reduction of risk (goal > 64%)

bath water temp for kids

< 100

hot water heater settings with kids in the house

< 120

when you think of hypothyroidism, what risk should immediately enter your mind?

CAD

cold, clammy...

eat some candy (hypoglycemic)

A client is admitted to the Labor & Delivery Unit with severe preeclampsia. Which nursing intervention does the nurse include in the plan of care for this client? You answered this question Incorrectly 1. Monitor for headache. 2. Place client in left recumbent position. 3. Insert indwelling urinary catheter. 4. Administer propranolol for BP > 100 diastolic. 5. Initiate external fetal heart monitoring.

1., 2., 3., & 5. Correct: Headache is a sign of increasing BP and increasing ICP. The left recumbent position moves the fetus off the mom's aorta and will help decrease the BP. This client needs to have UOP closely monitored because of the fluid volume excess (FVE), so an indwelling urinary catheter is needed. The fetus needs to be monitored for complications, and the fetal heart rate (FHR) should be 120-160/minute so close monitoring is required.

Which interventions decrease risk of infection or damage to delicate tissue when the nurse is changing a wound dressing? You answered this question Incorrectly 1. Warm cleansing solutions to body temperature. 2. Clean the wound when there is drainage present. 3. Use cotton balls to clean the suture site. 4. Use sterile gauze squares to dry the wound 5. Use sterile forceps when cleaning the wound.

1., 2. & 5. Correct: Using cleansing solutions at body temperature enhances the healing process by not lowering the temperature of the wound and enhancing circulation to the wound bed. Drainage should be removed so that it does not become infected because drainage and exudate can create an environment where bacteria can thrive. Sterile forceps should be used so that contaminated hands/gloves do not increase the risk of infection at the wound site.

The nurse has been trained to work in a decontamination station for hazardous exposure victims. What should the nurse tell the victim about the process? You answered this question Incorrectly 1. First you will remove clothing and dispose of it in hazardous material containment area. 2. You will be placed in a warm shower for decontamination. 3. You will spend a minute or so using soap over the entire body before rinsing. 4. You will spend approximately 15 minutes in the shower. 5. You will apply soap from head to toe and then rinse for a few minutes.

1., 2., 3. & 5. Correct: If the victim can remove his/her own clothing, then instructions should be given to do so and dispose of in hazardous material container. The person will wash for several minutes, beginning with a minute or so of full body rinsing with water to remove any visible contaminants, followed by soap and finally the rinse. The length of time for washing and rinsing will vary with institution and known contaminants. Using soap with good surfactant qualities is important. Generally, the victim is instructed to rinse with tepid water, apply soap from head to toe, and then rinse again with copious amounts of water.

The family of a bedfast 80 year old is providing care in the home. Which reports by the family indicate adequate understanding of interventions that will reduce the risk for skin breakdown? You answered this question Incorrectly 1. I make sure that the sheets and the foam pad in the chair stay dry. 2. I will not encourage my parent to turn in the bed at night. 3. The perineal area should be kept dry and clean. 4. My parent eats 2 meals per day and drinks a supplement. 5. I may reposition my parent more than every 2 hours if their perception of pressure is intact.

1., 3., 4. & 5. Correct: Keeping moisture from the skin is important for reducing the risk of skin breakdown. Keeping the client dry after using a bedpan is important to maintain healthy skin. As long as the intake of food is adequate, no further action is needed with nutrition. The client who is aware of sensations of pressure on the body has less risk of skin breakdown than those that have lost sensation.

What nursing interventions should the nurse initiate in a client who experiences sundowning? You answered this question Incorrectly 1. Limit naps. 2. Encourage TV watching in the evening. 3. Create a calm, quiet environment. 4. Open window blinds during the day. 5. Leave the lights on at night. 6. Maintain a routine.

1., 3., 4., & 6. Correct: Sundowning occurs when the client becomes more confused and agitated in the late afternoon or evening. Behaviors commonly seen include agitation, aggressiveness, wandering, resistance to redirection, and increased verbal activity such as yelling. Limit naps because too much daytime napping may interfere with sleeping at night. Light therapy may reduce agitation and confusion so open the blinds. Caregivers should remain calm and avoid confrontation. Routine helps the client feel secure.

What interventions should the nurse include in the care plan of a client admitted with Guillain-Barre syndrome? You answered this question Incorrectly 1. Assess for descending paralysis. 2. Keep a sterile tracheostomy at the bedside. 3. Monitor for heart rate above 120/min. 4. Maintain in side-lying, supine position. 5. Have client perform active range of motion (ROM) every 2 hours while awake.

2. & 3. Correct: This client is at risk for respiratory paralysis as the disease progresses. An emergency tracheostomy may need to be performed so the nurse should watch out for imminent signs of respiratory failure. Signs include heart rate that is more than 120 bpm or lower than 70 bpm and respiratory rate of more than 30 bpm. The nurse should assess for signs of respiratory distress and prepare for intubation if needed. 1. Incorrect: Ascending paralysis should be assessed for with this disease. Paralysis begins in the lower extremities and moves upward. 4. Incorrect: The client should be assisted to a position with head of bed elevated for full chest excursion. 5. Incorrect: The nurse should perform passive range of motion exercises. Active exercise should be avoided during the acute phase as the client is easily fatigued and muscles are weak. Passive ROM stimulates circulation, improves muscle tone and increases joint mobilization.

During day shift, staff notifies the nurse that an elderly client seems slightly confused and has become incontinent. Upon assessing the client, the nurse notes an increased pulse with blood pressure lower than normal. What action by the nurse takes priority? You answered this question Incorrectly 1. Call primary healthcare provider stat. 2. Notify family that client is confused. 3. Have staff collect a urine specimen. 4. Apply oxygen at 2/L via nasal cannula.

3. CORRECT: In the elderly, symptoms of urinary tract infections (UTIs) may vary from standard manifestations usually seen in younger client. An older client may initially show neurologic signs such as confusion or falls in addition to frequency, incontinence or lower abdominal pain. Those clients with recurring UTIs may even have a standing prescription written for a urinalysis anytime confusion is noted.

The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Which client should the nurse assess first? You answered this question Incorrectly 1. Lumbar puncture reporting a headache. 2. Cystogram reporting burning on urination. 3. Thoracentesis reporting shortness of breath. 4. Cardiac catherization with a decreased pedal pulse below insertion site.

3. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. This client should report an improved respiratory, not shortness of breath. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. 1. Incorrect: A lumbar puncture involves removing cerebral spinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. 2. Incorrect: The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a biopsy. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Although this will require assessment, this client is not the priority at this time. 4. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catherization. This invasive procedure results in some edema to the vessel used for the procedure but assessing only one pedal pulse does not provide sufficient data to verify a complication.

A client diagnosed with hypothyroidism has received dietary education from the nurse. Which snack selection chosen by the client would indicate that education has been successful? You answered this question Incorrectly 1. Cup of almonds 2. Cheese and crackers 3. Popcorn 4. Sweet potato fries

3. Correct: Hypothyroidism clients tend to have constipation due to decreased motility of the GI tract and need increased fiber and fluid intake. Popcorn is high in fiber. 1. Incorrect: People with hypothyroidism have a slow metabolism and do not need high protein but a well balanced diet. Almonds are high in protein. PLUS --- the DASH diet - high risk for CAD

After artificial rupture of membranes (AROM), the baseline fetal heart rate tracking begins to show sharp decreases with a rapid recovery with and between contractions. Which of the following actions by the RN has priority? You answered this question Correctly 1. Position the client on her left side 2. Increase the IV fluid rate 3. Place the client in the knee-chest position 4. Administer oxygen per tight face mask

3. Correct: The fetal heart pattern is that of repetitive deep variable decelerations. This pattern is likely due to a prolapsed umbilical cord after AROM. The priority intervention is to relieve the pressure on the cord from being trapped between the presenting part and the pelvis. This can be accomplished by manual pressure on the presenting part, placing the client in Trendelenburg position, or placing her in the knee-chest position.

The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation? You answered this question Incorrectly 1. Clots in urine 2. Bladder pressure 3. Clear urine 4. Bladder spasms

3. Correct: The irrigation is regulated so that the urine is free of clots and slightly pink tinged. When it becomes clear after surgery, the fluid is going too fast and not clearing any blood clots effectively. 1. Incorrect: The irrigation should be increased if you see clots in order to keep the catheter patent. 2. Incorrect: Bladder pressure may mean that the indwelling urinary catheter is obstructed. Either increase flow or manually irrigate catheter to ensure patency and no retention of fluid in the bladder.

are Biot's respirations closer to cheyne stokes (neuro) or kussmaul (acid / base / renal) respirations

cheyne stokes

The pediatric nurse is assessing a child following an appendectomy. What is the nurse's main priority following surgery? You answered this question Incorrectly 1. Obtain vital signs every four hours. 2. Assess the need for pain medication. 3. Tally intake and output every eight hours. 4. Auscultate lung sounds every four hours.

4. CORRECT: No matter what type of surgery, recall that the effects of anesthesia and intubation, if performed, can lead to complications, particularly in children. The potential for atelectasis and pneumonia follows surgery; therefore the client is encouraged to cough and deep breathe to minimize these risks. Auscultating lung sounds frequently post-op is crucial. 1. INCORRECT: Although vital signs are important, initially the nurse should check vitals every half hour to one hour. Despite the frequency, another assessment is even more important.

A client has been on the nursing unit for two hours following a retropubic prostatectomy for the treatment of prostate cancer. The client is receiving a continuous bladder irrigation of normal saline infusing at 1000 mL/hr. The client's urine output for the past two hours is 410 mL. What is the nurse's first action? You answered this question Incorrectly 1. Inspect the catheter tubing for obstruction. 2. Irrigate the catheter with a large piston syringe. 3. Notify the primary healthcare provider. 4. Stop the irrigation flow.

4. Correct: The catheter output should be at least the volume of irrigation input plus the client's actual urine. A severe decrease in output indicates obstruction in the drainage system. The first action is to stop the irrigation flow to prevent further bladder distention. Bladder distention is one of the main causes of hemorrhage in the fresh post op period. 1. Incorrect: The next action is to check the external system for kinks or obstruction to assess if this is the cause of the decreased urine output. Obstruction of the catheter tubing can also cause bladder distention.

A client has just developed an abdominal wound evisceration post bowel resection. In what position should the nurse place the client? You answered this question Incorrectly 1. Sims' position. 2. Dorsal recumbent. 3. Right side lying in the fetal position. 4. Supine, head of bed at 15 degrees with knees and hips bent.

4. Correct: This position will decrease pressure on the suture line and abdomen. 3. Incorrect: Turning the client on their side will allow the abdominal contents to protrude out of the wound even more. 1. Incorrect: Sims' is a semi-prone position where the client assumes a posture halfway between the lateral and prone positions. If you place the client in this position the bowel contents can protrude out of the wound even more. 2. Incorrect: In this position the client's head and shoulders are slightly elevated on a small pillow. This does not ease the tension as much as supine with HOB elevated 15 degrees and knees and hips flexed.

what effects the eye, hyperglycemia or hypoglycemia?

hyperglycemia (positive symptom)

when you're bulemic, you're hypokalemic. You know this, but which negative symptoms are you also likely to experience...?

hypoglycemia

The homecare nurse is visiting a client to assess the response to new medications ordered for benign prostatic hyperplasia (BPH). What symptoms reported by the client would indicate to the nurse the medications are not working? You answered this question Incorrectly 1. Bladder pain 2. Fever with chills 3. Urinary frequency 4. Terminal dribbling 5. Nighttime sweats

1, 3 and 4. CORRECT: Symptoms of benign prostatic hyperplasia are very similar to those of a urinary tract infection. As the prostate enlarges and presses against the bladder wall, it becomes more difficult for a client to start and maintain a stream of urine, or even to completely empty the bladder. Medications prescribed for this disorder are meant to shrink the prostate, allowing urine to flow easily when voiding. When the medications are ineffective, the client again experiences the original symptoms such as bladder pain, urinary frequency and a tendency to continue 'dribbling' urine after the bladder is emptied. The client may then need a different medication or a change in the dose currently prescribed.

A client receiving 50 mL/hr of enteral feedings has a gastric residual volume of 200 mL and is reporting nausea. What is the appropriate nursing intervention? You answered this question Incorrectly 1. Stop the feeding and assess gastric residual volume in 1 hour. 2. Reduce the infusion rate to 25 mL/ hour and reevaluate residual volume in 4 hours. 3. Change the feeding schedule from continuous to intermittent delivery. 4. Discard the 200 mL and continue the feedings at the same rate.

1. Correct: The safest response is to STOP the feedings and re-assess in 1 hour. Nausea may be a sign of intolerance. Continuing the feeding may also result in vomiting with possible aspiration. 2. Incorrect: Reducing the rate requires a primary healthcare provider's prescription and does not fix the problem. In this answer, the NCLEX people are giving you a scope of practice question. If you select this answer, you are telling the people who write the test that you are going to write prescriptions for your clients.

A nurse plans to educate a group of new parents about how to prevent burn injuries in children. What should the nurse include? You answered this question Incorrectly 1. Eliminate use of placemats. 2. Establish "no" zones for space heaters. 3. Cover unused electrical outlets. 4. Warm baby bottle in microwave for 30 seconds. 5. Set the hot water heater thermostat to 140°F (60°C).

1., 2., & 3. Correct: Placemats and tablecloths can be pulled down by children. If something hot is sitting on it, the child can be scalded. The parents should be taught to block access to stove, fireplace, space heaters, and water heaters. They need to be inaccessible to small children. Covering unused electrical outlets will prevent a child from sticking things, such as a fork, in it which could result in an electrical burn.

The nurse is removing the client's peripheral IV line prior to discharge. The nurse completes the appropriate steps in what order? correct the order you answered... Wash hands and apply gloves. Clamp IV line closed securely. Loosen tape and tegaderm cover. Stabilize cannula with one hand. Apply gauze and tape tightly.

The Correct Order Wash hands and apply gloves. Clamp IV line closed securely. Stabilize cannula with one hand. Loosen tape and tegaderm cover. Apply gauze and tape tightly.

warm and dry...

must be high (hyperglycemic)

is your head higher in trendelenburg or reverse trendelenburg

reverse (trendelenburg was created first, if that helps)

is your head higher in semi fowlers or supine?

semi fowlers

A nurse suspects that a client admitted to the emergency department is in diabetic ketoacidosis. What data would lead the nurse to this conclusion? You answered this question Incorrectly 1. Dry mucous membranes 2. Fruity-smelling breath 3. Biot's respirations 4. Glycosuria 5. Client report of abdominal pain

1., 2., 4., & 5. Correct: The client with diabetic ketoacidosis will have signs of dehydration due to polyuria and includes dry mucous membranes. Fruity breath odor is from the acetone that occurs with breakdown of fats and formation of ketones, which are acids.. With DKA, the client would be spilling glucose into the urine. Vomiting and abdominal pain are frequently the presenting symptoms of DKA. 3. Incorrect: The client will have Kussmaul respirations. Biot's respiration is a respiratory pattern characterized by periods of rapid respirations, then apnea periods. These are not the type of respirations that occur with diabetic ketoacidosis (metabolic acidosis).

Which prescription by the emergency room primary healthcare provider for a client who fell from a ladder should the nurse question? You answered this question Incorrectly 1. Record intake and output hourly. 2. Prepare the client for lumbar puncture. 3. Perform neurologic checks every 10 minutes. 4. Schedule a brain computed tomography (CT) scan.

2. Correct: The traumatic injury to the brain from the fall may result in increased intracranial pressure. The reduction of pressure in the lumbar spine during a lumbar puncture may result in the potential for herniation of the brain. A lumbar puncture should not be performed.

Prior to removal of cataracts, the client is to receive eye drops in both eyes. The nurse knows what action takes priority? You answered this question Incorrectly 1. Remove any exudate around eyes with warm water. 2. Instill exact number of drops into lower conjunctival sac. 3. Instruct client to look upward when drops are instilled. 4. Avoid dropping the medication directly on the cornea.

4. CORRECT: The most important safety consideration when instilling eye drops is to avoid dropping the medication directly onto the cornea. The extreme sensitivity of the cornea before, and after, eye surgery could cause serious eye problems if meds were dropped onto the cornea. 1. INCORRECT: It is important to clean away any exudate prior to instilling eye drops to maintain aseptic technique and decrease chance of infection. Though this is an important action, there is another task which takes priority. 2. INCORRECT: Instilling the exact number of drops is appropriate when implementing written prescriptions from the primary healthcare provider. This is an important nursing action but not the priority. 3. INCORRECT: Instructing the client to look upward helps prevent drops from running out of the eye but there is another issue more important.