect. 5. Incorrect: If the ABGs indicated that compensation had not begun (uncompensated) then the CO2 would be normal. Since it is high, the lungs are attempting to compensate for the metabolic alkalosis retaining more acid (Decrease breathing to hold on to acid). 7. Incorrect: Full compensation does not occur until the pH is normal. The pH is still abnormal here.

An intravenous infusion of 5% dextrose in water is prescribed at a rate of 1000 mL in 8 hours. The tubing has a drop factor of 15. How many drops per minute (gtts/min) are delivered? Round your answer to the nearest whole number. Provide your answer using numbers and decimal points only.

31 The formula used to calculate drop rates is the total number of milliliters divided by the total number of minutes multiplied by the drop factor. In this circumstance, the minutes portion must be figured first, that is, 8 hours equals 480 minutes. Then, dividing 1000 by 480 equals 2.08333333. This is multiplied by the drop factor, which is 15. Multiplying 15 by 2.08333333 equals 31.25, which rounds to 31.

An elderly, confused client with dehydration is admitted to the medical unit. Which intervention would be appropriate for the RN to delegate to the unlicensed assistive personnel? 1. Perform a physical assessment. 2. Start an IV of NS with KCL 20 mEq at 50 mL/hr. 3. Insert a urinary catheter. 4. Weigh the client.

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Which comment by the mother indicates understanding of the diet needed to maintain health and adequate nutrition in the toddler? 1. "It is important to give my child low fat milk after one year of age". 2. "If the child won't eat new foods after three tries, he is not going to eat it". 3. "I think that the sooner one starts to give vitamins to children, the better". 4. "I try to provide whole grains, fruits, vegetables, and meat daily".

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A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education was successful when a nurse selects which set of ABGs as compensated respiratory alkalosis? 1. pH - 7.46, PaCO2 - 30, HCO3 - 26 2. pH - 7.45, PaCO2 - 35, HCO3 - 25 3. pH - 7.36, PaCO2 - 43, HCO3 - 24 4. pH - 7.43, PaCO2 - 31, HCO3 - 20

4. Correct: This set of ABGs indicate compensated respiratory alkalosis. The pH is normal, but on the alkalotic side of normal (normal 7.35-7.45; perfect is 7.4). The PaCO2 is low, indicating alkalosis, so it matches the alkalotic pH. The bicarb are low at 20 which indicates acidosis. The bicarb is low to get rid of base. Compensation has occurred. 1. Incorrect: pH - 7.46, PaCO2 - 30, HCO3 - 26. The pH is high. The PaCOs is low. The bicarb is normal. This is uncompensated respiratory alkalsosis. 2. Incorrect: pH - 7.45, PaCO2 - 35, HCO3 - 25. All of these values are normal. No acid base problem here. 3. Incorrect: pH - 7.36, PaCO2 - 43, HCO3 - 24. The pH is normal. The PaCO2 is normal. The bicarb is normal.

The charge nurse is evaluating a new nurse who is performing a linear wound dressing change on a surgical client. Which action by the new nurse requires intervention by the charge nurse? Select all that apply 1. Hand hygiene is done prior to the dressing change. 2. Dressing tape is removed in the direction of the hair growth. 3. The soiled dressing is discarded in a biomedical waste bag. 4. Clean gloves are donned in order to clean the wound. 5. The wound area farthest from the nurse is cleaned first, then the center of the wound, followed by the area closest to the nurse. 6. New sterile dressing is applied to the wound.

4., & 5. Correct: Most dressing changes following surgery are sterile and require that the nurse use standard precautions and wear sterile gloves to clean the incision and apply sterile dressings. Clean gloves can be used to remove the old dressing. Dressings are never touched by ungloved hands. Remember, clean to dirty. The wound center is considered the cleanest area, so that is cleaned first. The area beside the wound farthest from the nurse is considered the next cleanest area. The area closes to the nurse is considered the most contaminated and is cleaned last. The new nurse performed this step correctly.

An adult client has partial and full thickness burns over the anterior trunk, the anterior and posterior aspect the left leg, the anterior aspect of the right leg, and the peritoneal area. Utilizing the rule of nines, what percentage of the body surface area is burned? Round your answer to the nearest whole number.

46 The anterior trunk counts for 18% of the body; entire left leg counts 18%; anterior right leg counts 9%. The peritoneal area counts 1%. Body surface on this client is 46%.

In what order should the nurse address these client events that occur at the same time? Place in order of highest to lowest priority. UAP reports a heart rate of 40/min in a client. The water seal chamber is empty in a client's closed chest drainage unit. Client's tracheostomy needs to be suctioned. Client who is on bedrest due to a deep vein thrombus attempting to get out of bed. Client reporting urinary frequency and dysuria.

Client's tracheostomy needs to be suctioned. The water seal chamber is empty in a client's closed chest drainage unit. UAP reports a heart rate of 40/min in a client. Client who is on bedrest due to a deep vein thrombus attempting to get out of bed. Client reporting urinary frequency and dysuria.

In what order should the nurse assess assigned clients following shift report? 1. Client admitted with chemotherapy-induced neutropenia with a temperature of 100.8 F (38.2 C). 2. Client diagnosed with aplastic anemia needing education regarding ways to decrease infection risk. 3. Client diagnosed with cancer who is crying and states, "I am not ready to die". 4. Client with non-Hodgkin's lymphoma who is refusing prescribed chemotherapy regimen. 5. Client one day post splenectomy.

Order: 1, 5, 3, 4, 2 The first client the nurse needs to assess is the one admitted with chemotherapy-induced neutropenia with a temperature of 100.8 F (38.2 C). Any temperature elevation in a neutropenic client may indicate the presence of a life-threatening infection. This client will likely need blood cultures and antibiotics quickly. The second client that should be assessed by the nurse is the client who is one day post splenectomy. There is no indication that this client is in any immediate danger, but as a surgical client one day postop, this client should be assessed prior to moving on to the other three clients. The nurse needs to assess for any possible complications associated with surgery. The third client the nurse needs to see is the client diagnosed with cancer who is crying and states, "I am not ready to die". This client is facing death and is exhibiting grief. The role of the nurse is to respond appropriately to the client's needs by listening carefully and addressing the social, emotional and spiritual aspects of the client's symptoms. This client should be seen after clients who have a physical problem that could be life threatening. The fourth client the nurse should assess is the client with non-Hodgkin's lymphoma who is refusing prescribed chemotherapy regimen. This client does not need immediate care. The nurse needs to talk to the client about why the client is refusing chemotherapy and if any education or referrals are needed. Clients who are stable and awaiting discharge teaching can be seen last.