NCLEX-RN PassPoint #1

An infant is brought to the clinic with a possible diagnosis of Wilms' tumor. When obtaining the health history, which question should the nurse consider a priority to ask the parent?

"Did the healthcare provider find a mass in the abdominal area?" Explanation: The most common sign of Wilms' tumor is a painless, palpable abdominal mass, sometimes accompanied by an increase in abdominal girth. Projectile vomiting after a feeding is found with pyloric stenosis. A reddish, jelly-like bowel movement referred to as "currant jelly" is seen in intussusception. A pulsating anterior fontanel is a normal finding.

Which guidelines define and regulate what the nurse may and may not do as a professional?

nurse practice act Explanation: Each state legislature has enacted a nurse practice act. These statutes outline the legal scope of nursing practice within a particular state. State boards of nursing oversee the statutory law. State legislatures create boards of nursing within each state; the state legislature itself doesn't regulate the scope of nursing. Facility policies govern the practice within a particular facility. Nurse practice acts set educational requirements for the nurse, distinguish between nursing practice and medical practice, and define the scope of nursing practice in that state. Standards of care, criteria that serve as a basis for evaluating the quality of nursing practice, are established by federal organizations, accreditation organizations, state organizations, and professional organizations.

A nurse is about to give a client with type 2 diabetes mellitus the prescribed insulin before breakfast on the first day postpartum. Which client statement indicates an understanding of insulin requirements immediately postpartum?

"I will need less insulin now than during my pregnancy." Explanation: Postpartum insulin requirements are usually significantly lower than requirements during pregnancy. Occasionally, clients may require little or no insulin during the first 24 to 48 hours postpartum. Management of type 2 diabetes includes healthy eating, regular exercise, possibly diabetes medication or insulin therapy, and blood sugar monitoring. However, there is no way of knowing if the client will now be able to control the diabetes without insulin.

The rapid response team has been called to manage an unwitnessed cardiac arrest in a client's hospital room. How long should the nurse estimate the maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage?

4 to 6 minutes Explanation: After a person is without cardiopulmonary function for 4 to 6 minutes, permanent brain damage is almost certain. To prevent permanent brain damage, it is important to begin cardiopulmonary resuscitation promptly after cardiopulmonary arrest.

The nurse has done fall prevention teaching with the family of a client who is being discharged home. Which action by the client and family indicates that the teaching has been effective?

AN: Eliminating home safety hazards EX: Falls in the home occur most frequently from hazards in the home, such as loose rugs, cluttered hallways, and power cords. The other choices do not address fall prevention.

A client is admitted to the orthopedic unit in balanced skeletal traction using a Thomas splint and Pearson attachment. Which is the primary purpose of traction?

AN: Realign fracture fragments EX: Traction promotes realignment of the bone fragments. This will facilitate subsequent internal fixation. Traction immobilizes the fracture site and may increase the client's comfort. Mobilization could result in further damage. The use of traction does not prevent neurologic damage and can, in fact, cause pressure that leads to nerve damage. Traction increases circulation to the affected part but does not control internal bleeding. Traction may create, rather than prevent, a problem with skin integrity.

A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute kidney failure. The client's family asks the nurse why the client has developed acute renal failure. What should the nurse tell the family? "Because of the cardiogenic shock, there is:

AN: a decrease in the blood flow through the kidneys." EX: There are three categories of acute renal failure: prerenal, intrarenal, and postrenal. Causes of prerenal failure occur outside the kidney and include poor perfusion and decreased circulating volume resulting from such factors as trauma, septic shock, impaired cardiac function, and dehydration. In this case of severe myocardial infarction, there was a decrease in perfusion of the kidneys caused by impaired cardiac function. An obstruction within the urinary tract, such as from kidney stones, tumors, or benign prostatic hypertrophy, is called postrenal failure. Structural damage to the kidney resulting from acute tubular necrosis is called intrarenal failure. It is caused by such conditions as hypersensitivity (allergic disorders), renal vessel obstruction, and nephrotoxic agents.

The nurse used a secure access code to obtain a morphine 2 mg/ml vial from the computerized automated dispensing cabinet (ADC). Before exiting the system, the nurse is prompted to count the remaining vials. The nurse counts 10 remaining vials, but the system reads 9 remaining vials. What is the next action by the nurse?

Ask another nurse to assist with following the procedure to resolve the discrepancy. Explanation: Morphine is a controlled substance. Federal law requires an accurate record for each controlled substance administered to prevent diversion and misuse. Accurate counts of vials are an important part of maintaining this accurate record. In the event of a discrepancy, the nurse should ask another nurse to act as a witness and follow the facility procedure for resolving a discrepancy. Resolving the discrepancy is a priority and should happen before medicating the client. The nurse should not change the number or waste the extra vial because this will not maintain an accurate record of the controlled substance administration as required by law.

CASE STUDY: (1 of 6) A 35-year-old male is admitted to a small hospital for chest pain. The client is alert and oriented to person, place, time, and situation. Anxious-appearing, answers questions appropriately. No family was present at the bedside. Heart rate elevated and rhythm regular. 9/10 crushing pain to left chest wall radiating to the left arm. The client reports indigestion and an acidic feeling in the esophagus. Respirations are elevated and regular, with a report of dyspnea. The abdomen is soft and nontender, bowel sounds hyperactive. The client reports three episodes of diarrhea today. Extremities are strong and equal. Skin intact, clammy, and diaphoretic. 18 gauge IVs noted to bilateral forearms. Placed client on 3 liters oxygen via nasal cannula and Normal saline started in the left forearm at 75 ml/hr. Heparin drip started. Which finding(s) should the nurse be concerned about? Select all that apply.

Chest pain 9/10 Elevated troponin levels Family history of heart disease EKG results Clammy, diaphoretic skin EX: Chest pain at 9/10 can indicate that the client is at risk for a cardiac event. This is a concerning finding. Elevated troponin levels support the likelihood of a cardiac event. This should be a concerning finding. A significant family history of heart disease, especially in the males of the family, increases the client's risk of a cardiac event. EKG results of sinus tachycardia with ST depression and T wave inversion are suspicious for a semi cardiac event. This should be a concerning finding. Clammy, diaphoretic skin is an abnormal finding and is supportive evidence of an impending cardiac event. Previous use of antacid tablets does not affect the nurse's care of the client. A history of celiac disease is not a concerning assessment at this time. The nurse should be more concerned about a potential cardiac event.

A client is receiving fluid replacement with lactated Ringer's solution after 40% of the body was burned 10 hours ago. The assessment reveals a temperature of 97.1°F (36.2°C), heart rate of 122 bpm, blood pressure of 84/42 mm Hg, central venous pressure (CVP) of 2 mm Hg, and urine output of 25 mL for the last 2 hours. The intravenous (IV) rate is currently at 375 mL per hour. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse should request which prescription from the health care provider?

IV rate increase Explanation: The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is lactated Ringer's solution, normal saline, or albumin.

A client has demonstrated a risk for self-harm, so the health care provider has ordered a vest restraint. What action should the nurse take to prevent pressure injuries in this client?

Secure the vest restraint over the client's shirt. Explanation: A vest restraint should be applied over clothing to avoid skin breakdown. Applying lubricant or changing vests every 2 to 4 hours is not necessary or appropriate with a vest restraint. A vest restraint should be fit so that the nurse can place a flat palm between the vest and skin. If there is more space, there is a higher risk for skin breakdown.

A client has an indwelling urinary catheter and is prescribed physical therapy. As the client is being placed in a wheelchair, which action by the assistant would need further clarification by the nurse?

The catheter bag is placed on the client's lap for safe transport. Explanation: If the catheter bag were placed in the client's lap, the nurse would clarify to the assistant that the bag needs to be placed lower than the client's bladder so not to have backflow from the catheter tubing to the bladder. Placing the catheter on a lower portion of the wheelchair allows urine to flow through the tubing while minimizing risk of backflow. It is appropriate to drain the urine from the catheter bag before physical therapy and to make sure that there are no kinks in the tubing that would prevent urine flow to the drainage bag.

A school-age client is admitted to the facility with a diagnosis of acute lymphocytic leukemia (ALL). The nurse formulates a nursing diagnosis of Risk for infection. What is the most effective way for the nurse to reduce the client's risk of infection?

practicing thorough hand washing Explanation: Both ALL and its treatment cause immunosuppression. Therefore, thorough hand washing is the single most effective way to prevent infection in an immunosuppressed client. Reverse isolation doesn't significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. Standard precautions are intended mainly to protect caregivers from contact with infectious matter, not to reduce the client's risk of infection. Staff and others needn't wear masks when visiting because most infections are transmitted by direct contact. Instead of relying on masks and other barrier methods, the nurse should keep persons with known infections out of the client's room.

The health care provider has ordered ondansetron 0.15 mg/kg IV to a pediatric client who weighs 40 lb (18.1 kg). The dose on hand is 2 mg/mL. How many milliliters will the nurse administer to the client? Round the answer to the nearest tenth.

1.4 EX: (0.15 mg/kg) x (1 mL/2 mg) x (18.1 kg) = 1.4 mL.

A client wants to avoid methods of birth control that contain estrogen. Which method would be the nurse recommend?

injectable contraception Explanation: Birth control methods that contain estrogen increase the risk for clotting disorders, especially in women over the age of 35 years who smoke or who have had a previous clotting problem.Contraception injections contain progesterone, but no estrogen. Combined hormonal contraceptives, vaginal rings, and the birth control patch all contain estrogen.

The nurse is caring for a client that has been in labor for 6 hours. When does the nurse document that the client has ended the third stage of labor?

when the placenta has been birthed Explanation: The third stage of labor is indicated by the birth of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor includes the first 4 hours after birth.

A student nurse is reviewing physician orders written on a client's chart. Which entry is written incorrectly because it contains material from the "do not use" list of the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission)?

epoetin alfa 6500 U SQ daily. Explanation: The order written as "Epoetin alfa 6500 U SQ daily" is incorrect according to the Joint Commission's "do not use" list. "U" should not be used because it may be mistaken as zero (0), 4 (four), or cc. The healthcare professional should write "unit" instead. The other medication orders are written correctly. The order for diazepam does not include a trailing zero in the dosage. The order for levothyroxine sodium includes a leading zero prior to the dose. The acetaminophen order is correct in the use of the word "every" instead of Q.D., QD, q.d., or qd.

A client gives birth to a neonate prematurely at 28 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). Three days later, the client's partner seems withdrawn and barely speaks to the staff when visiting the child in the NICU. Which interpretation of this behavior is most appropriate?

The client's partner has depression because of grieving. Explanation: During the depression stage of grief, hopelessness, powerlessness, and despair are common. Some depressed people put their feelings into words; others withdraw, becoming noncommunicative and indicating a wish to be left alone. A parent in denial would postpone recognizing the child's condition and attempt to ignore its reality or seriousness. A parent in the anger stage would exhibit resentment, bitterness, or rage and might blame the health care team for the child's condition. There is no indication that the neonate's parent needs antidepressants.

A client is to have radiation therapy after a modified radical mastectomy. What instruction should the nurse give the client about caring for the skin at the site of the radiation therapy?

Wash the area with water. Explanation: A client receiving radiation therapy should avoid lotions, ointments, and anything that may irritate the skin, such as exposure to sunlight, heat, or talcum powder. The area may safely be washed with water if it is done gently and care is taken not to injure the skin.

Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which finding should alert the nurse to notify the health care provider (HCP) immediately?

a 3-cm increase in abdominal circumference Explanation: Abdominal circumference is measured to monitor for abdominal distention. An increase of 3 cm in 8 hours would require notification of the HCP; it would indicate a substantial degree of abdominal distention, possibly from fluid or gas accumulation. Normally, after surgery, an infant experiences occasional periods of fussiness. However, as long as the infant is able to be quiet by himself or with the aid of a pacifier, the HCP does not need to be contacted. Absence of bowel sounds would be expected after surgery because of the effects of anesthesia. It takes approximately 48 hours for gastric motility to resume. New stomas are typically bright red or pink.

At 6 cm dilation, a client in labor receives a lumbar epidural for pain control. Which nursing diagnosis is most appropriate?

altered tissue perfusion related to effects of anesthesia Explanation: A disadvantage of lumbar epidural is the risk for hypotension, which can lead to altered tissue perfusion. Epidurals are associated with longer labor and hypothermia, not rapid delivery and hyperthermia. Any pain the client experiences wouldn't be directly related to the wearing off of anesthesia.

Acetaminophen was given to an adolescent for headache. Which of the following parameters would indicate the effectiveness of the medication?

change in behavior Explanation: Positive changes in behavior and vital signs are indicators of an effective response to pain medication. Sleeping isn't a reliable indicator of pain relief because the teen may use sleep as a coping mechanism. Vital signs may or may not change.

After a bronchoscopy with biopsy, the nurse assesses the client. The nurse should report which finding to the health care provider?

laryngeal stridor Explanation: Laryngeal stridor is characteristic of respiratory distress from inflammation and swelling after bronchoscopy. It must be reported immediately. Green sputum indicates infection and would occur 3 to 5 days after bronchoscopy. A mild cough or hemoptysis is typical after bronchoscopy. If a tissue biopsy specimen was obtained, sputum may be blood streaked for several days.

The client with preeclampsia asks the nurse why she is receiving magnesium sulfate. The nurse's most appropriate response to is to tell the client that the priority reason for giving her magnesium sulfate is to

prevent seizures. Explanation: The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyperstimulated neurologic system caused by preeclampsia by interfering with signal transmission at the neural musculature junction. Reducing blood pressure, slowing labor, and increasing diuresis are secondary effects of magnesium.

The nurse is discussing the care of a client with an unlicensed assistive personnel (UAP). This client is at high risk for elopement due to dementia and previous elopement attempts. What task should the nurse delegate to the UAP that would be most helpful in reducing the risk for elopement?

providing basic care needs, including toileting Explanation: Addressing basic care needs, including toileting and eating, can help reduce the client's urge to wander. This decreases the risk for elopement. Giving the client street clothes or a tour of the unit may increase the desire and capacity to elope from the unit. Applying restraints is not the most appropriate way to decrease the risk for elopement. Other techniques should be tried first.

(3 of 6) A 35-year-old male is admitted to a small hospital for chest pain. Vital Signs BP 160/100mm Hg Heart rate: 110 beats/min Respiratory rate: 23 breaths/min Pulse Ox: 95% on room air Temp: 98.6*F (37*C) Complete the following sentence(s) by choosing from the lists of options. The nurse knows the client is at greatest risk for_____1_____ , and therefore, the priority need is___2____ to obtain_____3__________.

1.) Myocardial Infarction 2.) a transfer to an acute-care facility continue to monitor in the ER 3.) Cardiac catheterization IV antibiotics EX: Chest pain at 9/10 can indicate that the client is at risk for a cardiac event. This is a concerning finding. Elevated troponin levels support the likelihood of a cardiac event. This should be a concerning finding. A significant family history of heart disease, especially in the males of the family, increases the client's risk of a cardiac event. EKG results of sinus tachycardia with ST depression and T wave inversion are suspicious for a semi cardiac event. This should be a concerning finding. Clammy, diaphoretic skin is an abnormal finding and is supportive evidence of an impending cardiac event. Previous use of antacid tablets does not affect the nurse's care of the client. A history of celiac disease is not a concerning assessment at this time. The nurse should be more concerned about a potential cardiac event.

The nurse is instructing a client with acute asthma who is taking short-term corticosteroid therapy. The nurse should tell the client that steroids will have which expected outcome?

have an anti-inflammatory effect Explanation: Corticosteroids have an anti-inflammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion. Corticosteroids do not have a bronchodilator effect, act as expectorants, or prevent respiratory infections.

When providing discharge teaching for a client with uric acid calculi, the nurse would include an instruction to avoid which type of diet?

high purine Explanation: To control uric acid calculi, the client would follow a low-purine diet, which excludes high-purine foods such as organ meats. The other diets do not control uric acid calculi.

A client's caretaker calls the home care nurse and states accidentally puncturing the central venous catheter after discontinuing the total parenteral nutrition. What instructions should the nurse provide to the caretaker?

Clamp the catheter. Explanation: The nurse should instruct the caretaker to clamp the catheter to prevent the client from experiencing an air embolism. The client should be positioned on the left side with head lower than the feet, not higher. The catheter should not be removed by the caretaker; it will need to be removed in an acute care or outpatient setting by a healthcare provider. As the client is not experiencing signs or symptoms of an air embolism or other complication, there is no need to contact 911 at this time.

The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. What should the nurse assess?

changes from the normally expected findings Explanation: Noting changes from the normally expected findings is the most important component when assessing an older client's integumentary system. Comparing one extremity with the contralateral extremity (i.e., comparing one side with the other) is an important assessment step; however, the most important component is noting changes from an expected normal baseline. Noting wrinkles related to age is not of much consequence unless the client is admitted for cosmetic surgery to reduce the appearance of age-related wrinkling. Noting skin turgor is an assessment of fluid status, not an assessment of the integumentary system.

A client says to the nurse, "My intravenous line hurts." The nurse assesses the client's peripheral intravenous line and suspects phlebitis. What assessment data confirm the nurse's suspicion? Select all that apply. respiratory distress redness pain around the infusion site warmth edema above the insertion site

redness pain around the infusion site warmth edema above the insertion site EX: Redness, warmth, pain, and edema are all signs and symptoms of phlebitis. Respiratory distress is a sign of an air embolus.

A nurse has attended an in-service workshop to address the phenomenon of ageism in the healthcare system. Which practice is indicative of ageism?

speaking to older adults in a way one would with clients who have mild cognitive deficits Explanation: Accommodation of normal, age-related changes such as decreased skin turgor and slightly decreased nutritional needs is not an indication of ageism. Similarly, safety measures are unlikely to be motivated by ageist beliefs. Assuming that all older adults have cognitively deficits, however, is an indication of ageism.

A client who is 10 weeks pregnant develops spotting; however, the cervix remains closed. What should the nurse should suspect?

threatened abortion Explanation: Spotting in the first trimester may indicate that the pregnancy is in jeopardy. Bed rest and avoidance of physical and emotional stress are recommended. Abortion is usually inevitable if the bleeding is accompanied by pain with dilation and effacement of the cervix. An inevitable abortion is associated with cervical dilation. An ectopic pregnancy is in the fallopian tubes, and a false positive pregnancy could reflect a missed abortion.

The client exhibits a flat affect, psychomotor deficits, and depressed mood. The nurse attempts to engage the client in an interaction but the client does not respond to the nurse. Which response by the nurse is most appropriate?

"I'll sit here with you for 15 minutes." Explanation: The most appropriate action is for the nurse to remain with the client even if the client does not engage in conversation with the nurse. A client with severe depression may be unable to engage in an interaction with the nurse because the client feels worthless and lacks the necessary energy to do so. However, the nurse's presence conveys acceptance and caring, thus helping to increase the client's self-worth. Telling the client that the nurse will come back later, stating that the nurse will find someone else for the client to talk with, or telling the client that the nurse will get something to read conveys that the client is not important, reinforcing their negative view of self. Additionally, such statements interfere with the client's development of a sense of security and trust in the nurse.

A nurse is changing a dressing and providing wound care. Place the following activities in the correct order. All options must be used. 1. put on latex gloves 2. assess the drainage in the dressing 3. wash hands thoroughly 4 slowly remove the soiled dressing

-Wash hands thoroughly. -Put on latex gloves. -Slowly remove the soiled dressing. -Assess the drainage in the dressing. Explanation: The correct order for a dressing change involves the nurse washing her hands, putting on gloves, removing the dressing, and observing the drainage.

The health care provider is in a client's room doing an assessment. The health care provider walks out of the room and says to the nurse, "I have prescribed furosemide 40 mg orally twice daily for 5 days. Enter the prescription into the computerized order entry system for me." What is the best response by the nurse?

"I will find you a computer that is not being used so you can enter the order into the computerized order entry system." Explanation: The nurse cannot give the furosemide right away because the prescription needs to be put in the computerized order entry system first. This is not an emergency. The correct response is to have the health care provider put the prescription in the computerized order entry system because it is not an emergency. Verbal orders are for emergencies only. The charge nurse does not need to know about the prescription. The charge nurse does not need to put the order in the computerized order entry system. The nurse assigned to the client is responsible for the client's care. The nurse can call the pharmacy right away to have the furosemide sent, but the prescription needs to be entered first. The pharmacy will not send the medication, because it is not an emergency, without an order first. The nurse should not put the prescription in the computerized order entry system. The health care provider needs to put the prescription in the computerized order entry system. Verbal orders are for emergencies only.

CS (2 of 6) The nurse working in the hospital is caring for a 70-year-old male client who is experiencing a new onset of one-sided numbness and garbled speech.Vital signs: temperature, 98.0°F (36.7°C); pulse, 78 beats/min and irregular; respirations, 18 breaths/min; blood pressure, 148/90 mm Hg; pulse oximeter, 96% on room air.0725 Computed tomography (CT) scan of the brain Serum glucose level Serum sodium level Serum potassium level Prothrombin time (PT) and partial thromboplastin time (PTT) For each finding, click to specify if the finding indicates a stroke, a transient ischemic attack (TIA), or hypoglycemia. Each finding may be associated with more than 1 disease process. Confusion Fascial Droop Garbled Speech One-sided paralysis Elevated blood pressure

Confusion: Stroke, TIA, Hypoglycemia Fascial Droop: Stroke, TIA Garbled speech: Stroke, TIA One-sided Paralysis: Stroke, TIA Elevated blood pressure: Stroke, TIA EX: Garbled speech is a finding that would cause the nurse concern. This could indicate a change in cerebral function and impact the ability to communicate with the client.A facial droop indicates an alteration in neuromuscular function and would cause concern.Right-sided weakness also indicates an alteration in neuromuscular function that would cause concern. The client has a history of hypertension; however, the blood pressure is only slightly elevated.The client has a history of ingesting alcohol most nights of the week; however, this is not the finding that would cause the most concern.The client has had type 2 diabetes for 10 years. This is not of immediate concern to the nurse. The client stopped smoking 5 years ago. This is not a finding of concern.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

Impaired gas exchange Explanation: For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.

CS (3 of 6) The nurse working in the hospital is caring for a 70-year-old male client who is experiencing a new onset of one-sided numbness and garbled speech. The nurse reviews the results of laboratory and diagnostic testing. Complete the following sentence by choosing from the lists of options. Based upon the findings of the laboratory and diagnostic tests, the client will most likely need:

- Antithrombotic therapy with alteplase antihypertensive medication EX: Garbled speech is a finding that would cause the nurse concern. This could indicate a change in cerebral function and impact the ability to communicate with the client.A facial droop indicates an alteration in neuromuscular function and would cause concern.Right-sided weakness also indicates an alteration in neuromuscular function that would cause concern. The client has a history of hypertension; however, the blood pressure is only slightly elevated.The client has a history of ingesting alcohol most nights of the week; however, this is not the finding that would cause the most concern.The client has had type 2 diabetes for 10 years. This is not of immediate concern to the nurse. The client stopped smoking 5 years ago. This is not a finding of concern.

CS (6 of 6) The nurse working in the hospital is caring for a 70-year-old male client who is experiencing a new onset of one-sided numbness and garbled speech. The client received antithrombotic therapy for a stroke 2 days ago. Which assessment finding(s) indicate that the client's condition is improving? Select all that apply. Speaks slowly Coughs when eating Dorsiflexes right foot Right pupil greater than left Pockets food in the right cheek Makes a fist with the right hand Transfers with assistance to a chair

- speak slowly - Dorsiflexes right foot - makes a fist with the right hand - transfer with assistance to a chair EX: Garbled speech is a finding that would cause the nurse concern. This could indicate a change in cerebral function and impact the ability to communicate with the client.A facial droop indicates an alteration in neuromuscular function and would cause concern.Right-sided weakness also indicates an alteration in neuromuscular function that would cause concern. The client has a history of hypertension; however, the blood pressure is only slightly elevated.The client has a history of ingesting alcohol most nights of the week; however, this is not the finding that would cause the most concern.The client has had type 2 diabetes for 10 years. This is not of immediate concern to the nurse. The client stopped smoking 5 years ago. This is not a finding of concern.

CS (4 of 6) The nurse working in the hospital is caring for a 70-year-old male client who is experiencing a new onset of one-sided numbness and garbled speech. The nurse is caring for the client recovering from antithrombotic therapy for a stroke and is reviewing the new orders from 0845 and the new Nurse's Notes from 1000. Select the three (3) body areas that would be the focus of care for this client. mobility vital signs urine output neurologic status swallowing ability blood glucose level infection precautions

- vital signs - neurologic status - swallowing ability EX: Garbled speech is a finding that would cause the nurse concern. This could indicate a change in cerebral function and impact the ability to communicate with the client.A facial droop indicates an alteration in neuromuscular function and would cause concern.Right-sided weakness also indicates an alteration in neuromuscular function that would cause concern. The client has a history of hypertension; however, the blood pressure is only slightly elevated.The client has a history of ingesting alcohol most nights of the week; however, this is not the finding that would cause the most concern.The client has had type 2 diabetes for 10 years. This is not of immediate concern to the nurse. The client stopped smoking 5 years ago. This is not a finding of concern.

CASE STUDY: (1 of 6) An adult client is admitted to labor and delivery. 0500: The client is admitted from triage with rupture of membranes in early labor. The nurse is performing an admission assessment and going over the labor process. While doing so, the nurse notices that the client nods frequently and the responses are not always appropriate. The client also frequently looks to their partner before answering and has a heavy accent. Click to highlight the findings that will require follow up. The client is admitted from triage with rupture of membranes in early labor. The nurse is performing an admission assessment and going over the labor process. While doing so, the nurse notices that the client nods frequently and the responses are not always appropriate.The client also frequently looks to their partner before answering and has a heavy accent.

-rupture of membranes - client nods frequently and the responses are not always appropriate - client also frequently looks to their partner before answering - heavy accent. EX: The length of time the membranes are ruptured needs to be tracked. Nodding with inappropriate responses indicates a lack of understanding and requires follow up. Looking to the partner frequently could indicate a lack of understanding and uncertainty. It can also indicate a subservient position or a potential abusive situation. Early labor is not a concerning cue. While a heavy accent can provide some difficulty in understanding, it is not concerning at this time.

A client is being transferred from the recovery room to the medical-surgical nursing unit. The nurse from the recovery room should report which information to the nurse in the medical-surgical unit? Select all that apply. type of surgery current vital signs names of all surgeons participating in the surgery amount of blood loss fluids infusing including rate and type of fluid

-type of surgery -current vital signs -amount of blood loss -fluids infusing including rate and type of fluid ex: Transfer reports must include information about the client's surgery; all current treatments and medications; vital signs, including pain level; fluid status, including blood loss; and current intravenous infusions. It is not necessary to identify the surgeons who were present during the surgery.

(4 of 6) A 35-year-old male is admitted to a small hospital for chest pain Select five (5) potential actions the nurse should take to transfer the client: 1 Give report to the receiving facility. 2 Secure the client's IV and oxygen tubing. 3 Ensure the client has all personal belongings. 4 Educate the client on reasons for the transfer and the process. 5 Verify that a transfer order is in place. 6 Remove the client's identification armband. 7 Attach defibrillation pads to the client's chest. 8 Cleanse the client with a chlorhexidine scrub.

1. Give report to the receiving facility. 2. Secure the client's IV and oxygen tubing. 3. Ensure the client has all personal belongings. 4. Educate the client on reasons for the transfer and the process. 5. Verify that a transfer order is in place. EX: Chest pain at 9/10 can indicate that the client is at risk for a cardiac event. This is a concerning finding. Elevated troponin levels support the likelihood of a cardiac event. This should be a concerning finding. A significant family history of heart disease, especially in the males of the family, increases the client's risk of a cardiac event. EKG results of sinus tachycardia with ST depression and T wave inversion are suspicious for a semi cardiac event. This should be a concerning finding. Clammy, diaphoretic skin is an abnormal finding and is supportive evidence of an impending cardiac event. Previous use of antacid tablets does not affect the nurse's care of the client. A history of celiac disease is not a concerning assessment at this time. The nurse should be more concerned about a potential cardiac event.

Case Study (3 of 6) An Adult client is admitted to L&D Complete the following sentence(s) by choosing from the lists of options. The nurse knows to focus on the ______1____ first in order to _____2_____. choose one for spot 1 rupture of membranes language barrier epidural administration choose one for spot 2 communicate appropriately with the client prevent infection provide pain control

1.) Langage barrier 2.) Communicate appropriately with the client EX: The length of time the membranes are ruptured needs to be tracked. Nodding with inappropriate responses indicates a lack of understanding and requires follow up. Looking to the partner frequently could indicate a lack of understanding and uncertainty. It can also indicate a subservient position or a potential abusive situation. Early labor is not a concerning cue. While a heavy accent can provide some difficulty in understanding, it is not concerning at this time.

CASE STUDY (4 of 6) An adult client is admitted to L&D Complete the following sentence(s) by choosing from the lists of options. The nurse should first contact the the ____1_____ in order to ______2_____ choose one for spot 1 -the provider -the hospital interpreter -the charge nurse choose one for spot 2 -communicate appropriately with the client - verify oders - change assignments with another nurse since the nurse does not speak the same language

1.) the hospital interpreter 2.) communicate appropriately with the client EX: The length of time the membranes are ruptured needs to be tracked. Nodding with inappropriate responses indicates a lack of understanding and requires follow up. Looking to the partner frequently could indicate a lack of understanding and uncertainty. It can also indicate a subservient position or a potential abusive situation. Early labor is not a concerning cue. While a heavy accent can provide some difficulty in understanding, it is not concerning at this time.

(5 of 6) A 35-year-old male is admitted to a small hospital for chest pain. The nurse is deciding the best way to communicate with the receiving facility. the nurse_____1____ and ____2_____.

1.Speak directly with the receiving nurse place all the documents in a sealed folder and give it to Emergency serves personnel to deliver to the receiving facility 2. Use the SBAR communication technique EX: Chest pain at 9/10 can indicate that the client is at risk for a cardiac event. This is a concerning finding. Elevated troponin levels support the likelihood of a cardiac event. This should be a concerning finding. A significant family history of heart disease, especially in the males of the family, increases the client's risk of a cardiac event. EKG results of sinus tachycardia with ST depression and T wave inversion are suspicious for a semi cardiac event. This should be a concerning finding. Clammy, diaphoretic skin is an abnormal finding and is supportive evidence of an impending cardiac event. Previous use of antacid tablets does not affect the nurse's care of the client. A history of celiac disease is not a concerning assessment at this time. The nurse should be more concerned about a potential cardiac event.

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?

increased restlessness Explanation: In ALS, an early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress.

A nurse is evaluating an external fetal monitoring strip. Identify the area on this strip that causes the nurse to be concerned about uteroplacental insufficiency.

top photo with the U drop. Explanation: This fetal monitoring strip illustrates a late deceleration. The decrease in fetal heart rate begins at the end of the contraction and doesn't return to baseline until the contraction is over. Late decelerations are associated with uteroplacental insufficiency, shock, or fetal metabolic acidosis.

(6 of 6) A 35-year-old male is admitted to a small hospital for chest pain. The nurse has given report to the receiving facility. Select the three (3) statements by the receiving nurse that indicate a need for additional follow-up. "The client is being transferred because of a bad stomach infection." "The client is having chest pain." "I will ensure that the client is continued on oxygen upon arrival." "The client has not received any medication while at your facility." "I will have a translator device ready when the client arrives." "I understand the client should receive a gluten-free diet when appropriate."

"The client is being transferred because of a bad stomach infection." "The client has not received any medication while at your facility." "I will have a translator device ready when the client arrives." EX: Chest pain at 9/10 can indicate that the client is at risk for a cardiac event. This is a concerning finding. Elevated troponin levels support the likelihood of a cardiac event. This should be a concerning finding. A significant family history of heart disease, especially in the males of the family, increases the client's risk of a cardiac event. EKG results of sinus tachycardia with ST depression and T wave inversion are suspicious for a semi cardiac event. This should be a concerning finding. Clammy, diaphoretic skin is an abnormal finding and is supportive evidence of an impending cardiac event. Previous use of antacid tablets does not affect the nurse's care of the client. A history of celiac disease is not a concerning assessment at this time. The nurse should be more concerned about a potential cardiac event.

A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond?

"You may experience progressive deterioration in all voluntary muscles." Explanation: The nurse should tell the client that muscular dystrophy causes progressive, symmetrical wasting of skeletal muscles, without neural or sensory defects. The mixed form of the disease typically strikes between ages 30 and 50 and progresses rapidly, causing deterioration of all voluntary muscles. Because the client asked the nurse this question directly, the nurse should answer and not simply refer the client to the physician. Limb-girdle muscular dystrophy causes a gradual decrease in arm and pelvic muscle strength, resulting in slight disability. Facioscapulohumeral muscular dystrophy is a slowly progressive, relatively benign form of muscular dystrophy; it usually arises before age 10

CASE STUDY (2 of 6) An adult client is admitted to L&D 0500Vitals: Heart rate 72 beats per minute, Respirations 22 breaths per minute, Blood Pressure 112/66 mmHg, Temperature 98.9°F (37.1°C)Fetal heart rate is 150 beats per minuteThe client is 1 cm dilated with irregular contractions. Rupture of membranes was confirmed with Fern testing. The nurse considers the client's cues and determines more information is needed. Which two (2) follow-up questions would be appropriate for the nurse to ask the client? "Are you safe?" "Do you understand English?" "Do you need me to speak louder?" "What can I do to provide more comfort?" "What language do you speak and understand?"

-"Do you understand English?" - "what language do you speak and understand?" EX: The length of time the membranes are ruptured needs to be tracked. Nodding with inappropriate responses indicates a lack of understanding and requires follow up. Looking to the partner frequently could indicate a lack of understanding and uncertainty. It can also indicate a subservient position or a potential abusive situation. Early labor is not a concerning cue. While a heavy accent can provide some difficulty in understanding, it is not concerning at this time.

CASE STUDY (5 of 6) An adult client is admitted to L&D The nurse would like to learn more about the client's views on childbirth. Which four (4) questions should the nurse ask to learn more about the client's belief system? "How do you view childbirth?" "Do you have a treatment plan?" "Would you like to speak to a religious leader or clergy during your stay?" "Do you have everything you need for the baby?" "Do you have any concerns about being in the hospital and/or childbirth?" "Is there anything we can do to make you more comfortable during childbirth?"

-"How do you view childbirth?" -"Do you have a treatment plan?" -"Do you have any concerns about being in the hospital and/or childbirth?" -"Is there anything we can do to make you more comfortable during childbirth?" EX: The length of time the membranes are ruptured needs to be tracked. Nodding with inappropriate responses indicates a lack of understanding and requires follow up. Looking to the partner frequently could indicate a lack of understanding and uncertainty. It can also indicate a subservient position or a potential abusive situation. Early labor is not a concerning cue. While a heavy accent can provide some difficulty in understanding, it is not concerning at this time.

CASE STUDY (6 of 6) The nurse is speaking to the client and partner using the hospital interpreter. Complete the following sentence(s) by choosing from the lists of options. The nurse knows the client is now able to understand when they make the statement: "I would like to have more privacy during the birthing process" "My husband can't bring in our religious leader after the baby is born" " My cultural needs cannot be met here outside of my home country"

-"I would like to have more privacy during the birthing process" - " My cultural needs cannot be met here outside of my home country" EX: The length of time the membranes are ruptured needs to be tracked. Nodding with inappropriate responses indicates a lack of understanding and requires follow up. Looking to the partner frequently could indicate a lack of understanding and uncertainty. It can also indicate a subservient position or a potential abusive situation. Early labor is not a concerning cue. While a heavy accent can provide some difficulty in understanding, it is not concerning at this time.

A new parent in the obstetrical unit notifies the nurse that their newborn is missing from the bassinet in the room. What should the nurse do? Select all that apply. Notify the media of the infant abduction so they can announce a search. Contact the risk management department of the hospital. Close the unit and prevent anyone from entering or exiting. Search the entire unit for the infant. Alert the hospital security department of the abduction. Remove all items from the location where the infant was last seen.

-Close the unit and prevent anyone from entering or exiting. -Search the entire unit for the infant. -Alert the hospital security department of the abduction. Explanation: If an infant abduction is suspected, the nurse should search the entire unit for the infant, notify security, and close the unit to anyone entering or exiting. The nurse should secure the location where the infant was last seen to protect any forensic evidence that may exist. The nurse will eventually need to notify the risk management department, but it does not need to be done immediately. The nurse should not notify the media of the abduction as that would be a violation of privacy laws and may not be helpful to the investigation.

CASE STUDY (1 of 6) 70-year-old male client EMS who were called at 0625 hours for a new onset of numbness and tingling of the right arm and leg. Client fell while walking to the bathroom at home and spouse noticed the client's speech was garbled. Past medical history per spouse: hypertension x 5 years; type 2 diabetes x 10 years. Lifestyle: stopped smoking 5 years ago; ingests "several" beers "most nights" of the week. Physical ass: lethargic, easily aroused; unable to assess orientation because of garbled speech; follows verbal directions; right-sided facial droop noted; absent right hand grasp, right leg and foot rotated outward, right leg reflexes absent; left-sided hand grasp present; left leg full function The findings that cause the nurse most concern are ___1___, ___2__, ___3__ Garbled speech rt facial droop type 2 diabetes hyper tension hx of smoking rt sided paralysis alcohol intake

-type 2 diabetes - alcohol intake - right sided paralysis EX: Garbled speech is a finding that would cause the nurse concern. This could indicate a change in cerebral function and impact the ability to communicate with the client.A facial droop indicates an alteration in neuromuscular function and would cause concern.Right-sided weakness also indicates an alteration in neuromuscular function that would cause concern. The client has a history of hypertension; however, the blood pressure is only slightly elevated.The client has a history of ingesting alcohol most nights of the week; however, this is not the finding that would cause the most concern.The client has had type 2 diabetes for 10 years. This is not of immediate concern to the nurse. The client stopped smoking 5 years ago. This is not a finding of concern.

The nurse is planning care for a client with a burn after the initial phase of the burn injury. Which goal should the nurse establish with the client?

AN: preventing infection explanation: The inflammatory response begins when a burn is sustained. As a result of the burn, the immune system becomes impaired. There is a decrease in immunoglobulins, changes in white blood cells, alterations of lymphocytes, and decreased levels of interleukin. The human body's protective barrier, the skin, has been damaged. As a result, the burn client becomes vulnerable to infections. Education and interventions to maintain a positive self-concept would be appropriate during the rehabilitation phase. Promoting hygiene helps the client feel comfortable; however, the primary focus is on reducing the risk for infection.

(2 of 6) A 35-year-old male is admitted to a small hospital for chest pain. The client reports that the discomfort started last night with symptoms of acid reflux and reports taking two antacid tabs and sleeping restlessly. This morning, the client reports the chest pain was 4/10 discomfort and progressed throughout the morning to 9/10, crushing pain radiating to the left arm. The client reports that their boss called emergency services. The client lives at home alone, eats a gluten-free diet, and denies a smoking history. BMI is 32. The client reports a significant family history of heart disease. EKG shows sinus tachycardia with ST depression and T wave inversion. Troponin levels elevated. For each assessment finding, click to specify if it indicates myocardial infarction or gastroenteritis. Each finding may support more than one disease process.

Acid reflux: Myocardial Infarction & Gastroenteritis Diarrhea: Gastroenteritis Radiating chest pain: Myocardial Infarction ST depression: Myocardial Infarction Elevated Troponin levels: Myocardial Infarction Hyperactive Bowel Sounds: Gastroenteritis Diaphoretic Skin: MI & Gas EX: Chest pain at 9/10 can indicate that the client is at risk for a cardiac event. This is a concerning finding. Elevated troponin levels support the likelihood of a cardiac event. This should be a concerning finding. A significant family history of heart disease, especially in the males of the family, increases the client's risk of a cardiac event. EKG results of sinus tachycardia with ST depression and T wave inversion are suspicious for a semi cardiac event. This should be a concerning finding. Clammy, diaphoretic skin is an abnormal finding and is supportive evidence of an impending cardiac event. Previous use of antacid tablets does not affect the nurse's care of the client. A history of celiac disease is not a concerning assessment at this time. The nurse should be more concerned about a potential cardiac event.

CS (5 of 6) The nurse working in the hospital is caring for a 70-year-old male client who is experiencing a new onset of one-sided numbness and garbled speech. The nurse is preparing a plan of care for the client recovering from emergency treatment for a stroke. For each intervention, click to specify if the action would be appropriate or inappropriate for the client. Intervention: Assess swallowing Assist with lumbar puncture Implement aspiration precautions Turn and reposition every 2 hours Perform range-of-motion exercises Monitor blood glucose every 4 hours Set nasogastric tube to low intermittent suction

Assess swallowing- appropriate Assist with lumbar puncture- inappropriate Implement aspiration precautions- APP Turn and reposition every 2 hours- APP Perform range-of-motion exercises-APP Monitor blood glucose every 4 hours-INAPP Set nasogastric tube to low intermittent suction-INAPP EX: Garbled speech is a finding that would cause the nurse concern. This could indicate a change in cerebral function and impact the ability to communicate with the client.A facial droop indicates an alteration in neuromuscular function and would cause concern.Right-sided weakness also indicates an alteration in neuromuscular function that would cause concern. The client has a history of hypertension; however, the blood pressure is only slightly elevated.The client has a history of ingesting alcohol most nights of the week; however, this is not the finding that would cause the most concern.The client has had type 2 diabetes for 10 years. This is not of immediate concern to the nurse. The client stopped smoking 5 years ago. This is not a finding of concern.

The nurse is assessing a client, who has lung cancer with spinal metastasis, for pain. The client tells the nurse that the ordered opioid medication helps, but there is still a shooting pain down the client's left leg. Identify the best pharmacologic measure to address this pain.

an adjuvant, such as gabapentin Explanation: The pain that this client is describing is classic neuropathic pain. The fact that the client has spinal metastasis is more evidence of this. Opioids and ibuprofen do not fully address neuropathic pain.