Practice Questions 2022

The nurse is discussing common health issues with the parents of a teenager. Which of the statements made by the parents would indicate that the adolescent may have Anorexia Nervosa? 1️⃣ My child's teeth are starting to erode 2️⃣ My child has a fear of gaining weight 3️⃣ My child has stopped going to the gym 4️⃣ My child binge eats when they are stressed

2️⃣ My child has a fear of gaining weight This is a classic symptom of anorexia nervosa. The child will restrain himself from food because they are so fearful of gaining weight.

The nurse provides teaching for a client prescribed disulfiram for alcohol abstinence. Which of the following statements by the client indicates the need for further teaching? 1️⃣ "I can take liquid cold and cough medications if I am feeling sick" 2️⃣ "I will wear a bracelet altering others of being on disulfiram therapy" 3️⃣ "I will abstain from alcohol for 2 weeks after the last does" 4️⃣ "I understand that disulfiram therapy does not cure alcoholism"

1️⃣ "I can take liquid cold and cough medications if I am feeling sick" This statement does not indicate that teaching has been effective. The client needs to avoid alcohol while on this medication. That means all things containing alcohol! Cold and cough medications contain alcohol and would produce an unpleasant response.

The nurse receives reports on 4 clients. Which client should the nurse assess first? 1️⃣ A client who recently received a thyroidectomy with a temperature of 100.1 F who reports feeling anxious 2️⃣ A client who received a dose of nitroglycerin and reports a bad headache 3️⃣ A client with pancreatitis who report pain rating 7 out of 10 and has a heart rate of 98 beats/min 4️⃣ A client with a continuous bladder irrigation who reports bladder spasms

1️⃣ A client who recently received a thyroidectomy with a temperature of 100.1 F who reports feeling anxious This client is showing signs of a thyroid storm. After a thyroidectomy, thyroid hormone levels may stay elevated causing a thyroid storm (an acute and life-threatening emergency). This patient should be seen by the nurse first!

The nurse on a med surg floor is getting a report from the nurse on the night shift. The following clients have family members reporting concerns. Which client should the nurse see first? 1️⃣ A client with a glasgow coma scale of 9 and is no longer responding when called 2️⃣ Client who has a migraine and is reporting pain 10/10 3️⃣ A client who is waiting to be discharged and is becoming impatient 4️⃣ A client with amyotrophic lateral sclerosis is experiencing weakness

1️⃣ A client with a glasgow coma scale of 9 and is no longer responding when called Glascow coma score of 9 is not good. A patient with a GCS of 8 or lower is classified as a coma "When you are 8, intubate." This patient's GCS of 9 indicates they have a declining neurological status which threatens the airway and breathing (ABC's)! This patient is the priority concern!

The nurse reviews the arterial blood gas results of a client and notes the following: pH = 7.45, PCO2 = 30 mmHg, and HCO3 = 22 mEq/L. The nurse analyzes these results as indicating which condition? 1️⃣ Metabolic acidosis, compensated 2️⃣ Respiratory alkalosis, compensated 3️⃣ Metabolic alkalosis, uncompensated 4️⃣ Respiratory acidosis, uncompensated

2️⃣ Respiratory alkalosis, compensated

The nurse is reviewing the laboratory results for her four clients. Which lab result would be most important for the nurse to report to the primary health care provider? 1️⃣ Client with atrial fibrillation who takes warfarin and has an INR of 1.4 2️⃣ Client with sepsis receiving Azithromycin who has a creatinine level of 0.8 mg/dL 3️⃣ Client with a catheter-associated urinary tract infections (CAUTI) who has a white blood cell count of 15,000/mm 4️⃣ Client who has elective cholecystectomy with a hematocrit of 45% and a hemoglobin of 14 g/dL

1️⃣ Client with atrial fibrillation who takes warfarin and has an INR of 1.4 A client on Warfarin (Coumadin) should have an INR of 2-3. This patient is at increased risk for stroke and the nurse needs to report this to the primary health care provider.

A 58-year old male client was admitted to your med-surg unit with coronary artery disease. He is being discharged home with a prescription for sublingual nitroglycerin (NTG) to treat angina. After educating the client about the medication, which of the following statements made by the client indicates the teaching was effective? select all that apply 1️⃣ I should sit down before taking this medication 2️⃣ I will call 911 if my pain doesn't get better or worse within 5 minutes of taking the first tablet 3️⃣ I should swallow the tablet 4️⃣ If I experience flushing, I will call 911 immediately 5️⃣ I can expect to have a headache when taking this medication

1️⃣ I should sit down before taking this medication 2️⃣ I will call 911 if my pain doesn't get better or worse within 5 minutes of taking the first tablet 5️⃣ I can expect to have a headache when taking this medication 1. Nitroglycerin is a vasodilator that causes dizziness and orthostatic hypotension. The client should lie or sit down before taking this medication. 2. If the client has worsening or unimproved pain after 5 minutes after the first tablet, the emergency medical services (EMS) should be called. 5. Headaches are a normal side effect of nitroglycerin due to the drug's vasodilation effect. 911 does not need to be called.

The nurse on the med surg floor is doing discharge teaching for a client with peripheral artery disease (PAD). Which of the following statements by the client indicates the need for further education? (Select all that apply) select all that apply 1️⃣ I will use a heating pad to promote circulation 2️⃣ I elevate my legs while watching tv 3️⃣ I will perform daily skin care and apply moisturizing lotion 4️⃣ I will dangle my legs off the bed while sitting 5️⃣ I will join a gym and walk on the treadmill

1️⃣ I will use a heating pad to promote circulation 2️⃣ I elevate my legs while watching tv 1. Most patients with PAD have impaired sensation and may burn themselves without feeling it. Heating pads should be avoided. Further education is needed. 2. Remember: elevation is appropriate for vein problems (PVD), not arterial problems. Further education is needed.

The nurse in the emergency department received a client with severe head and back injuries from a recent Motor Vehicle Accident (MVA). The nurse will perform what action to best visualize the airway? 1️⃣ Jaw-thrust maneuver in the supine position on a backboard 2️⃣ Jaw-thrust maneuver in Fowler's position 3️⃣ Head-tilt chin-lift in supine position on a backboard 4️⃣ Head-tilt chin-lift in Trendelenburg position

1️⃣ Jaw-thrust maneuver in the supine position on a backboard The nurse should use the jaw-thrust maneuver and place the client on the backboard to immobilize the spine.

A client at 13 weeks gestation arrives at the clinic for her appointment. The nurse is reviewing her history and obtains a list of her current medications. The nurse recognizes which of the following medications should be clarified to the health care provider immediately? (select all that apply) 1️⃣ Lisinopril 2️⃣ Albuterol 3️⃣ Insulin Aspart 4️⃣ Isotretinoin 5️⃣ Lithium 6️⃣ Levothyroxine

1️⃣ Lisinopril This is a teratogenic drug, which should be avoided during pregnancy. 4️⃣ Isotretinoin ✅ This is a teratogenic drug, which should be avoided during pregnancy. 5️⃣ Lithium ✅ This is a teratogenic drug, which should be avoided during pregnancy.

A client who was admitted from the emergency department for myocardial infarction (MI) is receiving Alteplase (tPA). Knowing this medication and its adverse effects, the nurse should plan to prioritize which of the following? 1️⃣ Observe for signs of bleeding 2️⃣ Monitor signs of kidney failure 3️⃣ Keep the client NPO until after the infusion is complete 4️⃣ Observe for any neurological changes

1️⃣ Observe for signs of bleeding Alteplase (tPA) is a thrombolytic drug; the drug breaks down blood clots for treatment of myocardial infarction, ischemic stroke, blood clots, etc. Observing for signs of bleeding is the main priority when a patient is receiving this medication!

You as the nurse are caring for a client with diabetes mellitus who previously had been well controlled with glyburide daily, but recently their fasting blood glucose levels have been 190 to 210 mg/dL. Which medication may have contributed to the client's hyperglycemia? 1️⃣ Prednisone 2️⃣ Atenolol 3️⃣ Phenelzine 4️⃣ Allopurinol

1️⃣ Prednisone NCLEX TIP: Corticosteroids cause a spike in blood sugar!

You are educating your nulliparous client about the signs of "true" labor. Which of the following statements made by the client indicates the need for further education? 1️⃣ True labor is felt in the back and above the umbilicus 2️⃣ True labor is when contractions get more intense with walking 3️⃣ During true labor, I may experience bloody show 4️⃣ True labor begins in my lower back and radiates to my abdomen

1️⃣ True labor is felt in the back and above the umbilicus This is a false statement and shows the client needs further teaching. This is a sign of false labor.

The nurse is doing discharge teaching for a postpartum client who is breast-feeding. Which instruction should the nurse include? 1️⃣ Birth control measures are unnecessary while breast-feeding 2️⃣ The diet should include additional fluids 3️⃣ Prenatal vitamins should be discontinued 4️⃣ Soap should be used to cleanse the breasts

2️⃣ The diet should include additional fluids A breastfeeding mother should drink additional fluids to produce breast milk. (Fun fact: breast milk is mostly made up of water!)

A client is found to be comatose and hypoglycemia with a blood sugar of 50 mg/dL. What nursing action is implemented first? 1️⃣ Infuse 1000 mL of D5W over a 12-hour period 2️⃣ Administer 50% glucose intravenously 3️⃣ Check the client's urine for the presence of sugar and acetone 4️⃣ Encourage the client to drink orange juice with added sugar

2️⃣ Administer 50% glucose intravenously This is the correct answer because the hypoglycemic client needs immediate attention. This is the quickest and most appropriate intervention!

The nurse is assessing a 38-week newborn 2 hours after a precipitous vaginal delivery. What findings can be expected during this time in the newborn? (Select all that apply) select all that apply 1️⃣ Skin on the nose blanches to a yellowish hue 2️⃣ Blueness of the hands and feet 3️⃣ Assessment of the umbilical cord shows one artery and one vein 4️⃣ White pearl-like cysts on the palate 5️⃣ Toes hyperextend when the lateral sole surface is stroked

2️⃣ Blueness of the hands and feet 4️⃣ White pearl-like cysts on the palate 5️⃣ Toes hyperextend when the lateral sole surface is stroked 2. This is called Acrocyanosis. This is a normal finding when the neonate is transitioning to extrauterine life. This finding is expected. 4. These are called epstein pearls and are benign. You can educate the parents that they will disappear in a few weeks. This is a normal finding and does not need further intervention. 5. This is called the Babinksi reflex and is a normal finding at birth. This reflex should disappear around 1 year of age. This is a normal finding and does not need further intervention.

A client comes into the emergency department with suspected carbon monoxide poisoning from a house fire. Which manifestations would correlate with this finding? 1️⃣ Oxygen saturation of 83% 2️⃣ Cherry red color of the mucous membranes 3️⃣ Singed hair on the face 4️⃣ Nasal flaring and trouble breathing

2️⃣ Cherry red color of the mucous membranes This is a typical and very specific sign of CO poisoning. Carbon monoxide travels faster than oxygen, making CO bind to hgb first. This results in vasodilation and a "cherry red" color of the mucous membranes.

A client is admitted to the ambulatory unit for an endoscopy. The nurse administered diazepam 1 mg intravenously for sedation and titrates the dosage up to 2.5 mg. The client's blood pressure begins to drop (83/65) and starts to show signs of respiratory depression (periods of apnea & oxygen saturation of 84%). The nurse should administer which antidote drug? 1️⃣ Naloxone 2️⃣ Flumazenil 3️⃣ Atropine 4️⃣ Protamine Sulfate

2️⃣ Flumazenil Flumazenil is the antidote for benzodiazepines which commonly end in "-zolam or "-zepam"

A nurse in the cardiac intensive care unit is caring for a client with a continuous infusion of dopamine. Which assessment finding indicates that the infusion rate may need to be adjusted? 1️⃣ Central venous pressure of 4 mmHg 2️⃣ Heart rate of 125 beats/min 3️⃣ Mean arterial pressure is 82 mmHg 4️⃣ Systemic vascular resistance is 1000 dynes/sec/cm^5

2️⃣ Heart rate of 125 beats/min Dopamine is an Intropin. This causes vasoconstriction in order to improve hemodynamic status in clients with heart failure or shock. It increases heart rate and blood pressure. However, it can increase HR and BP too much causing tachycardia and arrhythmias. A heart rate of 125 should warrant the nurse to make adjustments to the infusion rate.

The nurse is teaching a mother of a newborn on ways to prevent sudden infant death syndrome (SIDS). Which of the following statements made by the mother requires further teaching? 1️⃣ I will place the infant on their back for naps and bedtime 2️⃣ I will be sure to place blankets in the crib so they don't get too cold 3️⃣ I will not let my baby sleep in the same bed as me 4️⃣ I will avoid exposure to tobacco smoke

2️⃣ I will be sure to place blankets in the crib so they don't get too cold Extra items should be removed from the crib because they could strangle or suffocate the infant. This statement requires further teaching.

The nurse working on a mental health unit has a client with general anxiety disorder who has been prescribed diazepam. Which statement made by the client indicates that the nurse's teaching has been effective? 1️⃣ I can skip doses on days I am not experiencing anxiety 2️⃣ I will take this medication before I go to bed 3️⃣ I will use sunscreen while in the sun because this medication makes me sensitive to sunlight 4️⃣ I will eliminate foods such as chocolates, aged cheese, & fermented meats from my diet while on this medication

2️⃣ I will take this medication before I go to bed Benzodiazepines commonly cause sedation which can interfere with daytime activities such as work and driving. So the best time to take this medication is at night. This statement indicates that teaching has been effective.

The nurse is caring for a client who just returned from the recovery room after undergoing an Appendectomy. The nurse identifies which of the following is an early sign of hypovolemic shock? 1️⃣ Sleepiness 2️⃣ Increase heart rate 3️⃣ Increase depth of respirations 4️⃣ Increase orientation to surroundings

2️⃣ Increase heart rate Increased HR and decreased blood pressure are two two early signs of hypovolemic shock.

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. What statement should the nurse make to the client? 1️⃣ Sounds like an infection, you may need antibiotics 2️⃣ The vaginal discharge may be bothersome, but it's normal during pregnancy 3️⃣ You should call and ask your healthcare provider 4️⃣ Use tampons if the discharge is bothersome

2️⃣ The vaginal discharge may be bothersome, but it's normal during pregnancy Thin, colorless vaginal discharge is called Leukorrhea. It begins around the first semester of pregnancy. This is a normal finding and is the best statement for the nurse to say.

You are caring for a client with Graves' disease. Which of the following signs and symptoms would you expect to see? select all that apply 1️⃣ Extreme fatigue 2️⃣ Weight loss 3️⃣ Exophthalmos 4️⃣ Sensitivity to Cold 5️⃣ Hyperactivity

2️⃣ Weight loss 3️⃣ Exophthalmos 5️⃣ Hyperactivity 2. Clients with hyperthyroidism have a lot of energy and ↑ metabolism so they tend to lose weight despite having ↑ appetites. 3. Clients with hyperthyroidism may have exophthalmos (see picture below). This is when the eyes bulge due to inflammation. 5. Clients with hyperthyroidism have a lot of energy!

Four clients enter the emergency department at the same time. Which client should the nurse see first? 1️⃣ 69-year-old with pain, swelling, erythema, and warmth in the left leg. 2️⃣ 70-year-old client with left lower abdominal pain and vomiting for 2 days 3️⃣ 25-year-old client with sudden-onset radiating chest pain and heart rate of 110/min 4️⃣ 30-year-old with diabetes who has lost there insulin glargine

3️⃣ 25-year-old client with sudden-onset radiating chest pain and heart rate of 110/min SUDDEN, CRUSHING, RADIATING are keywords that may indicate a myocardial infarction. This patient is the primary concern. An ECG should be performed immediately and the client should be placed on a cardiac monitor.

A nurse working in the emergency department has four clients arrive at the same time. Which client should the nurse see first? 1️⃣ An 80-year old who is complaining of frequent liquid colored stools 2️⃣ A 50-year old who complains of pain in his knees 3️⃣ A 20-year old who got a singed beard while camping with his friends 4️⃣ A 1-month old infant who is crying from hitting his head and has bulging fontanelles while crying

3️⃣ A 20-year old who got a singed beard while camping with his friends A singed (burnt) beard or any singed hair near the face is most likely a result of inhaling smoke. This can cause injury to the lungs or carbon monoxide poisoning and is very dangerous. Remember your ABC's: airway always takes priority. This patient is most likely to be in immediate danger, so the nurse would need to see this patient first.

Four clients experienced a burn. Which client should the nurse be most concerned about getting an infection? 1️⃣ A client who is 13 years old with a first-degree burn on their leg 2️⃣ A client who has burned himself in the past 3️⃣ A client with burned areas including the hands & perineum 4️⃣ A client who had a burn that took place in an open field

3️⃣ A client with burned areas including the hands & perineum Open areas of the body such as the ears, perineum, mouth are more prone to infection because bacteria can easily enter. We are most concerned about infection in this patient.

The nurse is caring for clients on a medical-surgical floor. The nurse gets a report from the previous nurse. Based on this report which client would be the first priority to assess? 1️⃣ A client with a deep vein thrombosis in their left leg who missed the last dose of Coumadin 2️⃣ A client with COPD who has an O2 saturation of 90% and diminished breath sounds 3️⃣ A client with sepsis who is developing petechiae 4️⃣ A client with type 2 diabetes whose last chem stick read 160 mg/dL

3️⃣ A client with sepsis who is developing petechiae Clients with sepsis are at risk for a life-threatening condition called disseminated intravascular coagulation (DIC). A classic sign of DIC is petechiae. This client would take priority!

You are taking the history of a 17-year-old female client who has a BMI of 17. She reports restricting herself from eating, fear of gaining weight, and reports severe constipation. Which of the following would you most suspect? 1️⃣ Bulimia nervosa 2️⃣ Binge eating disorder 3️⃣ Anorexia nervosa 4️⃣ Refeeding syndrome

3️⃣ Anorexia nervosa This patient is showing signs and symptoms of anorexia nervosa: self-restriction from eating, BMI <18.5, constipation, and fear of gaining weight.

A client with end-stage renal disease who was recently placed on a Do Not Resuscitate (DNR) code status is admitted to the medical floor. The nurse walks into the room and finds the patient passed out and appears to not be breathing. Which of the following actions should the nurse take first? 1️⃣ Initiate high quality CPR 2️⃣ Call the health care provider 3️⃣ Check the apical pulse 4️⃣ Active the code blue system

3️⃣ Check the apical pulse Checking the apical pulse is the appropriate action at this time. You will need to confirm the patient is not breathing and has passed.

The nurse is assessing a client after receiving a nitroglycerin infusion for a client with a recent myocardial infarction. Which clinical finding is the priority concern? 1️⃣ Client appears flushed 2️⃣ Client reports a headache 3️⃣ Client report feeling very dizzy & lightheaded 4️⃣ Client reports feeling nervous

3️⃣ Client report feeling very dizzy & lightheaded ✅ This indicates profound hypotension, which means low blood pressure. The organs are not being perfused with blood if hypotension is occurring. This would be a priority action & the infusion should be decreased or discontinued!

A client is receiving lithium carbonate 900 mg/day for bipolar disorder. The laboratory notifies the nurse that the client's lithium levels are 1.0 mEq/L. Based on this result, what is the most appropriate action the nurse could take? 1️⃣ Decrease the dosage 2️⃣ Discontinue the medication immediately 3️⃣ Continue at the current dosage 4️⃣ Increase the dosage

3️⃣ Continue at the current dosage The patient's current lithium level is 1.0 mEq/L. This is within normal range so no adjustments need to be made at this time!

The nurse is caring for a client who is receiving IV heparin and oral warfarin. You receive the following laboratory values for your client: aPTT is 4 times the control value. PT/INR is 1.5 times the control value. Which of the following actions would be appropriate to make at this time? 1️⃣ Administer a vitamin K injection 2️⃣ Hold the next warfarin dose 3️⃣ Decrease the heparin rate 4️⃣ Re-educate the client about their vegetable consumption

3️⃣ Decrease the heparin rate The patient's control value is higher than the therapeutic range. This increases their chances of bleeding; the heparin rate should be decreased.

A client has a prescription for hydrochlorothiazide due to edema from heart failure. The nurse should monitor which adverse effects related to the administration of this medication? 1️⃣ Hypouricemia, hyperkalemia 2️⃣ Fluid volume overload, hypoglycemia 3️⃣ Hypokalemia, sulfa allergy 4️⃣ Hyperkalemia, hypoglycemia, penicillin allergy

3️⃣ Hypokalemia, sulfa allergy Thiazide diuretics such as hydrochlorothiazide are sulfa-based medication; clients with a sulfa allergy are at high risk for an allergic reaction. Thiazide diuretics are potassium wasting drugs. This is why hypokalemia is a potential ADR.

A client gives birth within 2 hours of arriving on your floor. She has a smooth delivery and delivers the placenta 5 minutes later. You as the labor & delivery nurse assess the fundus and notes that the uterus is midlines and boggy. Which action should the nurse take first? 1️⃣ Increase IV oxytocin rate 2️⃣ Notify the health care provider 3️⃣ Perform fundal massage 4️⃣ Check for hemorrhage

3️⃣ Perform fundal massage Fundal massages stimulate the contraction of the uterine smooth muscle.

The registered nurse (RN) on a busy med-surg unit has assistance from the licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which tasks would be most suitable to assign to the LPN? select all that apply 1️⃣ Discharge teaching to a client with heart failure 2️⃣ Assisting with linen change, feeding, and bathing a client with Parkinson's disease 3️⃣ Performing wound care and sterile dressing change for a client with a stasis ulcer 4️⃣ Repositioning a client every 2 hours with a stage 1 pressure ulcer 5️⃣ Administering a schedule analgesic to a client with chronic back pain

3️⃣ Performing wound care and sterile dressing change for a client with a stasis ulcer 5️⃣ Administering a schedule analgesic to a client with chronic back pain 1. only RN can do teaching 2. more appropriate for the UAP 4. more appropriate for the UAP

The nurse is caring for a client with congestive heart failure and is about to administer their morning dose of spironolactone (Aldactone). Which of the following lab values should be reported before giving the scheduled medication? 1️⃣ Calcium: 10 mg/dL 2️⃣ Sodium: 132 mEq/L 3️⃣ Potassium: 5.3 mEq/L 4️⃣ Chloride: 102 mEq/L

3️⃣ Potassium: 5.3 mEq/L normal calcium: 9-11mg/dL normal sodium: 135-145 normal potassium: 3.5-5 normal chloride: 95-105mEq/L

The nurse is caring for a client with a newly diagnosed seizure disorder. The healthcare provider prescribes seizure precautions for the client. The nurse prepares to initiate which intervention? 1️⃣ Place restraints on the client to prevent injury 2️⃣ Prepare to insert a urinary catheter 3️⃣ Set up suction equipment at the bedside 4️⃣ Remove all linen from the bed

3️⃣ Set up suction equipment at the bedside This is part of seizure precautions: setting up suction equipment and oxygen. This would be an appropriate nursing intervention.

A client receiving magnesium sulfate has a drop in their urinary output from 140 mL at 10 AM to 100 mL at 11 AM. What would be the priority nursing intervention? 1️⃣ Call the primary healthcare provider 2️⃣ Decrease the infusion 3️⃣ Stop the infusion 4️⃣ Reassess in 15 minutes

3️⃣ Stop the infusion ✅ YES! This patient is at risk for magnesium toxicity and the magnesium infusion should be stopped. This is the priority nursing intervention.

A client comes into the emergency department after being in a MVA. After imaging studies, it's found that the client has a fracture to the jawbone. Your assessment shows that there is severe edema around the face and jaw, drooling, and blood in the mouth. The client rates their pain 8 out of 10. What is the priority nursing intervention? 1️⃣ Administer an analgesic for pain 2️⃣Administer nasal oxygen at 2 L/min 3️⃣ Suction the mouth and oropharynx 4️⃣ Apply an ice pack to the face

3️⃣ Suction the mouth and oropharynx ✅ Excessive saliva and edema can compromise the airway making this the priority nursing intervention.

You are educating your client who was recently diagnosed with insomnia on ways to improve their sleep. The nurse should include which intervention to improve the client's sleep? 1️⃣ Eat 2 ounces of chocolate before bedtime 2️⃣ Drink 1 glass (12 oz) of red wine 2 hours before bedtime 3️⃣ Take a walk 3 hours before bedtime 4️⃣ Sleep with a continuous positive airway pressure (CPAP) machine

3️⃣ Take a walk 3 hours before bedtime Non-strenuous exercises such as leisurely walking can reduce the client's stress level and relax the muscles. This is an appropriate intervention.

A 19-year-old female is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce? 1️⃣ Use sunscreen while outside, even if it's cloudy 2️⃣ Do not break, crush, or chew the capsules 3️⃣ Use two forms of contraception while on this medication 4️⃣ Apply eyes drops when wearing contacts to lubricate the eyes

3️⃣ Use two forms of contraception while on this medication Isotretinoin is teratogenic, meaning it can cause serious harm to the developing fetus while in the mother's womb. This patient should take precautions to not become pregnant while using this medication.

The nurse is caring for a client admitted for a recent myocardial infarction (MI) 18 hours ago. Which finding should be reported to the health care provider (HCP)? 1️⃣ The CNA tells you they have a temperature of 100.4 F 2️⃣ The client reports nausea and vomiting 3️⃣ You hear a new s3 heart sound during your assessment 4️⃣ Premature ventricular contraction (PVC) occasionally seen on the EKG strip

3️⃣ You hear a new s3 heart sound during your assessment S3 heart sounds are due to rapid ventricular filling in early diastole. This finding may indicate pulmonary congestion which may indicate signs of heart failure! This should be reported to the HCP immediately.

The nurse is evaluating a client with bipolar disorder who was prescribed lithium therapy a few months ago. Which statement made by the client would cause the most concern? 1️⃣ "I've been napping more than normal this week." 2️⃣ "My mouth has been so dry since being on this medication." 3️⃣ "I've gained 4 lbs since being on this medication." 4️⃣ "I've had diarrhea for the past couple of days. I think I have the stomach flu."

4️⃣ "I've had diarrhea for the past couple of days. I think I have the stomach flu." Dehydration and sodium loss from vomiting or diarrhea can cause lithium levels to go up in the bloodstream, leading to TOXICITY. This statement should cause the most concern!

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? 1️⃣ "Stay as still as you can" 2️⃣ "Exhale very quickly" 3️⃣ "Inhale and exhale quickly" 4️⃣ "Instruct the client on how to perform Valsalva maneuver"

4️⃣ "Instruct the client on how to perform Valsalva maneuver" This is the proper technique when removing a chest tube. The Valsalva maneuver is when you take a deep breath, exhale, and bear down.

A 25-year-old male patient who weighs 70 kg has sustained burns to the back of the right arm, posterior trunk, front of the left leg, and their anterior head and neck. Using the Rule of Nines, calculate the total body surface area percentage that is burned. 1️⃣ 38% 2️⃣ 55% 3️⃣ 40.5% 4️⃣ 36%

4️⃣ 36% Back of right arm - 4.5%Posterior trunk - 18%Front of left leg - 9%Anterior head & neck- 4.5%4.5% + 18% + 9% + 4.5% = 36%

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder? 1️⃣ A 24-year-old woman who runs marathons 2️⃣ A 42-year-old man who has COPD 3️⃣ A 68-year-old man who had recent knee surgery 4️⃣ A 65-year-old woman who smokes cigarettes

4️⃣ A 65-year-old woman who smokes cigarettes Smoking increases your risk of osteoporosis! This client is at the most risk for developing osteoporosis.

The nurse is monitoring a client with a peptic ulcer. Which assessment finding would most likely indicate a perforated ulcer? 1️⃣ Bradycardia 2️⃣ Numbness in the legs 3️⃣ Nausea & vomiting 4️⃣ A rigid, boardlike abdomen

4️⃣ A rigid, boardlike abdomen A rigid, boardlike abdomen is a classic sign of a gastrointestinal (GI) bleed such as a perforated ulcer. This finding would most likely indicate a perforated ulcer.

A client who had cardiac surgery 28 hours ago has a urine output of 19 mL/hr at 0900 and 18mL/hr at 1000. The client received a 500 mL bolus of IV fluid. The client's blood urea nitrogen is 45 mg/dL and the serum creatinine is 2.2 mg/dL. A nurse interprets the client is at risk for: 1️⃣ Hypovolemia 2️⃣ Hypotension 3️⃣ Urinary tract Infection 4️⃣ Acute renal failure

4️⃣ Acute renal failure This patient's BUN and creatinine levels are high! An elevated BUN and an elevated serum creatinine level indicates the client is at risk for kidney damage.

The nurse is performing a postpartum assessment on a woman 6 hours after delivery of a term infant. Which assessment finding should be reported to the health care provider? 1️⃣ Oral Temperature of 100.1 F 2️⃣ A gush of lochia appears as the uterus is massaged 3️⃣ White blood cell count of 14,000/mm3 4️⃣ Foul-smelling lochia

4️⃣ Foul-smelling lochia Foul smelling lochia, fever (>100.4 F ), abdominal tenderness, and tachycardia may all be signs of endometrial infection and should be reported to the health care provider.

A nurse caring for a client with a chronic obstructive pulmonary disease (COPD) exacerbation. The client is also receiving insulin due to a history of type 2 diabetes mellitus. The client has been received dexamethasone. The nurse anticipates the need for which of the following? 1️⃣ Monitoring and recording intake and output 2️⃣ Stopping the medication once the symptoms stop 3️⃣ Closely monitor for hypotension 4️⃣ Increasing the insulin dose

4️⃣ Increasing the insulin dose Corticosteroids like dexamethasone increase blood sugar, which means the diabetic client would need more insulin to counteract this rise in blood pressure.

A mother with uncontrolled diabetes mellitus just gave birth to a newborn at term gestation. When caring for the newborn, which clinical finding would alarm the nurse? 1️⃣ Respiration of 50 2️⃣ APGAR score of 8 3️⃣ Cyanosis of the hands & feet 4️⃣ Jitteriness

4️⃣ Jitteriness A mother with uncontrolled diabetes increases the newborn's risk for hypoglycemia (because glucose supply is cut off at birth). Common signs of hypoglycemia are jitteriness, hypotonia, lethargy, and irritability. These signs would alarm the nurse.

A pediatric nurse gets assigned to a child who was admitted due to persistent vomiting. The nurse knows this child is at greatest risk for which of the following? 1️⃣ Diarrhea 2️⃣ Metabolic acidosis 3️⃣ Hyperactive bowel sounds 4️⃣ Metabolic alkalosis

4️⃣ Metabolic alkalosis Vomiting causes your body to lose HCl (an acid) which leads to an increased risk for alkalosis. The question states the child is vomiting persistently so we know the child is at risk for metabolic alkalosis!

The school nurse is helping with a field trip for 3rd graders. An 8-year-old who is conscious has clammy skin, sweating, and is shaking. The client has type 1 diabetes controlled with insulin detemir & NPH. What is the most suitable action by the nurse? 1️⃣ Give an IM injection of glucagon 2️⃣ Give the child a peanut butter and jelly sandwich 3️⃣ Administer Lispro (a fast-acting insulin) in the abdomen 4️⃣ Provide 4 oz of fruit juice

4️⃣ Provide 4 oz of fruit juice When treating a hypoglycemic patient, it's good to go by the "15X15X15 rule." 15 grams of carbohydrates, recheck blood glucose in 15 min, and repeat 15 grams of carbohydrate if blood sugar remains low.

The charge nurse on a med-surg floor is making assignments for the day. Which assignment is most appropriate? 1️⃣ LPN assigned to a newly admitted client with COPD who is having trouble breathing. 2️⃣ UAP assigned to feed a patient with a recent stroke who is on aspiration precautions. 3️⃣ LPN assigned to a client who is receiving blood for a gastrointestinal bleed. 4️⃣ RN assigned to a client who is being transferred to the intensive care unit due to a pulmonary embolism.

4️⃣ RN assigned to a client who is being transferred to the intensive care unit due to a pulmonary embolism. This is within the RN's scope of practice. A patient who is being transferred to the ICU is unstable. The registered nurse is the only one who should care for unstable clients. This is the only acceptable answer to this question!

The nurse on a cardiac floor is reviewing the lab results of a client who is receiving warfarin for atrial fibrillation. The patient's INR is 5.0. Which of the following actions should the nurse take? 1️⃣ Anticipate infusing fresh frozen plasma 2️⃣ Continue with the morning dose of warfarin 3️⃣ Request a prescription to administer protamine 4️⃣ Request a prescription to administer Vitamin K

4️⃣ Request a prescription to administer Vitamin K Vitamin K is the correct antidote for warfarin overdose and this would be an appropriate action to take by the nurse.

A client with chronic heart failure is being discharged home with furosemide and sustained-release potassium chloride tablets. Which instructions should the nurse give to the client regarding the potassium supplements? 1️⃣ Take potassium tablets on an empty stomach 2️⃣ If you can't swallow the pill, you can crush it and mix it with pudding 3️⃣ A diet rich in protein and vitamin D will help with absorption 4️⃣ Take it with a full glass of water and stay sitting upright afterward

4️⃣ Take it with a full glass of water and stay sitting upright afterward This is the correct instruction when teaching a client how to take potassium supplements! Flushing the pill with water will help to avoid potential erosion and esophagitis.

A client scheduled for bowel surgery states to the nurse, "I don't know if I want this surgery." Which response by the nurse is appropriate? 1️⃣ It's totally up to you 2️⃣ Don't worry. Everything will be fine 3️⃣ Why don't you want to have this surgery? 4️⃣ Tell me the concerns you have about this surgery

4️⃣ Tell me the concerns you have about this surgery This is an open-ended question that requires active listening by the nurse. This is the appropriate response by the nurse and shows therapeutic communication!

A nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse accurately tells the client that fetal circulation consists of: 1️⃣ Umbilical arteries that carry oxygenated blood to the fetus 2️⃣ Umbilical veins that carry deoxygenated blood to the fetus 3️⃣ Two umbilical veins & one umbilical artery 4️⃣ Two umbilical arteries & one umbilical vein

4️⃣ Two umbilical arteries & one umbilical vein

The nurse is teaching an underweight and malnourished client who was recently diagnosed with type 1 diabetes about the proper methods/techniques when giving insulin. Which one of the following shows a proper technique? 1️⃣ Pinch the skin up and use a 90-degree angle 2️⃣ Massage the area of injection after injecting the insulin 3️⃣ Warm the skin with a warm towel or washcloth prior to the injection 4️⃣ Use a 45-degree angle with the skin pinched up

4️⃣ Use a 45-degree angle with the skin pinched up For a thin client, you want to use a 45-degree angle with the skin pinched up.

A client in active labor with a cervical dilation of 5 cm and who is 80% effaced is having contractions. You as the labor nurse are monitoring her contractions. Which uterine assessment finding would require intervention? 1️⃣ Contraction duration of 70 seconds 2️⃣ Contraction frequency of every 4 minutes 3️⃣ Contraction intensity of 50 mmHg 4️⃣ Uterine resting tone of 30 mmHg

4️⃣ Uterine resting tone of 30 mmHg Uterine resting tone should not exceed 20 mmHg. The uterus must relax in order for the fetus to get oxygen. So a uterus that is not relaxing enough puts the fetus at risk. This assessment would require further intervention.

A client in active labor with a cervical dilation of 5 cm and who is 80% effaced is having contractions. You as the labor nurse are monitoring her contractions. Which uterine assessment finding would require intervention? 1️⃣ Contraction duration of 70 seconds 2️⃣ Contraction frequency of every 4 minutes 3️⃣ Contraction intensity of 50 mmHg 4️⃣ Uterine resting tone of 30 mmHg

4️⃣ Uterine resting tone of 30 mmHg Uterine resting tone should not exceed 20 mmHg. The uterus must relax in order for the fetus to get oxygen. So a uterus that is not relaxing enough puts the fetus at risk. This assessment would require further intervention.

A nurse is assessing a newborn with an infection from candida albicans. Which of the following assessments support this? 1️⃣ Fine, soft hair that covered the baby's entire body 2️⃣ Small, white cysts on the newborns palatinate 3️⃣ White, cheesy like substance that covers the newborn's skin 4️⃣ White patches on the tongue and palate

4️⃣ White patches on the tongue and palate Oral candidiasis (thrush) present as white patches on the tongue and palate. They do not scrape off and bleed when touched. Back Submit Clear form

The nurse is caring for a client with chest trauma. Assessment reveals headache, sleepiness, and confusion. Oxygen saturation is reading 87%. Which acid-base imbalance does the nurse suspect this patient is experiencing? Pt. chart: -pH = 7.31 -PaO2 = 76mmHg -PaCO2 = 54mmHg -HCO3 = 24mEq/L a. respiratory acidosis b. metabolic acidosis c. respiratory alkalosis d. metabolic alkalosis

a. respiratory acidosis Low pH <7.35 & High PaCO2 >45 mm Hg *Remember Respiratory = Opposite

You walk into your client's room and they say, "I haven't gotten any sleep while being in the hospital." Which response by the nurse illustrates a therapeutic communication with this client? a. Don't worry, you will sleep tonight b. You're having trouble sleeping while being in the hospital? c. I'm sorry d. I would have a hard time sleeping here also

b. You're having trouble sleeping while being in the hospital? This is an open-ended question and shows active listening skills, both of which displays a therapeutic response

A nurse who is precepting a nursing student observes the nursing students donning personal protective equipment (PPE). Which series of steps performed by the nursing student indicates that no further teaching is needed? a. mask/ respirator, hand hygiene, gown, goggles/face shield, gloves b. hand hygiene, gown, mask/ respirator, goggles/face shield, gloves c. gown, gloves, mask/ respirator, hand hygiene d. hand hygiene, mask/ respirator, gown, goggles/ face shield, gloves

b. hand hygiene, gown, mask/ respirator, goggles/face shield, gloves

A client taking furosemide for chronic heart failure is experiencing constipation. What should the nurse recommend to the client to help alleviate constipation? a. drink more fluids during the day, especially warm tea b. increase the amount of fiber in your diet c. exercise more frequently d. take warm shower

b. increase the amount of fiber in your diet

The nurse is precepting a nursing student caring for a client with Glaucoma. The student is administering Travoprost, an ophthalmic medication. Which action by the student indicates a need for further teaching? a. has the client tilt their head back slightly when administering the eye drops b. removes dried secretions with a moistened gauze by wiping from the outer to the inner canthus c. holds the dropper 1-2cm above the conjunctiva sac and drops the medications directly into the sac d. has the client close the eyelids and gently apply pressure to the nasolacrimal duct for 30-60 seconds

b. removes dried secretions with a moistened gauze by wiping from the outer to inner canthus proper way- inner to outer to prevent bacteria entering the eye

A client with generalized anxiety disorder has received a new prescription for fluoxetine. The nurse should teach the client about which possible side effect? a. weight loss b. sexual dysfunction c. sedation d. skin rash

b. sexual dysfunction Remember the 3 S's of SSRis (Sexual dysfunction, stomach upset, serotonin syndrome). The nurse should teach the client about this possible side effect.

A client is scheduled for an elective laparoscopic cholecystectomy. The nurse should notify the health care provider (HCP) about what findings before the surgery? a. platelet count of 300,000.mm^3 b. temperature of 100.4 F (38 C) with a mild cough c. WBC count of 9,000/mm^3 d. hemoglobin 15 g/dL and hematocrit 48%

b. temperature of 100.4 F (38 C) with a mild cough -normal platelet count: 150,000-400,000/ mm3 -temperature may indicate pt has an infection -normal WBC count: 4,500- 11,000/mm^3 -normal Hgb: 12-18g/dL and normal hematocrit: 35-55%

The nurse is doing discharge teaching with a client with newly diagnosed type 1 diabetes. The nurse is teaching the client how to mix regular insulin and NPH insulin in the same syringe. Which of the following actions would require further teaching? a. withdrawing the regular insulin first b. withdrawing the NPH insulin first c. injects air into NPH insulin vial first d. injecting an amount of air equal to the desired dose of insulin into each vial

b. withdrawing the NPH insulin first Nancy Reagan RN

A 42-year-old male client comes into the emergency department with a thermal burn injury. You are the oncoming nurse receiving the following vital signs. Blood pressure: 70/40; heart rate: 140 bpm; respiratory rate: 23/min. The patient is faint in color and you are having difficulty finding his pedal pulse. Which action will the nurse take first? a. get a doppler device to find the pedal pulse b. obtain an electrocardiogram (ECG) c. document your findings and continue to do hourly vital signs d. begin IV fluids

begin IV fluids When a patient has burns, think SHOCK. This is especially true since the vital signs indicate shock. Administering IV fluids is the priority action.

A parent comes into the clinic with her 4 -year old son who is sick with the flu. Which of the following statements made by the parent would require further education and intervention by the nurse? a. "I gave my child a strawberry popsicle this morning for hydration" b. "my son was complaining that his body ached so I gave him Ibuprofen" c. "my son had severe nausea so I gave him Bismuth subsalicylate" d. "I've been giving him Acetaminophen every 4 hrs for his fever"

c. "my son had severe nausea so I gave him Bismuth subsalicylate" You should not give a child salicylates (Aspirin). It increases the risk of developing Reye's syndrome which causes brain & liver damage to children with recent viral infections.

The nurse is caring for a client with bipolar disorder who is in an acute manic episode. Which dinner should the nurse choose as the most appropriate option to promote client nutrition? a. baked potato, spinach, croissants, and milk b. baked lasagna, salad, and water c. cheeseburger, orange slices, and a strawberry milkshake d. chicken noodle soup, a dinner roll, and iced tea

c. cheeseburger, orange slices, and a strawberry milkshake this is easily consumed while on the go because it is "finger food"

The nurse observes a new nurse performing chest compression on a 75-year old male. Which of the following would indicate the need for further teaching? a. compressing the chest to a depth of at least 2in b. placing the heel of the hand on the center of the chest c. compression rate of 140-160/min d. allowing the chest to recoil completely after each compression

c. compression rate of 140-160/min too fast: normal tempo = 10-120bpm

The nurse in the emergency department receives report on 4 clients. Which client should be seen first? a. a 55yr old who is NPO asking for a snack b. a 60yr old who has a mean arterial pressure (MAP) of 80mmHg c. a 20yr old who has a capillary refill of fewer than 3 seconds d. a 35yr old whose right hand is cooler than his left hand

d. a 35yr old whose right hand is cooler than his left hand pt should be assessed first due to the risk of losing his hand due to inadequate perfusion and blood supply

The charge nurse is making assignments for the day. Which client assignment should the nurse who is pregnant receive for the day? a. a 10yr old pt with parvovirus B-19 infection admitted after having a mild rash b. a 18month old with a rash on the face, sore throat, and a low grade fever, suspected to have Rubella c. a 14yr old with herpes simplex virus 1 (HSV-1) and has a cold sore on her lip d. a 7yr old pt admitted for severe throat pain with positive group A streptococcus cultures

d. a 7yr old pt admitted for severe throat pain with positive group A streptococcus cultures group A streptococcus does not pose a risk to the developing fetus, this would be the best pt for the pregnant nurse

The nurse working in an OBGYN clinic is collecting data from a pregnant client who is 8 weeks pregnant. Which of the following statements by the client needs further intervention? a. client reports breast tenderness b. client reports feeling extreme fatigue c. client reports vaginal discharge that is white d. client is taking Enalapril for HTN

d. client is taking Enalapril for HTN ACE inhibitors are teratogenic

You are a nurse working in a long term care facility. You are caring for a client with end-stage Alzheimer's disease. What communication techniques are appropriate to use when speaking with your client? Select All That Apply: a. ask open-ended questions b. speak loudly so they can hear you c. turn up the television so they can hear it better d. use simple statements and questions e. face the client while speaking to them

d. use simple statements and questions e. face the client while speaking to them