NCSBN Review Pretest

A client calls the clinic and states to the triage nurse: "I had an upset stomach and took Pepto-Bismol and now my tongue looks black. What's happening to me?" What would be the nurse's best response? "Are your stools also black?" "How long have you had an upset stomach?" "Come to the clinic so you can be seen by the health care provider." "This is a common and temporary side effect of this medication."

"This is a common and temporary side effect of this medication." The best response would be to explain that a dark tint of the tongue is a common and temporary side effect of bismuth subsalicylate (Pepto-Bismol). Although it may also turn stools a darker color, do not confuse this with black, tarry stools, which is a sign of bleeding in the intestinal tract. After addressing the client's initial concern and the reason for the call, the nurse can ask about the upset stomach and then ask the client to come to the clinic if necessary.

A client, who is receiving a blood transfusion, reports having a headache and low back pain. What are the nurse's actions? (Select all that apply.) Flush the line with saline Incorrect Send the tubing and bag to the blood bank Correct! Establish a saline lock or patent IV Correct Response Administer acetaminophen (Tylenol) 1000 mg Stop the blood transfusion Correct! Obtain first voided urine (within one hour of reaction) Correct Response

The transfusion should be stopped immediately to reduce the risk of further damage. A sample from the transfusion will be cross-matched with client samples from before and after transfusion to check for errors in cross-matching. If this is an acute hemolytic transfusion reaction, intravascular hemolysis causes hemoglobinuria with varying degrees of kidney failure and possibly even disseminated intravascular coagulation (DIC). A urinalysis would reveal any hemoglobinuria that occurred due to hemolysis. If it's a febrile nonhemolytic transfusion reaction (as determined by the lab tests), then the headache can be treated with a lower dose of acetaminophen.

The nurse is assessing the uterine fundus of a client who delivered a healthy neonate 10 hours ago. Identify the area where the nurse would expect to feel the fundus. Use your cursor to select an area on the image below. Insert picture of female abdomen in anatomical position

The uterus should be felt at the level of the umbilicus from about 1 to 24 hours after birth. Choose small box over umbilicus

The nurse is caring for a young adult client with an acute attack of inflammatory bowel disease. Which of the following findings indicates a potential complication? (Select all that apply) Visible blood and mucus in the stool Abdominal distention Chills and fever Frequent diarrhea Abdominal pain and tenderness

Abdominal distention Chills and fever Expected findings in the client with inflammatory bowel disease include persistent diarrhea, abdominal pain and tenderness, and even visible blood and mucus in the stools. Abdominal distention, along with chills and fever, can indicate possible intestinal obstruction (toxic megacolon) or fistula formation.

Indicate the location of pain that supports the diagnosis of suspected pancreatitis. (Insert picture of abdomen in anatomical position with arrows pointing to abdomen and umbilicus. Choose correct area)

Acute pancreatitis produces sharp pain in the epigastric (just under xyphoid process area because of the anatomical position of the pancreas behind the stomach. It is not unusual for a client to report "my stomach hurts" yet be holding the pelvic or periumbilical region. The client may even report upper back pain. Nurses need to clearly assess correct locations regardless of how the client identifies it verbally.

The client with newly diagnosed irritable bowel syndrome (IBS) states: "All this fiber I have to eat now is making me full of gas! It makes me want to stop taking it." What instruction by the nurse will help the client manage this side effect and increase compliance with the diet? (Select all that apply.) Discuss a work-up for lactose intolerance with the health care provider Correct Response Cut back on fiber and then add it again slowly to the diet Correct Response Eat a balanced and nutritious variety of foods Incorrect Eat three regularly scheduled meals every day Incorrect Reduce intake of gas-forming foods Correct!

Adequate fiber intake is critical to controlling IBS but can result in bloating and gas if added to the diet too quickly. Increasing fiber intake by 2 to 3 grams per day will help reduce the risk of gas and bloating. Some foods, as well as dairy products, also contribute to gas formation. Eating a balanced nutritious diet is good self-care practice but does not decrease gas production. Large meals can cause cramping (and diarrhea) so eating four to five small meals a day is recommended instead of less-frequent big meals.

The client, who is four days post-op for a transverse colostomy and is scheduled for discharge tomorrow, asks the nurse to empty the colostomy pouch. What is the best response by the nurse? "Let me demonstrate to you how to empty the pouch." "Show me what you have learned about emptying your pouch." Correct! "You should be emptying the pouch yourself." "What have you learned about emptying your pouch?"

Adult learn best in a democratic, participatory and collaborative environment. They do not want to be lectured at or scolded ("you should be emptying the pouch yourself"). But anxiety about discharge, as well as fatigue or pain could have had an impact on the client's ability to be fully engaged in any previous learning. While the nurse could ask the client to explain what s/he has already learned, this client must demonstrate what s/he has learned about emptying the pouch. The nurse should support the client's efforts and positively reinforce how to care for the stoma and empty the pouch.

A nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the nurse asks the child, "Are you ready to take your medicine?" the response is an immediate, "No!" What would be an appropriate next action by the nurse? Give the medication to the parent and ask the parent to give it Explain to the child that the medicine must be taken now Leave the room and return five minutes later and give the medicine Correct! Mix the medication with ice cream or applesauce

Because the nurse gave the child a choice about taking the medication, the nurse must comply with the child's response in order to build or maintain trust. Toddlers do not have an accurate sense of time, so leaving the room and coming back later is another episode to the toddler. Medications should not be mixed with food nor fluids because the amount taken, especially in children, cannot be controlled.

The client states to the nurse: "I am ready to stop all of these treatments. I just want to go home and enjoy my family for the little bit of time I have left." Which action is most appropriate?

Encourage the client to discuss this decision with the health care provider and family The client has the right to stop treatment and should be supported in clearly communicating this decision with the health care provider and family. The nurse needs to act as an advocate for the client. It is factually incorrect to wait until the request is repeated; clients should not need to express their wishes repeatedly before caregivers listen to them. The nurse should not be the one to share sensitive information with the family; the client controls that information. Social services may get involved but time is of the essence for those who are terminally ill.

The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning the care of this client? Heal the infection Protection for the granulation tissue Debride the eschar Incorrect Keep the tissue intact Correct Response

If the black tissue (eschar) is dry and intact, no treatment is necessary; the stable eschar serves as the body's natural cover. If the area changes with cellulitis or pain, then this is a sign of infection and requires debridement.

The nurse recognizes that obtaining accurate post anesthesia vital signs is extremely important. Which of the following client conditions are not appropriate for electronic blood pressure measurement? (Select all that apply.) Irregular heart rate Blood pressure greater than 140 mm Hg systolic Shivering Peripheral vascular obstruction

Irregular heart rate Shivering Peripheral vascular obstruction Clients with irregular heart rates, peripheral vascular disease, seizures, tremors, and shivering are not candidates for using an electronic blood pressure machine.

A nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which of these findings should the nurse anticipate the infant might exhibit? Irritability Lethargy Sunken anterior fontanelle Negative Moro reflex

Irritability Irritability is an initial finding for cerebral hypoxia, which would occur from the retained fluid in the brain that results in increased intracranial pressure. Signs of increased intracranial pressure in infants include bulging fontanel, irritability, high-pitched cry, and continual crying when held. Changes in the pulse are variable, e.g., rapid to slow and bounding to feeble. Respirations are more often slow, deep and irregular.

A severely injured client is moved into an examination area of the emergency department. The family member who accompanied the client to the ED is screaming at the nurse, saying that someone better start doing something right away. What is the best response by the nurse? "I need you to go to the waiting area. You can come back when you're more in control." "I'm going to give you a few minutes alone so you can calm down." "I can't think when you are yelling at me. Talk to me in a normal voice." "I know you are upset. But please control yourself and sit down. Otherwise I will have to call security." Correct!

Most violent behavior is preceded by warning signs, such as yelling or swearing. The challenge for nurses is to apply interventions that de-escalate a person's response to stressful or traumatic events. The keys to effective limit setting are using commands to express the desired behavior and providing logical and enforceable consequences for noncompliance. Nurses should acknowledge the agitated person's feelings and be empathetic, reminding him or her that they are there to help.

A community health clinic nurse is assessing a walk-in client who is experiencing lightheadedness. The client has a history of arthritis and takes naproxen (Aleve) and treats high cholesterol with fish oil and garlic. The assessment reveals that the client is pale, blood pressure is 88/40, pulse is 114, respiratory rate is 22, and temperature is 98.2 F (36.7 C). What specifically should the nurse ask this client about? (Select all that apply.) Tingling or numbness in the extremities Incorrect Color of bowel movements Correct Response Bruising Correct! Frequency and amount of naproxen used Correct! Photophobia

NSAIDS (Aleve), fish oil, and garlic can all increase the risk for bleeding. The vital signs and pale skin color indicate possible hypovolemia (tachycardia and hypotension) secondary to blood loss. The nurse should inquire about other findings that may indicate bleeding, i.e., black tarry stools, bruising, and should determine the amount of NSAIDs taken daily.

The new graduate nurse interviews for a position in a nursing department of a large health care agency that uses the approach of shared governance. Which of these statements best illustrates the shared governance model? Nursing departments share responsibility for client outcomes Staff groups are appointed to discuss nursing practice and client education issues An appointed board oversees any administrative decisions Non-nurse managers supervise nursing staff in groups of units

Nursing departments share responsibility for client outcomes Shared governance or self-governance is a method of organizational design. It promotes empowerment of nurses to give them responsibility for client care issues and outcomes with other divisions in the agency.

A client diagnosed with diabetes mellitus has a blood glucose of 175 this morning. After the nurse reports this lab result along with the client's findings of being hungry and thirsty, what type of insulin should the nurse expect the health care provider to order? Humulin-R insulin Correct! Mixture of insulin aspart (NovoLog) and insulin glargine (Lantus) Insulin glargine (Lantus) NPH insulin (Humulin-N)

Of these choices, the best answer is to administer the short-acting Humulin-R, or regular insulin; this insulin will begin to work in about 30 minutes. The client should wait to eat breakfast so that the insulin can begin working. Never mix insulin glargine (Lantus), which is a long-acting insulin, with any other kind of insulin. NPH is an intermediate-acting insulin and would not provide the needed quick response.

The 86 year-old client will be participating in a transitional care program after discharge from the hospital. What is the primary purpose of a transitional care program? Reduce readmissions to the hospital Correct! Reduce insurance costs Increase client understanding of discharge instructions Increase satisfaction with nursing care

Older adults who complete a transitional care program after being discharged from the hospital are much less likely to be readmitted to the hospital. The Affordable Care Act mandates that each facility have a "quality assurance and performance improvement program", designed to help reduce unnecessary hospital readmissions.

A child is brought to the emergency department with suspected ingestion of a toxic substance. Place the following actions in priority order by dragging and dropping the options. Obtain a history of the ingestion Reverse or eliminate the toxic substance Start an IV infusion Stabilize the child

Stabilize the child Start an IV infusion Obtain a history of the ingestion Reverse or eliminate the toxic substance The first priority is to assess the ABCs. Provide supplemental oxygen (and ventilator support, if needed). Next, an IV infusion is started using a large bore needle; this will allow for blood to be drawn for a toxicology screen as well as IV therapy. Then, a history of the ingestion is needed to guide the provider in planning care. Once the substance is identified, or there is a high index of suspicion, then treatment to reverse or eliminate the toxic substance is begun.

A nurse is assigned to care for four clients. After listening to change-of-shift report, how would the nurse prioritize care for the following clients? (Drag the responses into the correct order.) The client with a tracheostomy The client who is in skeletal traction The client scheduled for a colonoscopy The postoperative client who has an order to be discharged to home

The client with a tracheostomy The client scheduled for a colonoscopy The client who is in skeletal traction The postoperative client who has an order to be discharged to home The nurse will check on the client with a tracheostomy (airway) first. The nurse would then check on the client who is to undergo a procedure (to ensure the prep was completed and the results of the bowel movements are clear). Next, the nurse would check on the client in skeletal traction, and finally the nurse would prepare the client who is ready for discharge.

A client is scheduled to receive an oral solution of radioactive iodine (131I). What information is the priority for the nurse to include when teaching the client about this treatment? "Your family can use the same bathroom as you are using, without any special precautions." "Drink plenty of water and empty your bladder often during the initial three days of therapy." "In the first 48 hours, you should avoid contact with children and pregnant women; be sure to flush the commode twice after urination or defecation." Correct! "Use disposable utensils for two days; if you feel nauseous within 12 hours of the first dose, please vomit in the toilet and flush it twice."

The client's urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for six to eight hours. The client should drink 3 to 4 liters of fluid a day for the initial 48 hours to help remove the (131I) from the body. To minimize exposure to radiation, nursing staff should plan to give care in the shortest time possible (less time equals less exposure), working as far away from the radiation source as possible. Each nurse should also wear a personal film badge or pocket dosimeter.

The client is observed falling out of bed when reaching for something on the overbed table. The client then states: "Don't just stand there. I feel fine - help me up." What is the correct order of actions the nurse should take? Obtain a complete set of vital signs Call the health care provider Assist the client back to bed, with help from other staff Complete an incident report

The first step is always to assess the client for any obvious injuries and to obtain a complete set of vital signs (especially blood pressure) and neurologic assessments. If the client does not appear to be injured, staff members can assist the client back into bed. The nurse should then call the health care provider to report the incident. Finally, the nurse should complete the incident report. Of course, personal items should be placed close to the client so that s/he can reach them.

The 70 year-old male is recently diagnosed with osteoporosis. The nurse is teaching the client about this disease. Which of the following client responses requires further education by the nurse? (Select all that apply.) "It sounds like I'll need to drink more milk and eat more cheese and yogurt." "I should ask for help to clean the gutters instead of climbing a ladder." "Exercising in an aquatics class will make my bones much stronger." "I don't believe the doctor because I heard that only women can get osteoporosis." "I need to stop smoking."

"Exercising in an aquatics class will make my bones much stronger." "I don't believe the doctor because I heard that only women can get osteoporosis." Osteoporosis is commonly thought of as a "woman's problem", but after age 65 men and women are losing bone mass at about the same rate and calcium absorption decreases. Treatment for osteoporosis includes regular weight-bearing exercises, such as walking, in which bones and muscles work against gravity; aqua aerobics will not make bones stronger. The client needs adequate intake of calcium and vitamin D; while supplements may be needed, calcium is best absorbed from natural food sources. There is a direct link between tobacco use and decreased bone density.

After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond with which statement? "He may be scared and taking it out on you. Let's talk to figure out what to do next." "I will talk with him and try to figure out what to do or what the problem is." "Ignore him and get the rest of your work done. Someone else can care for him the rest of the day." "He has a lot of problems. You need to have patience with him."

"He may be scared and taking it out on you. Let's talk to figure out what to do next." This response explains the client's behavior without belittling the UAP's feelings. The UAP is encouraged to contribute to the plan of care to help solve the problem. The other responses are incorrect because they either belittle the UAP or ignore the problem and do not include the UAP in planning of how to deal with the issue.

The nurse is providing information to a 28 year-old female, who is a type 1 diabetic and planning a pregnancy. The nurse is assessing the client's understanding of insulin therapy during pregnancy. Which statement, made by the client, indicates a need for more teaching? "If I bottle-feed my baby, my insulin needs should return to normal within 7 to 10 days after birth." "I will probably need to give myself more insulin during the second and third trimesters of my pregnancy. "I may be more likely to experience hypoglycemia during the first three months of pregnancy." "I will need to increase my insulin dosage during the first three months of pregnancy."

"I will need to increase my insulin dosage during the first three months of pregnancy." Due to an increase in sensitivity to insulin, rapid fetal growth, and a reduction in eating associated with "morning sickness", women with pre-existing diabetes have a higher risk of hypoglycemia and will need decreased amounts of insulin. In the second trimester, the placenta is fully developed and hormone levels being to rise steadily, which increases maternal insulin needs. In the third trimester, insulin is absorbed more slowly and is less effective at lowering glucose, so the client may need larger doses of insulin. Insulin needs should return to normal soon after birth, if the client bottle feeds the baby.

The health care provider writes a new order for a fentanyl (Sublimaze) patch to manage the chronic pain experienced by the client in hospice care. The nurse is teaching a client and family members about the fentanyl patch and knows that teaching was effective when the client makes which of the following statements? (Select all that apply.) "I will take the old patch off before I apply the new patch on." "If my pain is too great while I am on the patch, I can take a supplemental pain medication." "I should cut up the patch before I throw it away so no one else can use it." . "It may take up to a half day or longer for the patch to start working, the first time I use it." "I can soak in a hot tub to help decrease my pain."

"I will take the old patch off before I apply the new patch on." "If my pain is too great while I am on the patch, I can take a supplemental pain medication." "It may take up to a half day or longer for the patch to start working, the first time I use it." Fentanyl patches are slowly absorbed via the subcutaneous tissue at a predetermined rate for up to 72 hours. Due to the slow absorption rate, the first patch may take 12 to 24 hours before effective analgesia is felt; a short-acting opioid may be given for breakthrough pain. The client can shower or bathe with the patch, but it should not be exposed to heat (hot tubs, heating pads) because it speeds up the absorption of the medication. Old patches are removed and the new patch is applied to a different skin area. Old patches are disposed by folding the old patch in half, not by cutting them up and throwing them in the trash (which may be dangerous for people and pets).

A client who has been experiencing influenza-like symptoms for the past 24 hours calls the health clinic and asks about the antiviral medication zanamivir (Relenza). How should the triage nurse respond? "Do you have trouble swallowing big pills?" "Your chart states that you have asthma, so this product would not be recommended." "Come in right away so we can treat you." "Call back tomorrow when you are sure you have the flu."

"Your chart states that you have asthma, so this product would not be recommended." Antiviral treatment should be initiated within 48 hours of illness onset. It won't cure the disease but it will shorten the time someone is sick and may reduce the severity of the illness. It is administered by oral inhalation. Zanamivir should not be used by people with chronic pulmonary disorders.

An elderly client is admitted to a home care agency following hospitalization for exacerbation of heart failure. The client lives alone, has difficulty completing activities of daily living (ADLs), and is unable to drive. List the order of the steps in the case management process by dragging and dropping the options below. Assessment of biophysical and sociocultural considerations Identification of nursing diagnoses Evaluation of progress towards client's goals Referral to personal care attendant and transportation services Reassessment of health status and ADL ability

. Assessment of biophysical and sociocultural considerations Identification of nursing diagnoses Referral to personal care attendant and transportation services Reassessment of health status and ADL ability Evaluation of progress towards client's goals Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's health needs.

A client who is unconscious is brought to the emergency department by an ambulance. What document should be given priority to guide the approach for the care of this client?

A notarized original of the advance directive brought in by the partner This document specifies the client's wishes of what actions are to be taken when the client becomes unable to make health care decisions. The advance directive often includes a living will and the power of attorney to whom will make the decisions for the client. The next document that would take precedent are the orders written by the heath care provider. The clinical pathways are used to evaluate the client's progress during therapy.

The nurse is assessing a 28 year-old female for risk factors contributing to osteoporosis. Which statement reported by the client should alert the nurse that additional teaching about this disease is indicated? (Select all that apply.) "I get sun exposure daily and always use sunblock protection." "I'm just started following the Mediterranean diet and already feel more energized." "I'm a professional dancer and train 8 to 10 hours a day." Correct! "I take 1000 mg OsCal (calcium carbonate) every morning with breakfast." Correct Response "I consume only skim milk, never whole milk." Incorrect

A nutritional plan that emphasizes fruits and vegetables, low-fat dairy and protein sources, and increased fiber (found in the Mediterranean diet) is beneficial to maintaining bone health and reducing the risk of heart disease. Adequate daily sun exposure is important for vitamin D synthesis, which is important for bone health. Although a calcium supplement is a good idea for this client and calcium carbonate should be taken with food for better absorption, calcium is absorbed more efficiently when it's taken in amounts of 500 to 600 mg at one time. Also, overtraining in women causes decreased estrogen levels and may increase the risk for osteoporosis.

The client, who is diagnosed with dementia, wanders throughout the long-term care facility. How can the nurse best ensure the safety of a client who wanders? Attach a monitoring band to the client's wrist Correct Response Explain the risk of walking with no purpose Frequently reorient the client to time, person, place Incorrect Apply a restraint to keep keep the client in a chair when awake

A wander management system is used to give people with dementia and other "at risk" clients the ability to move freely where they live. The sensor in the bracelet trips an alarm that's attached to exterior doors if the client attempts to leave the facility. It is inappropriate to use restraints or other restrictive devices to keep clients in chairs or beds (unless they are potentially harmful to themselves or others.) Reality orientation is inappropriate for someone with dementia.

The oncology nurse is preparing to administer the initial dose of vincristine to a child diagnosed with acute lymphocytic leukemia (ALL). Which intervention is most appropriate to add to the plan of care? (Select all that apply.) Verify blood return before, during and after intravenous administration Correct! Monitor liver enzyme tests Correct Response Monitor for numbness or tingling in the fingers and toes Correct! Apply ice to the injection site if extravasation occurs Select appropriate catheter for intrathecal administration Incorrect

ALL is the most common type of cancer in children and treatment protocols include vincristine. Vincristine (Oncovin) is for intravenous use only; intrathecal administration can be fatal. Vincristine is a vesicant that can cause significant local damage if extravasation occurs; treatment includes subcutaneous injection of an antidote and warm compresses (topical cooling may worsen the effect). Peripheral neuropathy is a major side effect associated with vincristine. The nurse should monitor for decreased hepatic functioning because vincristine is metabolized in the liver.

A registered nurse (RN) works for a visiting nurse agency (VNA) and makes a home visit to admit a client newly diagnosed with type 1 diabetes. The client has a small foot ulcer that was debrided and needs daily wound care. Which of the following options is the most important intervention to ensure a successful outcome? Involve the client in making health care decisions Correct! Schedule daily RN visits to the client Refer to a local diabetes support group Arrange for a friend or relative to visit daily

Although all interventions may benefit the client, the involvement of the client in making health care decisions improves outcomes. The client is more motivated to adhere to recommendations when involved in the process, setting priorities and making decisions.

A client takes 20 mg of furosemide by mouth at 10 am. What information would be essential for the nurse to include at the change of shift report at 3 pm? The client's potassium level is 4 mEq/L prior to medication administration The client is to receive another dose of furosemide at 10 pm The client's urine output was 1500 mL in five hours Correct! The client lost two pounds in the last 24 hours

Although all of these may be correct information to include in report, the essential piece would be the urine output in the past five hours. This focuses on the effectiveness of the medication therapy. Potassium is checked prior to administration of a loop diuretic and is reported if abnormal.

The client is transported to the emergency department with minor injuries suffered during a home fire. The client experiences intense anxiety after learning his home was completely destroyed. What is the most important initial intervention for this client? Provide a brochure on methods to promote relaxation Explore the feelings of grief associated with the loss Incorrect Determine available community and personal support resources Correct Response Suggest that the client rent an apartment with a sprinkler system

Although the sudden loss of a home can cause significant emotional distress, the most important initial intervention focuses on identifying (community) resources and obtaining assistance for housing and other immediate needs. Information on home safety, relaxation exercises, and grief counseling can wait until the client's basic need for shelter is met.

A client asks the nurse for information about a living will. Which statement made by the client demonstrates an understanding of a living will? (Select all that apply.) "I should sit down and discuss my wishes for end of life care with my loved ones." Correct! "My wishes for end of life treatment are stated in writing." Correct! "A living will must be renewed by a designated family member each time I am hospitalized." "A living will is a legal document that becomes a permanent part of my health care record." Correct! "It lists all my assets and how they should be divided among my family after I die." "I will need to identify someone to be my health care proxy." Correct!

An advance health care directive is also known as a living will. It is a legal document in which a person specifies his or her wishes concerning medical treatments at the end of life, when s/he is unable to make those decisions. Advance care planning involves sharing personal values and wishes with loved ones and selecting someone, (called a medical power of attorney or health care proxy) who will eventually make medical decisions on the client's behalf. A living will does not expire; it remains in effect unless it is changed. A living will does not include information regarding assets or a person's estate.

The client is admitted to the hospital with a diagnosis of exacerbation of right ventricular heart failure. Which of the following findings would the nurse expect with right-sided heart failure? (Select all that apply.) Anorexia and nausea Peripheral edema Cough Orthopnea Abdominal discomfort

Anorexia and nausea Peripheral edema Abdominal discomfort The classic findings of right-sided heart failure arise from blood backing up into the systemic circulation resulting in abdominal organ engorgement and dependent edema. The nurse would expect to find orthopnea and cough with left-sided heart failure.

A client who has been experiencing influenza-like symptoms for the past 24 hours calls the health clinic and asks about the antiviral medication zanamivir (Relenza). How should the triage nurse respond? "Do you have trouble swallowing big pills?" "Your chart states that you have asthma, so this product would not be recommended." Correct Response "Come in right away so we can treat you." Incorrect "Call back tomorrow when you are sure you have the flu."

Antiviral treatment should be initiated within 48 hours of illness onset. It won't cure the disease but it will shorten the time someone is sick and may reduce the severity of the illness. It is administered by oral inhalation. Zanamivir should not be used by people with chronic pulmonary disorders.

A 5 month-old is hospitalized with a diagnosis of bronchiolitis related to respiratory syncytial virus (RSV). The parent reports the baby has been sneezing and wheezing, has had a runny nose for two days, and has not eaten for more than nine hours. Vital signs are: temperature 100.2 F (38 C), pulse 102, respiratory rate 32. Place the nurse's actions in order of priority by dragging and dropping the options below. Institute droplet isolation precautions Assess for respiratory distress Promote adequate tissue oxygenation Administer prescribed medications Promote desired fluid intake Provide family teaching

Assess for respiratory distress Promote adequate tissue oxygenation Institute droplet isolation precautions Administer prescribed medications Promote desired fluid intake Provide family teaching When caring for a client with bronchiolitis related to RSV, the primary nursing interventions are aimed at promoting oxygenation. Remember the ABCs. Assessing respiratory distress and promoting adequate oxygenation address basic physiologic needs. Instituting droplet precautions is required to prevent transmission of the disease to others. Administering prescribed medications will alleviate symptoms such as wheezing and will promote healing. It is important to maintain fluid and electrolyte balance by promoting fluid intake. Even though the infant has not eaten for a long time, this is less important than the respiratory status. Finally, the nurse will need to provide support to the parents, who may have a lot of anxiety and concern about their child. They will need to be taught about their infant's diagnosis and treatments so that they can care for the child at home. Involving them in the care while the child is hospitalized will facilitate this learning process while alleviating anxiety.

The nurse enters the client's room and finds the client, who was previously alert, lethargic and slow to respond. Prioritize the nursing actions by dragging and dropping the options below. Complete a quick neurological assessment: orientation, pupil response, ability to follow commands Attempt to elicit a response by physically shaking the client and loudly stating "open your eyes and talk to me." Call the rapid response team and report the client's situation; request immediate assistance Remain with the client; send another staff member to get the list of medications and the chart

Attempt to elicit a response by physically shaking the client and loudly stating "open your eyes and talk to me." Complete a quick neurological assessment: orientation, pupil response, ability to follow commands Call the rapid response team and report the client's situation; request immediate assistance Remain with the client; send another staff member to get the list of medications and the chart When a client exhibits an acute change in condition, such as a reduced level of consciousness, it is an emergency situation and requires immediate intervention. First, the client's status must be determined through quick focused assessment. Most facilities have a rapid response team to assist the staff nurse so this asset should be mobilized next. Because the client should not be left alone, the nurse should call for help and ask a colleague to bring the list of medications along with the client's chart before the rapid response team arrives.

The health care provider has ordered a vanillylmandelic acid test and catecholamine test for a middle-aged client. Which of the following points should the nurse discuss with the client prior to these tests? (Select all that apply.) Continue taking all prescribed medications Avoid excessive physical exercise several days prior to the test A 24-hour urine collection procedure is required Identify and minimize factors contributing to stress and anxiety

Avoid excessive physical exercise several days prior to the test Identify and minimize factors contributing to stress and anxiety A 24-hour urine collection procedure is required Avoid caffeinated beverages, bananas, chocolate, cocoa, licorice and citrus fruit The nurse should confirm what the client has discussed with the health care provider about medications. Many times the client is instructed to stop taking antihypertensive medications prior to the test. Clients should be instructed to avoid anything that would increase urinary catecholamine levels and alter the test results before starting this 24-hour urine test, which is used to help diagnose a tumor in the adrenal glands. Catecholamines (dopamine, epinephrine, norepinephrine) increase heart rate, blood pressure, breathing rate, muscle strength and mental alertness.

A 65-year-old Hispanic-Latino client diagnosed with prostate cancer rates his pain as a six on a 0 to 10 scale. Other than Ibuprofen (Motrin), the client refuses all pain medication even though this does not relieve his pain. What should be the next action for the nurse to take? Document the situation in the progress notes Ask the client about the refusal of certain pain medications Correct! Talk with the client's family about the situation Report the situation to the primary care provider

Belief regarding pain is one of the oldest culturally-related research areas in health care. Astute observations and careful assessments must be completed to determine the level of pain a person can tolerate. Nurses should investigate the meaning of pain to each client within a cultural explanatory framework. After this initial assessment is done the other options would most likely be implemented.

A female client is admitted for a breast biopsy. She says, tearfully to a nurse, "If this turns out to be cancer and I have to have my breast removed, my partner will never come near me." Which of these statements would be the best response by the nurse? "Are you wondering about the effects on your sexuality?" "You sound concerned that your partner will reject you." "I hear you saying that you have a fear for the loss of love." "Are you worried that the surgery will lead to changes?" Correct!

By simply asking about changes, the nurse is encouraging further discussion without focusing on a specific issue. This technique of therapeutic communication will allow the client to decide what to talk about next. It is best to allow the client to identify the exact nature of the problem.

A 62 year-old client is admitted to the emergency department. The client has a history of anemia and peptic ulcer disease and is now experiencing chest pain, nausea and dizziness. The nurse anticipates which laboratory tests to be ordered right away? (Select all that apply.) Cardiac enzymes Toxicology screen Complete blood count (CBC) Lipid panel Helicobactor pylori (H. pylori)

Cardiac enzymes Complete blood count (CBC) Chest pain with nausea and dizziness may be findings associated with angina or myocardial infarction. Cardiac enzymes, including creatinine kinase, myoglobin, and troponin, are indicated to determine if muscle damage has occurred (to help rule out a heart attack). Low hemoglobin (Hgb) can precipitate an angina attack if there is not enough Hgb to deliver oxygen to the myocardium; given the client's history, a CBC would be indicated. There are no findings of either overdose or poisoning, so a toxicology screen is not needed. A lipid panel is used to show one's risk for coronary heart disease and the presence of Helicobacter Pylori is associated with increased cardiovascular disease risk and lower HDL, but these tests are not used diagnostically for chest pain.

The nurse is preparing a speech to a local service organization about clinical trials in cancer care. Which of the following statements would be correct to include? (Select all that apply.) Clinical trials have led to improved cancer prevention and treatment Correct! There is a clinical trial protocol for all types of people with cancer A clinical trial is one of the first steps in the research process Clinical trials require approval of a human subjects review board Correct!

Clinical trials involve the use and study of treatments on actual human subjects and have been important in making advances in cancer outcomes. After many stages of research have been completed, the clinical trial becomes one of the final steps of the process. Because they involve real people, human subjects review boards must approve the research. There is not a clinical trial for every type of cancer victim, as potential participants in clinical trials must meet specific protocols.

The nurse is assessing a client who is two days post-surgery and notes new and sudden onset of confusion. There is an order to discharge the client to go home today. What would be the best action for the nurse to take?

Collaborate with the health care provider about the change of condition Although all the responses may be correct for a post-surgical client, a status change involving confusion must be reported, particularly if it is a new finding. As an advocate for the client, the nurse should protect the client from physical harm and collaborate with the health care provider about a change in the plan for discharge.

A postoperative client has a prescription for acetaminophen with codeine. What should a nurse recognizes as a primary effect of this combination? Increased onset of action Minimized side effects Prevention of drug tolerance Enhanced pain relief Correct!

Combination of analgesics with different mechanisms of action can afford greater pain relief. Tylenol No. 3 is a combination of 300 mg of acetaminophen and 30 mg of codeine; Tylenol No. 4 is a combination of 300 mg of acetaminophen and 60 mg of codeine.

The nurse is named in a lawsuit. Which of these factors will offer the best protection for the nurse in a court of law? Sworn statement that health care provider orders were followed Above-average performance reviews prepared by nurse manager Complete and accurate documentation of assessments and interventions Clinical specialty certification by an accredited organization

Complete and accurate documentation of assessments and interventions The medical record is a legal document. Documentation should include all steps of the nursing process; it must be complete, accurate, concise and in chronological order. Inaccurate or incomplete documentation will raise red flags and may indicate the nurse failed to meet the standards of care. The attorney will review the medical record with the nurse before giving a deposition (sworn pretrial testimony.) Above-average performance reviews could be considered supporting information. Certification is an "extra" based on the nurse's initiative; it is, however, unrelated to accurate charting.

A nurse manager suspects a staff nurse of substance use disorder (SUD). Which approach would be the best initial action by the nurse manager?

Consult with human resources personnel about the issue and needed actions The nurse manager needs to consult with human resources to determine the proper procedures for documenting and reporting the nurse's behavior. The nurse manager could also consult the EAP if one is available. If the staff nurse is also suspected of diversion, and a written policy exists, the nurse manager would follow these procedures. Attempts should be made to help the nurse with SUD by providing counseling and treatment for this disease.

The nurse listens to report about a newly admitted client who has a skin ulcer that's tested positive for MRSA (methicillin-resistant Staphylococcus aureus). What precautions must be taken for this hospitalized client? (Select all that apply.) Keep all equipment in the client's room for his/her sole use Correct! Place the client in a single room Correct! Wear mask when providing routine care to the client Perform hand hygiene after direct contact with the client and before leaving the room Correct! Keep the door to the room closed, with a notice for visitors Correct!

Contact precautions are recommended in acute care settings for MRSA when there's a risk for transmission or wounds that cannot be contained by dressings. The client should be in a single room, with the door closed; the sign on the door instructs visitors to report to the nurse before entering the room. All equipment, such as stethoscopes and blood pressure devices, should be for the client's sole use and kept in the room. Health care workers must perform hand hygiene (wash hands with soap and water) after direct contact with the client and his/her environment and before leaving the isolation room. Contact precautions require health care workers to wear gloves and a gown; a face mask is not necessary for routine care.

A client frequently admitted to the locked psychiatric unit repeatedly compliments and then invites one of the nurses to go out on a date. The nurse should take which of these approaches?

Discuss the boundaries of a therapeutic relationship with the client The nurse-client relationship is one with professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust. The client may need to be educated about the interactions in a therapeutic relationship.

The order is for 900 mg of nafcillin and the nurse has a powder in a vial labeled "Nafcillin 1 gram, dilute with 3.4 mL of sterile water to produce 1 gram in 4 mL." How many milliliters will the nurse administer? Report the answer to the nearest tenth. _____mL.

Don't get confused by the quantity of the diluent (3.4 mL). When you are calculating reconstituted medication, only the final concentration directs your answers (in this case, 1 g in 4 mL). Using dimensional analysis: 4 mL/1 gram x 1 gram/1000 mg x 900 mg/1 = 3600/1000 = 3.6 mL Using ratio proportion: First convert the 1 g to 1000 mg 1000 mg/4 mL = 900 mg/x mL x = 3.6 mL

A client with a central line catheter is being discharged. Which of the following methods is the most accurate way to evaluate the client's partner's ability to provide central line catheter dressing changes at home? Allow repeated practice on a lifelike mannequin Provide pamphlets and pictures about the skill Incorrect Watch the partner change the dressing Correct Response Send the partner to a class about how to change dressings

Each of the teaching methods is appropriate for a manual skill such as a dressing change. However, the only one that actually demonstrates mastery is observing the partner perform the skill.

A male client admitted with a diagnosis of a spinal cord injury (SCI) at level C-5 asks the nurse how the injury will affect his sexual function. Which statement is the best response? "Normal sexual function is not possible." "Ejaculation will be normal." "Sexual functioning will not be impaired at all." "Sexual functioning may be possible." Correct!

Even though sexual function is controlled by parts of the central nervous system, sexual function after a SCI will depend on many factors, such as the severity of the injury and even the age of the client. The client will need to get to know his body and learn how it reacts in certain situations. The client should also talk to his health care provider for options to achieve an erection.

The health care team is planning discharge for a 90 year-old client diagnosed with musculoskeletal weakness. Which intervention would be the priority to help prevent falls in the home? Begin therapy for muscle strengthening and balance Place night lights in the bedroom and bathroom Correct Response Wear eyeglasses and hearing aid Take calcium and vitamin D supplements

Family members and the client should understand the simple actions they can take to help prevent falls in the home. More falls occur in the bedroom than in any other location; a simple environmental change would be to add night lights in the bedroom and bathroom. Muscle strengthening and balance exercises, taking calcium and wearing glasses may be all indicated for this client, but using night lights is an immediate and effective action to help prevent falls.

The health care provider writes a new order for a fentanyl (Sublimaze) patch to manage the chronic pain experienced by the client in hospice care. The nurse is teaching a client and family members about the fentanyl patch and knows that teaching was effective when the client makes which of the following statements? (Select all that apply.) "I will take the old patch off before I apply the new patch on." Correct! "If my pain is too great while I am on the patch, I can take a supplemental pain medication." Correct Response "I should cut up the patch before I throw it away so no one else can use it." Incorrect "It may take up to a half day or longer for the patch to start working, the first time I use it." Correct! "I can soak in a hot tub to help decrease my pain."

Fentanyl patches are slowly absorbed via the subcutaneous tissue at a predetermined rate for up to 72 hours. Due to the slow absorption rate, the first patch may take 12 to 24 hours before effective analgesia is felt; a short-acting opioid may be given for breakthrough pain. The client can shower or bathe with the patch, but it should not be exposed to heat (hot tubs, heating pads) because it speeds up the absorption of the medication. Old patches are removed and the new patch is applied to a different skin area. Old patches are disposed by folding the old patch in half, not by cutting them up and throwing them in the trash (which may be dangerous for people and pets).

A nurse is providing home care for a client with chronic bilateral heart failure. Which nursing diagnosis should have the priority when planning care for this client? Constipation related to immobility from challenges with breathing Risk for infection related to ineffective mobilization of secretions Impaired skin integrity related to dependent edema Activity intolerance related to an imbalance in oxygen supply and demand Correct!

Findings of bilateral heart failure may include dyspnea, fatigue, chronic cough, lack of appetite, mental confusion or impaired thinking, peripheral edema and weight gain. Due to an inadequate supply of oxygen and the stress of the extra heart muscle mass, the client will experience exertional dyspnea. Therefore, activity intolerance is the priority nursing diagnosis for this client. While there may be a concern about skin integrity, risk for infection and even constipation, oxygen needs are more important.

A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing intervention would provide the most comfort to the client? Swab the mouth with glycerin swabs Allow the client to melt ice chips in the mouth Perform frequent oral care using a tooth sponge Correct! Provide mints to freshen the breath

Frequent cleansing and stimulation of the mucous membrane is important for a client with a nasogastric tube to prevent development of lesions and to promote comfort. Ice chips or mints could be contraindicated with a nasogastric tube. Glycerin swabs have no mechanical or cleansing value and should not be used.

A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in this client's plan of care within the initial 24 hours? Wear masks with shields if there is potential for fluid splash Use disposable utensils and plates for meals Provide soft easily digested food with frequent snacks Wear gown and gloves during client contact Correct Response

HAV is usually transmitted via the fecal-oral route, or when someone with the virus handles food without washing hands after using the bathroom. The virus can also be contracted by drinking contaminated water, eating raw shellfish from water polluted with sewage or by being in close contact with a person who is infected - even if that person has no findings. In fact, the disease is most contagious before findings ever appear. The nurse should recognize the importance of isolation precautions from the initial contact with the client on admission until the noncontagious convalescence period.

A primigravida in the third trimester is hospitalized with a diagnosis of preeclampsia. The nurse determines that the client's blood pressure has a trend of increased readings. Which action should the nurse take first? Take the temperature Check the client's deep tendon reflexes Have the client turn to the left side Check the protein level in urine

Have the client turn to the left side The priority action in this situation is to turn the client to the left side to decrease pressure on the vena cava and promote adequate circulation to the placenta and kidneys. Urine protein level and output should be checked with each voiding. Temperature should be monitored every four hours or more often if indicated, but no data in the stem supports a check of temperature. The deep tendon reflexes are checked as needed especially when magnesium drips are being infused.

The interdisciplinary team is reviewing charts for potential candidates for hospice care. Which of the following clients meet the criteria for hospice care? (Select all that apply.) 91 year-old with Alzheimer's disease, who is no longer able to eat or drink oral fluids Correct! 72 year-old with prostate cancer metastasized to the bone, who is receiving palliative radiation therapy Correct! 53 year-old client with chronic, unrelieved pain, who is addicted to narcotics following a back injury 46 year-old with end stage liver disease, on a wait list for a donor organ 8 year-old client with acute myelogenous leukemia, for whom all treatment options have failed Correct!

Hospice care provides services for clients who are at the end of their life, usually with less than 6 months to live. There are no age requirements. Palliative care is provided by a multi-disciplinary team in a variety of settings, including the home, hospital or extended-care facilities. Clients actively seeking a cure or treatment for their disease do not meet the criteria for hospice care.

Which of these clients should the nurse assess and monitor for Clostridium difficile (C. difficile) diarrhea? A young adult at home taking a prescribed aminoglycoside An older adult client living in a retirement center taking prednisone A hospitalized middle-aged client receiving IV cephalexin (Keflex) Correct! An adolescent taking tetracycline for acne

Hospitalized clients, especially those receiving antibiotic therapy, are primary targets for C. difficile. Examples of antibiotics that frequently cause C. difficile are ampicillin, amoxicillin and cephalosporins, including cephalexin (Keflex). Antibiotics that occasionally cause C. difficile include penicillin, erythromycin, trimethoprim and quinolones, such as ciprofloxacin (Cipro).

The client is admitted with anemia, suspected to be caused by slowly bleeding esophageal varices. Which physician order should the nurse question? Obtain complete blood count (CBC) Send three stool samples for occult blood Administer ranitidine (Zantac) 150 mg tab twice a day by mouth Insert nasogastric (NG) tube to gravity

Insert nasogastric (NG) tube to gravity Esophageal varices are similar to varicose veins within the esophagus. A nurse would never insert an NG tube if this diagnosis is suspected because it might rupture the varices and cause an acute hemorrhage. The other orders make sense during a GI work-up for anemia. Checking CBC will provide hemoglobin and hematocrit values to quantify the degree of anemia. Ranitidine decreases stomach acid and may decrease loss of blood through a possible ulcer. Getting stool samples for occult blood can identify the presence of small amounts of blood in the stool that are not visible to the naked eye.

A 63 year-old client is diagnosed with severe pneumonia. Which intervention by the nurse promotes the client's comfort? Keep conversations short Correct Response Increase oral fluid intake Encourage visits from family Incorrect Monitor vital signs frequently

Keeping conversations short will promote the client's comfort by decreasing the demands on a client's breathing and energy. Increased intake of fluids and monitoring vital signs are not related to comfort. While the presence of family is supportive, demands on the client to interact with the visitors may interfere with the client's rest.

The nurse cares for a client who was admitted in status epilepticus and whose last seizure was four hours ago. What is the most important nursing assessment for this client? Level of consciousness Vital signs and oxygen saturation Injuries to the extremities Respiratory status

Level of consciousness Cerebral blood flow surges during seizure activity, depleting oxygen at the neuronal level. Cerebral anoxia may result in progressive brain tissue injury and destruction. The nurse should monitor the client's level of consciousness very closely.

The nurse receives an order for several medications for a client. Which combination of medications would require the nurse to contact the provider to discuss the orders? (Select all that apply.) Insulin Finasteride (Propecia, Proscar) Incorrect Lithium (Eskalith, Lithobid) Correct Response Furosemide (Lasix) Correct! Amlodipine (Norvasc) Verapamil (Calan, Covera, Isoptin, Verelan)

Lithium generally should not be given with diuretics. Furosemide may reduce excretion of lithium, which could result in lithium toxicity. Additionally, side effects of lithium are polyuria and polydipsia. The nurse should clarify the order before administering lithium and furosemide together.

A parent calls the hospital hot line and is connected to the triage nurse. The caller states: "I found my child with odd stuff coming from the mouth and an unmarked bottle nearby." Which of these comments would provide the best information to help the nurse to determine if the child has swallowed a corrosive substance? "Ask the child if the mouth is burning or throat pain is present." Correct Response "Has the child had vomiting, diarrhea or stomach cramps?" Incorrect "Take the child's pulse at the wrist and see if the child has trouble breathing lying flat." "What color are the child's lips and nails and has the child voided today?"

Local irritation of tissues indicates a corrosive poisoning. The other comments may be helpful in determining the child's overall condition. However, the question concerns evaluation for ingestion of a caustic substance.

An x-ray initially confirms the placement of a nasogastric (NG) feeding tube in the stomach. The nurse is now preparing to administer a medication through the tube. What action will the nurse take to verify tube placement? Measure the pH of aspirated gastric contents Assess for client coughing during administration of the medication Auscultate for the sound of air produced by forcing air through the NG tube Place the end of the tube in water and observe for bubbling

Measure the pH of aspirated gastric contents Bubbling or coughing would indicate the possibility of the tube being in the airway, but neither are used to determine placement in the stomach. Forcing air through the NG tube and auscultating the abdomen for the sound of the air is an unreliable method to determine tube placement. Measuring the pH of aspirated stomach contents confirms gastric placement.

The triage nurse identifies that a 16 year-old client is legally married and has signed the consent form for treatment. What should be an appropriate action by the nurse? Ask the teenager to wait until a parent or legal guardian can be contacted Refer the teenager to a community pediatric hospital emergency department Proceed with the triage process in the same manner as any adult client Correct! Withhold treatment until telephone consent can be obtained from the partner

Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this married client has the legal capacity of an adult. Otherwise, the age for legal signatures is 18 years of age.

The charge nurse sends a certified nursing assistant (CNA) to help a registered nurse (RN) with the admission of a client with multiple health problems. Which of the following tasks would be appropriate for the the CNA to perform with the nurse during the admission process? (Select all that apply.) Orient the client to the room Collect a urine specimen Obtain routine vital signs (temperature, pulse, respirations, blood pressure) Assist the client to change into a gown Observe and document the client's ability to walk to the bathroom

Orient the client to the room Collect a urine specimen Obtain routine vital signs (temperature, pulse, respirations, blood pressure) Assist the client to change into a gown CNAs can obtain routine vital signs, measure height and weight, and obtain urine specimens. CNAs also routinely help clients with activities of daily living (ADLs). Although nursing assistants can measure vital signs, it's up to the RN to determine how to use this data when developing the plan of care. The CNA cannot assess clients or perform any of the other steps of the nursing process. Any nursing intervention that requires independent, specialized nursing knowledge, skill or judgment must be performed by a nurse.

The health care provider orders an osmotic diuretic for a client diagnosed with a traumatic brain injury (TBI). Why is this medication ordered? Reduce pulmonary edema Reduce intracranial pressure Correct! Prevent electrolyte imbalance Prevent seizures

Osmotic diuretics, such as mannitol, are used to reduce intracranial or intraocular pressure. Osmotic diuretics reduce the amount of water normally reabsorbed by the renal tubules and loop of Henle, so urinary output is increased. Osmotic diuretics can cause excessive loss of water and electrolytes, which can lead to serious electrolyte imbalances. In addition to water intoxication and dehydration, adverse reactions of osmotic diuretics include pulmonary edema and circulatory overload. Anticonvulsants prevent seizures.

The nurse is performing the initial assessment of a client in the emergency department. Which statement by the client most strongly suggests domestic violence? "No one else in the family is as accident prone as I am." "I have only been married for two months." "I am determined to leave my house in a week." "I have tried leaving home, but have always gone back." Correct!

Persons being abused or neglected often develop a high tolerance for abuse. They commonly blame themselves for being abused or neglected. All members in the family are affected by the behaviors of abuse, even if they are not the actual object of the abuse. For these reasons, persons who have been abused or neglected often have an extensive history of being abused. They struggle for a long time before actions are taken to leave permanently.

The nurse is reviewing the lab results for a male client on a heparin infusion to treat a deep vein thrombosis (DVT) and cellulitis of the right lower leg. Which of the lab results would the nurse be most concerned about? Lab Results White blood cells Lab Results 15,100 per microliter (15.1 x 109/L) Lab Results Platelet count Lab Results 50,000 per microliter (500 x 109/L) Lab Results Hemoglobin Lab Results 14 g/dL (8.69 mmol/L or 140 g/L) Lab Results Hematocrit Lab Results 45% (0.45) Lab Results Partial Thromboplastin Time Lab Results 55 seconds White blood cells Partial thromboplastin time Hematocrit Hemoglobin Platelet count

Platelet count Thrombocytopenia (abnormally low amount of platelets) and heparin-induced thrombocytopenia can occur in clients on heparin therapy. In an adult, a normal platelet count is about 150,000 to 450,000 platelets per microliter of blood (or 150-450 x 109/L). The PTT is within the therapeutic range. It is expected that the white blood cells would be slightly elevated in a client with an infection (cellulitis).

A client is to receive three doses of potassium chloride 10 mEq in 100 mL of 0.9% normal saline to infuse over 30 minutes each. Which action is a priority assessment to perform before the nurse gives this medication? Bowel sounds Grip strength Urine output Correct! Oral fluid intake

Potassium chloride should only be administered after adequate urine output (greater than 20 mL/hour for two consecutive hours) has been established. For children the desired urine output is 1 mL/1 kg/1 hour. Impaired ability to excrete potassium via the kidneys can result in hyperkalemia.

The nurse is caring for a newly admitted client with a diagnosis of hyperosmolar hyperglycemic nonketotic state (HHNS). Which interventions would the nurse expect the health care provider to order? (Select all that apply.) Rapid infusion of intravenous fluids NPH insulin as IV bolus and then titrated by weight Check blood glucose levels every four hours BUN and creatinine levels

Rapid infusion of intravenous fluids BUN and creatinine levels Immediate labs would include arterial blood gases, complete blood count with differential, urinalysis, plasma glucose, BUN, electrolytes, chemistry profile and creatinine levels. The client will be very dehydrated in this hyperosmolar hyperglycemic state; therefore, rapid infusion of intravenous fluid will be needed to correct the hypovolemia. IV infusion of regular insulin may be used to rapidly correct the hyperglycemia, and glucose checks should be performed hourly until blood sugar levels have reached a more normal level. At that point, a long-acting insulin, such as glargine (Lantus), can be started to provide consistent baseline insulin coverage, supplemented with rapid-acting insulin dosed according to a sliding scale based on blood glucose readings.

The client, who is 12-hours post gastric bypass surgery, is restless and reports increasing back and shoulder pain unrelieved by pain medication. What action should the nurse take first? Report the complaint to the surgeon immediately Check the nasogastric (NG) tube for patency and reposition the tube Roll the client to side-lying position to ensure the epidural analgesia catheter is still in place Place the client in Trendelenburg position

Report the complaint to the surgeon immediately Anastomotic leak is the most serious complication after bariatric surgery and the most common cause of death. Clients should be monitored for increased back, shoulder, or abdominal pain, restlessness, unexplained tachycardia, and oliguria; these findings should be immediately reported to the surgeon. A nasogastric tube should not be manipulated postoperatively because it could damage the surgical site. In order to reduce intra-abdominal pressure on the diaphragm and improve tidal volumes, the head of the bed should be elevated 30 to 45 degrees, preferably in reverse Trendelenburg position. Patient controlled analgesia is used for pain management; epidural analgesia is not often used because of the difficulty of locating exact spinal segments for proper insertion of a catheter.

A client, who is receiving a blood transfusion, reports having a headache and low back pain. What are the nurse's actions? (Select all that apply.) Flush the line with saline Send the tubing and bag to the blood bank Establish a saline lock or patent IV Administer acetaminophen (Tylenol) 1000 mg Stop the blood transfusion Obtain first voided urine (within one hour of reaction)

Send the tubing and bag to the blood bank Establish a saline lock or patent IV Stop the blood transfusion Obtain first voided urine (within one hour of reaction) The transfusion should be stopped immediately to reduce the risk of further damage. A sample from the transfusion will be cross-matched with client samples from before and after transfusion to check for errors in cross-matching. If this is an acute hemolytic transfusion reaction, intravascular hemolysis causes hemoglobinuria with varying degrees of kidney failure and possibly even disseminated intravascular coagulation (DIC). A urinalysis would reveal any hemoglobinuria that occurred due to hemolysis. If it's a febrile nonhemolytic transfusion reaction (as determined by the lab tests), then the headache can be treated with a lower dose of acetaminophen.

A new nursing assistant is instructed to weigh clients diagnosed with anorexia nervosa only if the clients wear a gown with underwear but no street clothing. What is the rationale for this intervention? Allows the nursing assistant to better assess the client's skin Promotes feelings of success with gaining weight Eliminates the risk of hiding objects in clothing or shoes Correct! Symbolically removes barriers between the client and staff

Some of the goals of treating anorexia nervosa are to restore clients to a healthy weight and to normalize eating patterns. Clients should be weighed in the morning, after they have voided. They are only to wear a (hospital) gown and underwear; wearing street clothing allows the client to hide objects in pockets (or shoes) that will add weight. Some therapists believe the client should initially be weighed "blind" (backing up onto the scale) so they can't see the numbers. Regardless of how it's done, being weighed is anxiety-provoking for the client. Recall that nursing assistants cannot assess clients.

A 30 year-old client at 39-weeks gestation has just delivered and experienced a fetal demise. The client's partner is at the bedside. Which of the following nursing actions are appropriate at this time? (Select all that apply.) Place the infant on the maternal abdomen, skin-to-skin Clean and wrap the baby and offer it to the parents to view or hold when desired Correct! Ask the parents if there are any special religious or cultural rituals for neonatal death Correct! Offer the option of an autopsy to the parents at this time Stay with the parents and offer supportive care to both of them Correct!

Staying with the parents at this moment and offering physical and emotional support is appropriate. It is also appropriate to prepare the infant in a way that demonstrates care and respect for the baby and to offer everyone the opportunity to view and/or hold the infant as they desire. Placing a newborn on the mother's abdomen would be appropriate for a live birth, but inappropriate for this situation. The nurse must ask if there are cultural or religious rituals they would like for their infant. Although an autopsy should eventually be discussed, it would not be appropriate immediately after the birth.

A client is diagnosed with protein-energy malnutrition secondary to colitis. Which findings would support this diagnosis? (Select all that apply.) Cholesterol 110 mg/dL (2.85 mmol/L) Correct Response Total lymphocyte count (LTC) 1000/mcL Correct! High blood pressure Hemoglobin 10.9 g/dL (6.76 mmol/L) Correct! Sodium 146 mEq/L (146 mmol/L) Incorrect Increased lean body mass

TLC is used to assess immune function and is below 1500 when a client is malnourished. Hemoglobin may be low, secondary to low serum albumin, catabolism and anemia. A cholesterol level below 160 mg/dL (4.14 mmol/L) has been identified as a possible indicator of malnutrition. Sodium is not typically affected by protein-energy malnutrition (and the results are within normal limits in this scenario). With protein-energy malnutrition, there is a decrease in lean body mass, the heart rate is slower than normal, blood pressure is lower than normal and the person's temperature may be elevated.

A nurse has been assigned to four clients in the emergency department, with each client experiencing one of these conditions. Which client should the nurse check first?

Tension pneumothorax with slight tracheal deviation to the right Tracheal deviation indicates a significant volume of air being trapped in the chest cavity with a mediastinal shift. In tension pneumothorax the tracheal deviation is away from the affected side. The affected side is the side where the air leak is in the lung. This situation also results in sudden air hunger, agitation, hypotension, pain in the affected side, and cyanosis with a high risk of cardiac tamponade and cardiac arrest.

The clinic nurse assists the health care provider with physical examinations and the collection of laboratory specimens. Which of these findings does the nurse recognize as being reportable to the public health department? Positive eye discharge confirming conjunctivitis Clinical findings of impetigo Incorrect Skin scraping confirming the presence of ringworm Positive stool culture for shigella Correct Response

The Centers for Disease Control and Prevention (CDC) have a list of notifiable infectious diseases that is updated yearly. Shigellosis is the only reportable infection of those listed. Shigella are bacteria that can infect the digestive tract and cause (painful) diarrhea, cramping, vomiting, nausea; in severe cases it can cause seizures and kidney failure. Ringworm is a contagious fungal infection. Impetigo is a contagious, superficial bacterial skin infection. Conjunctivitis has many causes and is usually diagnosed from signs and symptoms and patient history.

The registered nurse (RN) and the unlicensed assistive person (UAP) are caring for clients on a surgical unit. Which action(s) by the UAP warrant immediate intervention? (Select all that apply.)

The UAP applies a fingertip pulse oximeter on a client's finger with dark blue nail polish The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in the hall The UAP assists a client, who had a total knee replacement two days ago, to shave using a straight-edge razor The UAP can perform a number of nursing tasks, such as emptying an indwelling urinary catheter bag and applying moisture barrier cream after peri care. However, it is unsafe for the UAP to ambulate a client who recently received an IV push narcotic. Although UAP can shave clients, it is unsafe to shave someone using a straight-edge razor because a client who had knee replacement surgery is probably taking an anticoagulant; only an electric razor should be used. Pulse oximeter readings must be done on a finger that is warm and free from dark fingernail polish.

A client calls the clinic and states to the triage nurse: "I had an upset stomach and took Pepto-Bismol and now my tongue looks black. What's happening to me?" What would be the nurse's best response? "Are your stools also black?" Incorrect "How long have you had an upset stomach?" "Come to the clinic so you can be seen by the health care provider." "This is a common and temporary side effect of this medication." Correct Response

The best response would be to explain that a dark tint of the tongue is a common and temporary side effect of bismuth subsalicylate (Pepto-Bismol). Although it may also turn stools a darker color, do not confuse this with black, tarry stools, which is a sign of bleeding in the intestinal tract. After addressing the client's initial concern and the reason for the call, the nurse can ask about the upset stomach and then ask the client to come to the clinic if necessary.

A client who is HIV-positive is diagnosed with a herpes simplex type 1 (HSV-1) infection. The nurse understands that which issue is the most likely reason for the HSV-1 infection in this client? The client has experienced emotional stress The client had contact with saliva The client is immunosuppressed The client has a history unprotected sexual activities

The client is immunosuppressed HSV-1, or oral herpes, is spread through contact with saliva and the painful, fluid-filled blisters are often activated by stress. But the best reason why someone who is HIV-positive would also have oral herpes is because they are vulnerable to opportunistic infections that take advantage of a weakened immune system. Other common HIV-related, opportunistic infections and diseases include tuberculosis, bacterial pneumonia and candidiasis.

The nurse reviews the most recent lab results for a client on telemetry who is experiencing premature ventricular beats at 12 per minute. Which lab test would require immediate action by the nurse? Magnesium 2.4 mg/dL (1.2 mmol/L) Calcium 9 mg/dL (2.25 mmol/L) Potassium 2.5 mEq/L (2.5 mmol/L) Correct! Partial thromboplastin time (PTT) 70 seconds

The client low potassium levels is at high risk for ventricular dysrhythmias (normal lab values are 3.5 to 5.0 mEq/L [3.5 - 5 mmol/L]). Premature ventricular contractions may also be caused by low magnesium levels, digoxin and aminophylline toxicity, and hypoxia. Normal values for magnesium are about 1.5 to 2.4 mg/dL (0.75-1.2 mmol/L); normal values for calcium are about 8.5-10.3 mg/dL (2.12 - 2.57 mmol/L)

The nurse is checking on clients in the unit. Which of these findings indicates that an infusion pump set to deliver a morphine drip basal rate of 10 mL per hour, plus PRN dosages for breakthrough pain, is not functioning correctly? The client states: "I just can't get relief from my pain." The level of the drug is 100 mL at 9 am and is 50 mL at 12 noon The level of the drug is 100 mL at 8 am and is 80 mL at 12 noon Correct! The client complains of discomfort at the IV insertion site

The minimal dose is 10 mL per hour, which would mean 40 mL is given in a four-hour period. If any PRN doses were given then less would be in the bag. Minimally, 60 mL should be left at 1200 (12 Noon). The pump is not functioning when more than expected medicine is left in the container.

The nurse, who is caring for a client with complex and unique health needs, describes the nature of the illness in an online social forum for nurses. Neither the client's real name nor any other personal identifiers are used. What, if any, consequence could result from posting this information online? The nurse could be reprimanded for not clearing the information first with hospital administration The nurse could be fired for breach of confidentiality There won't be any consequences because the client's real name was not used There won't be any consequences because the information was posted on a website for nursing professionals

The nurse could be fired for breach of confidentiality Even though the client was not identified by name, someone could probably figure out who the nurse was writing about. Many health care facilities have adopted a social media policy; it is important to understand that nurses can be fired for posting personal information about clients online, because this is an invasion of privacy. In addition to being a HIPAA violation, the Health Information Technology for Economic and Clinical Health Act (HITECH Act) gives states attorneys the right to pursue violations of patient privacy.

A client arrives in the emergency department after a radiologic accident at a local factory. After placing the client in a decontamination room, the nurse gives priority to which intervention? Ensure physiologic stability of the client Correct Response Double bag the client's contaminated clothing Wrap the client in blankets to minimize staff contamination Begin decontamination procedures for the client Incorrect

The nurse must initially assist in the stabilization of a client prior to the performance of any other tasks related to radiologic contamination. A radiation survey meter reading above background radiation levels indicates the possibility of contamination. Radiologic contamination rarely results in loss of consciousness or immediate visible signs of injury. Thus, other causes of injury or illness should be ruled out.

The nurse manager is interviewing a prospective employee who just completed the agency application. Which approach should the nurse manager use to assess skills competencies of this potential employee? "Let's talk about your comfort zone for working independently." "Let's review your skills checklist for type and level of skill for tasks." Correct! "What types of complex client-care tasks or assignments do you prefer?" "What degree of supervision for basic care do you think you need?"

The nurse needs to know that the potential employee has competence in certain tasks that are common on the unit. One way to do this is to do mutual review of the agency list of skills. The other questions might be asked during the skills checklist review.

The nurse has just listened to the change of shift report on an orthopedic unit. Which of the following clients should the nurse check first? A 16 year-old who had an open reduction of a fractured wrist 10 hours ago A 72 year-old who returned from a right hip replacement surgery two hours ago Correct! A 20 year-old in skeletal traction for two weeks since a motorcycle accident A 75 year-old who is in skin traction of the left leg prior to a scheduled fractured hip repair surgery

The nurse should compare clients to screen for one who has the most imminent risks and acute vulnerability for being unstable. The client who returned from surgery two hours ago is at risk for hemorrhage because the hip and femur are considered vascular areas and should be checked first. The 16 year-old is within the initial 24 hours post-op period and should be seen next. The 75 year-old is potentially vulnerable to age-related physical and cognitive impairments from being on bedrest and having a large bone fracture. The client who can safely be visited last is the 20 year-old who is two weeks post-injury.

The nurse is providing care to a client in labor. The client has chosen natural childbirth with assistance from a doula, her mother and boyfriend. Which of the following nursing actions can help the client achieve her goal of an unmedicated labor and birth? Limit the number of interactions with the doula Offer pain medication on a regular basis Assess the effectiveness of the labor support team and offer suggestions as needed Correct! Encourage the client to stay in bed in a side-lying position or semi-Fowler's position

The nurse's role involves clinical skills and administrative responsibilities that are not part of the doula's role. The RN is responsible for assessing both the mother and baby and remains an important part of the labor and birth in this scenario. The RN's expertise allows the RN to make helpful suggestions to the support persons and the client, such as encouraging the client to find comfortable positions, both in and out of bed. It is appropriate to let the client and her support persons know all of the pain control options, but it would be inappropriate to continually offer pain medication to someone who has chosen natural childbirth. Doulas use techniques such as imagery, massage, acupressure, and patterned breathing to reduce a woman's pain.

The client is diagnosed with post-traumatic stress disorder (PTSD). What are the some of the more common treatment options for PTSD? (Select all that apply.) Eye movement desensitization and reprocessing (EMDR) Correct Response Selective serotonin reuptake inhibitors (SSRIs) Correct! Opioid analgesics Cognitive behavioral therapies Correct!

The only two FDA approved medications for the treatment of PTSD are the SSRIs sertraline (Zoloft) and paroxetine (Paxil). There are other medications that are helpful for specific PTSD symptoms, but narcotics should not be used since they don't relieve psychogenic pain and there's a risk of dependence. Most people who experience PTSD undergo some type of psychotherapy, most commonly cognitive-behavioral therapy and/or group psychotherapy, EMDR and hypnotherapy.

A client is admitted to the hospital following an automobile accident. Upon admission the client's blood alcohol concentration was 0.18%. Twelve hours after admission the client is diaphoretic, tremulous, and irritable; pulse and blood pressure measurements are elevated. The client states: "I have to get out of here." What is the most likely cause for these findings? Dissatisfaction with hospital care Anxiety related to being hospitalized Shock related to the injuries Early stage of alcohol withdrawal Correct!

This client's blood alcohol concentration is more than twice the legal limit in most states. After a period of heavy or prolonged alcohol use, people will experience alcohol withdrawal symptoms, such as insomnia, tremors, hyperactivity, hypertension, tachycardia and diaphoresis. The client must be treated immediately to prevent progression to more severe alcohol withdrawal symptoms, including seizures (which may begin 6-48 hours after cessation of alcohol intake) and delirium tremens (DTs).

The nurse is assessing a client in the labor and delivery unit. Which of the following actions is correct when using palpation to assess the characteristics and pattern of uterine contractions? Place a hand on abdomen below the umbilicus and palpate uterine tone with fingertips Evaluate intensity by pressing fingertips into the uterine fundus Correct! Determine frequency by timing the end of one contraction until the end of the next contraction Assess uterine contractions every 30 minutes throughout the first stage of labor

To assess contractions for frequency, duration and intensity, the nurse will place one hand on the uterine fundus and use his or her fingers to feel the changes in the uterus as it contracts. The nurse can determine the frequency of the contractions by noting the time from the beginning of one contraction to the beginning of the next one. To determine the duration of the contraction, the nurse will note the time when tensing of the fundus is first felt (the beginning of one contraction) and again as relaxation occurs (end of contraction). It's best to time several consecutive contractions before charting frequency or duration.

Mass casualty survivors are brought to the emergency department (ED) after a disaster. The nurse is assigned to four clients who were triaged in the field and have just arrived in the ED. Which client will the nurse care for first? The person with multiple wounds and an open fracture The person with hypotension and a sucking chest wound Correct! The person with head trauma requiring mechanical ventilation The person with an undisplaced fracture of the radius

Typically, the tab colors used in triage are black, yellow, green and red. Red-tagged clients have immediate threats to life and require care right away; this would be the survivor with hypotension and a sucking check wound. Yellow-tagged clients have major injuries that need treatment within 30 minutes to 2 hours (the client with the open fracture), and green-tagged client have injuries that can be delayed more than 2 hours (the closed fracture). Black-tagged clients are treated last during a mass casualty situation because there is little chance for survival.

The 75 year-old female client is newly diagnosed with urge incontinence. She confides that she is often incontinent of large amounts of urine and expresses a fear of falling when rushing to the bathroom. What are the most appropriate nursing interventions to review with the client? (Select all that apply.) Assist with pessary insertion Perform pelvic floor muscle exercises Correct! Review preoperative instructions Schedule urination Correct! Restrict foods that may irritate the bladder Correct!

Urge incontinence involves periodic, but frequent, leakage of urine. Treatment involves treating the underlying cause, but in most cases, no cause can be found. Medication and behavioral interventions are tried before surgery is considered. Behavioral changes include bladder retraining with urge suppression, restricting foods that may irritate the bladder, drinking less than 8 ounces of fluid at one time and pelvic floor muscle exercises. A pessary is commonly used in the management of pelvic support defects such as cystocele and rectocele; it can also be used in the treatment of urinary stress incontinence, but not urge incontinence.

The oncology nurse is preparing to administer the initial dose of vincristine to a child diagnosed with acute lymphocytic leukemia (ALL). Which intervention is most appropriate to add to the plan of care? (Select all that apply.) Verify blood return before, during and after intravenous administration Monitor liver enzyme tests Monitor for numbness or tingling in the fingers and toes Apply ice to the injection site if extravasation occurs Select appropriate catheter for intrathecal administration

Verify blood return before, during and after intravenous administration Monitor liver enzyme tests Monitor for numbness or tingling in the fingers and toes ALL is the most common type of cancer in children and treatment protocols include vincristine. Vincristine (Oncovin) is for intravenous use only; intrathecal administration can be fatal. Vincristine is a vesicant that can cause significant local damage if extravasation occurs; treatment includes subcutaneous injection of an antidote and warm compresses (topical cooling may worsen the effect). Peripheral neuropathy is a major side effect associated with vincristine. The nurse should monitor for decreased hepatic functioning because vincristine is metabolized in the liver.

A nurse is anticipating providing guidance to parents of a toddler about readiness for toilet training. Which statement describes what the nurse should know in order to provide such guidance? Neuronal impulses are interrupted at the base of the ganglia Myelination of the spinal cord is completed by this age Correct Response The child learns voluntary sphincter control through repetition The toddler can understand cause and effect Incorrect

Voluntary control of the sphincter muscles can be gradually achieved due to the complete myelination of the spinal cord. The time frame is between the ages of 18 to 24 months of age. If the child has not begun walking without holding on then myelination of sphincters is not complete and toilet training would not be successful.

A nurse is teaching a client with a diagnosis of metastatic bone disease about actions to prevent hypercalcemia. It would be important for the nurse to include which of these points? Walking as much as possible keeps the calcium in the bone A restriction of fluid intake is to be less than one liter per day At least five servings of dairy products are to be eaten daily Early recognition of findings associated with tetany

Walking as much as possible keeps the calcium in the bone Mobility must be emphasized to prevent demineralization and breakdown of bones. Weight-bearing and resistance exercises will assist in this process.

A client with a central line catheter is being discharged. Which of the following methods is the most accurate way to evaluate the client's partner's ability to provide central line catheter dressing changes at home? Allow repeated practice on a lifelike mannequin Provide pamphlets and pictures about the skill Watch the partner change the dressing Send the partner to a class about how to change dressings

Watch the partner change the dressing Each of the teaching methods is appropriate for a manual skill such as a dressing change. However, the only one that actually demonstrates mastery is observing the partner perform the skill.