Short

Digoxin toxicity

-Cholinergic—nausea, vomiting, diarrhea, blurry yellow vision (think van Gogh), arrhythmias, AV block. -Can lead to hyperkalemia, which indicates poor prognosis.

What statement by a new LPN would indicate an understanding of how to maintain skin integrity for a client on bedrest?

1. "Clients on bedrest should be placed on therapeutic mattresses." 2. "I will assess for the skin every 4 hours." 3. "I will assess the skin using the Braden scale." 4. "A pillow will be placed between the knees when client is side lying." 5. "The incontinent client will be kept clean and dry." 1., 3., 4., & 5. Correct: Clients on bedrest should use a therapeutic bed or mattress. These prevent and treat pressure ulcers by molding to the body to maximize contact, redistributing weight, and reducing pressure. The Braden scale is the most preferred tool to monitor risk of developing pressure ulcers. It looks at sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A pillow between the knees can decrease pressure on knees if they were touching. Protect the client from moisture by keeping clean and dry. 2. Incorrect: When a client is on bedrest, the skin and subcutaneous tissue cannot perfuse adequately. Therefore, the skin should be monitored every 2 hours, not every 4 hours

The nurse has been assisting a client to achieve relaxation using deep breathing exercises. What statement by the client requires follow up?

1. "I can perform deep breathing exercises anywhere and at any time that I feel tension and anxiety." 2. "I should sit or lie in a comfortable position, making sure my back is straight." 3. "I will inhale slowly and deeply through my mouth and expand my chest." 4. "After inhaling, I will hold my breath for a few seconds before exhaling." 3. Correct: The proper method is to inhale slowly and deeply through the nose and allow the abdomen to expand. The chest should be moving only slightly. This statement is incorrect and requires followup. 1. Incorrect: Yes, deep breathing exercises can be done anywhere and anytime. This is a true statement. No followup is needed. 2. Incorrect: Yes, this is correct positioning. A true statement that needs no followup. 4. Incorrect: After inhaling, hold breath for a few seconds and exhale. This is a true statement that needs no followup

A client experiencing a manic episode tells the night nurse, "If you do not go to bed with me, I am going to have you fired." What is the nurse's best response?

1. "That is inappropriate behavior. You will have to go to your room if you say that again." 2. "You've got to be kidding! You can't get me fired for not sleeping with you." 3. "I don't want to hear that again! Don't ever say that again." 4. "I can see that you need attention, but this is not the way to get it." / 1. Correct: Set limits on manipulative behaviors. Explain what is expected and what the consequences are if limits are violated. The nurse needs to set limits on and control dangerous behavior. 2. Incorrect: Do not argue with the client. The behavior of a manic client is often aimed at decreasing the effectiveness of staff control. 3. Incorrect: This is confrontational and does not set appropriate boundaries or consequences. The manic client can elicit numerous intense emotions, even in the nurse caring for them. 4. Incorrect: Remember to set limits without demeaning the client, and do not encourage this behavior. Don't acknowledge that the client is seeking attention.

The nurse is contributing to the plan of care for a client with severe anxiety and new onset panic attacks following the loss of a spouse. Which factor is most important to recommend for the plan of care?

1. Available support system 2. Perception of the situation 3. Desire to return to work 4. Coping mechanisms. 4, The plan of care for a client in crisis involves a complex combination of factors to achieve a positive outcome. However, the most important consideration is the client's own coping skills. Treatment and subsequent recovery is more successful when the client has the coping skills and is able to participate in the recovery process

What foods should the nurse reinforce to the client to avoid for three days prior to a guaiac test?

1. Chicken 2. Carrots 3. Raw broccoli 4. Steak 5. Turnip greens. 3., 4., & 5. Correct: The guaiac test is used to detect fecal occult blood. Foods that affect this test include raw broccoli, red meats such as steak, turnip greens, cantaloupe, radish, and horseradish. All of these could cause a false positive reading for the guaiac test. 1. Incorrect: Red meats such as steak should be avoided, but chicken is okay. 2. Incorrect: Carrots are not prohibited and will not affect the results of the test

Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection?

1. Cleans perineum from front to back after newborn soils diaper. 2. Makes certain the umbilical cord remains dry with each diaper change. 3. Places the top of the diaper just above the umbilicus. 4. Wraps sterile petroleum gauze around umbilical cord. 5. Submerges newborn in warm water up to the chest for first bath. 1 2 4

A client diagnosed with hypothyroidism with myxedema is prescribed levothyroxine, which is to be taken in increasing dosages. Which finding, if present, indicates that the drug dosage is too high?

1. Dry skin and sensitivity to cold 2. Anorexia and fatigue 3. Weight gain and constipation 4. Angina and palpitations. 4. Correct: Angina and palpitations. When a nurse administers a thyroid replacement medication, there is an expected therapeutic response. The most desirable response is an increase in energy, improved affect, improved gastric motility, weight loss and less sensitivity to cold. If the dose is too high, the client may experience an increased HR, angina, palpitations, and a headache. In fact, the client is at risk of having a heart attack! 1. Incorrect: Dry skin and sensitivity to cold are s/s of hypothyroidism. The question is asking about too much thyroid. 2. Incorrect: Anorexia and fatigue are s/s of hypothyroidism. 3. Incorrect: Weight gain and constipation are s/s of hypothyroidism

Personal Protective Equipment (PPE)

1. Face shield 2. Sterile Gloves 3. Gown 4. Mask 5. Regular exam gloves. 1 3 4 5

The nurse is caring for a client in an outpatient clinic who is being treated with warfarin for prevention of a stroke due to atrial fibrillation. The international normalized ratio (INR) was noted to be 4.6. What action should the nurse take?

1. Inform the primary healthcare provider immediately. 2. Instruct the client to continue medication as ordered. 3. Inform the client to watch for signs of bleeding. 4. Inform the client to return to the clinic per routine monitoring schedule. 5. Take no action as this value is within target range. 1. & 3. Correct: The primary healthcare provider should be notified. The value of 4 is above the usual target range of 2-3. The client has a potential for decreased clotting and bleeding. The client should be told to watch for signs of bleeding. 2. Incorrect: The medication dosage is likely to be reduced. 4. Incorrect: The client should not leave the clinic until the primary healthcare provider has been notified. Further action is indicated and may include changing the usual warfarin dosage. 5. Incorrect: The normal range for a INR is 2-3. When a client is prescribed warfarin, the INR should increase to a therapeutic target range. The value of 4.6 is greater than the usual target range

What nursing actions should the nurse initiate in a client who experiences sundowning?

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

A registered nurse (RN) is delegating nursing activities to a licensed practical nurse (LPN) on a medical-surgical unit. If assigned by the RN, which activities can the LPN legally perform?

1. Nursing care plan 2. Blood transfusion 3. Physical assessment 4. Blood glucose testing 5. Intramuscular injection. 4. & 5. Correct: The LPN can perform blood glucose testing at the bedside. Blood glucose levels that fall outside of the normal range, however, should be reported to the RN who retains responsibility for overall client care. The LPN can give intramuscular injections as well as administer medications via other common routes. 1. Incorrect: The RN is responsible for developing the plan of care for the client; this is outside of the legal scope of practice for the LPN. 2. Incorrect: Blood transfusions must be performed by the RN; two RNs must verify that the blood type is correct prior to administration. 3. Incorrect: The RN is responsible for performing the client physical assessment; this is outside of the legal scope of practice for the LPN.

The nurse is caring for a client with full thickness burns to the left arm and left leg. What is the priority for this client?

1. Pain 2. Airway 3. Fluid volume status 4. Risk for injury. Correct: Yes! The client will have lots of fluid loss through the burn wound and also the fluid shift. 1. Incorrect: Pain is not the priority over fluid volume status. 2. Incorrect: This client does not have airway involvement. 4. Incorrect: Risk for a burn? Too late for that one.

Post thyroidectomy, the nurse monitors the client for complications by performing which action?

1. Perform blood glucose monitoring every 6 hours 2. Check for a positive Chvostek's 3. Monitor swallowing reflex 4. Monitor neck dressings for change in fit and comfort 5. Administer desmopressin per nasal spray for urinary output (UOP) greater than 200 mL/hr. 2., 3., & 4. Correct: A positive Chvostek's and Trousseau's signs are indicative of tetany as a result of low calcium levels. This can occur when one or more of the parathyroids are accidently removed when the thyroid is removed. A weak, raspy voice, swallowing difficulty, and impaired respiratory status can be caused by nerve injury. Change in fit and comfort of the dressing can indicate possible neck swelling, which can affect the airway.

Which client must the nurse assign to a private room?

1. Primiparous client who delivered twins at 28 weeks gestation two days ago 2. Postpartum client on IV Ampicillin and Gentamicin for chorioamnionitis 3. Postpartum client whose 2 hour old infant is being worked up for sepsis 4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C) 4. Correct: A temperature of 100.5° F (38.05° C) or greater in a client more than 24 hours postpartum is likely an indication of infection. This client should be kept separate from other mothers and babies. 1. Incorrect: The preterm twins are in the NICU and not in their mother's room (a client with term twins would need a private room because of space considerations). 2. Incorrect: Chorioamnionitis is not contagious. 3. Incorrect: The infant may have an infection and will remain in the NICU. The mother is not infected.

Which tasks can the LPN/LVN assign to an unlicensed assistive personnel (UAP)?

1. Tell a female client who has recurrent urinary tract infections how to wipe after urinating. 2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 3. Collect a urine specimen from a foley catheter tubing. 4. Document the intake and output of a client in acute renal failure. 5. Irrigate the foley catheter of a client who has had transurethral resection of the prostate (TURP). 6. Perform perineal care of a client who has urinary incontinence. 2 4 6

A nurse is caring for a client in an outpatient clinic. The client lost her husband of 51 years three months ago. Which findings support that the client is experiencing normal grief reactions rather than clinical depression?

1. The client is experiencing anhedonia. 2. The client states, "I have good and bad days." 3. The client smiles at the nurse while talking about her grandchild. 4. The client has a persistent state of dysphoria. 5. The client states, "I am having fewer crying spells." 2 3 5

MMR vaccine is contraindicated under which condition?

A known allergy to gelatin

Which health problem does the nurse recognize as putting the client at risk for hypomagnesemia?

Alcohol abuse / We get magnesium from food. Because an alcoholic drinks, and thereby eats very little, magnesium intake is often not adequate. Also, alcohol suppresses the release of ADH. Decreased ADH leads to diuresis and magnesium loss

The client has been prescribed a topical anticholinergic medication for the treatment of glaucoma. Which report by the client indicates a common side effect?

Blurred vision

elevated serum bilirubin. What color urine does the nurse expect to find?

Dark amber

The nurse is caring for a client receiving an intravenous infusion of normal saline that is prescribed at 150 milliliters per hour. Using a tubing that has a drop factor of 15, how many drops per minute should the nurse deliver? Round answer to the nearest whole number.

Divide 150 by 60 minutes to equal 2.5. Multiplying 2.5 by the drip factor of 15 equals 37.5. Since partial drops cannot be counted, always round to nearest whole number, which is 38.

signs and symptoms of emphysema

Emphysema is one of the diseases that comprises COPD. Emphysema involves gradual damage of lung tissue, specifically thinning and destruction of the alveoli or air sacs, making it progressively difficult to breath. Emphysema is usually accompanied by chronic bronchitis, with almost-daily or daily cough and phlegm. Cigarette smoking is the major cause of emphysema. People with emphysema experience shortness of breath with activities. It is not curable, but there are treatments that can help the client manage the disease. Look at the options now. Option 1: Atelectasis. Atelectasis is the collapse of part or, much less commonly, all of a lung. So this is false. Option 2: Increased AP diameter. This is true. It occurs because of chronically hyperinflated lungs and loss of lung elasticity. Option 3: Breathlessness is true. We just said that emphysema destroys the alveoli, making it progressively difficult to breath. ​ Look at option 4, use of accessory muscles to breathe. True. Accessory muscles of respiration are typically only used under conditions of high metabolic demand (e.g. exercise) or respiratory dysfunction (e.g. an asthma attack, or emphysema). Option 5: Lean backwards to breathe. This is false. This client tends to lean forward (orthopnea) and uses accessory muscles of respiration to breathe. Now option 6. Clubbing of fingernails. True. This is due to chronically decreased oxygen levels. Think about it, the alveoli are destroyed so gas exchange is impaired. Oxygen levels decrease

A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first to assure that the client's request is respected?

Ensure a do-not-resuscitate prescription has been provided

acute cholecystitis

In order to get this question correct, you need to know what acute cholecystitis is. The gallbladder is an organ that sits below the liver. It stores bile, which your body uses to digest fats in the small intestine. Acute cholecystitis occurs when bile becomes trapped in the gallbladder. This often happens because a gallstone blocks the cystic duct, the tube through which bile travels into and out of the gallbladder. When a stone blocks this duct, bile builds up, causing irritation and pressure in the gallbladder. This can lead to swelling and infection. So let's look at our options. Option 1: True. Any disease process ending in "itis" may present with fever and chills. So knowing that will make Option 2...True. Option 3: N/V? True. Many clients with acute cholecystitis present with acute onset of right upper quadrant pain associated with nausea and vomiting. Option 4: False. If you have nausea and vomiting, do you want to eat? No. You would not want to eat, so anorexia is seen. Option 5: True. A physical examination often reveals rigidity of the upper right abdomen that may radiate to the midsternal area or right shoulder. Rebound and guarding are present in some cases.

Hypothyroidism

Increase fiber

An adolescent is depressed. The client's prescribed medication is fluoxetine. What is the best response by the nurse when the client says, "How will this medicine make me feel better?"

It will regulate a neurotransmitter called serotonin

Sundowning is a symptom of Alzheimer's disease and other forms of dementia

It's also known as "late-day confusion." If someone has dementia, their confusion and agitation may get worse in the late afternoon and evening. Symptoms may be less pronounced earlier in the day. Daytime napping and inactivity can make it harder for the client to fall asleep at bedtime. To promote a good night's sleep, help them stay active during the day. Take the client for a walk or clear some space to dance. This might help improve sleep quality. You want the client to stay calm in the evening. So encourage simple activities that aren't too challenging or frightening. Frustration and stress can add to confusion and irritability. Those clients who have mid-stage or advanced dementia find it difficult to watch television or read a book. Consider playing soft music to create a calm and quiet environment. Some studies suggest light therapy can reduce agitation and confusion in clients with dementia. Turn on the lights in the daytime and open the window blinds. Routine is very important for these clients. A routine makes people feel secure. Dementia can make it hard to develop and remember new routines. The client might react to unfamiliar places and things with feelings of stress, confusion, and anger. These feelings can play a large role in sundowning. Stick to the same schedule every day to help the client feel more calm and collected

A client was prescribed thioridazine five days ago and presents at the clinic with a shuffling gait, tremors of the fingers, drooling, and muscle rigidity. Which adverse reaction to this medication is suspected?

Pseudoparkinsonism

Which food selection would need to be removed from the tray by the nurse for a client recovering from thyroidectomy?

Roasted almonds, Too hard and crunchy. Need soft diet because esophagus is right behind the thyroid and trachea. This would be difficult to swallow after surgery due to pain. This food selection would need to be removed

Which action would the nurse need to perform to increase stability while initiating a client transfer?

Spread feet to width of the shoulders

When arterial blood gases (ABGs) are drawn by lab personnel, which information is important for the nurse to document?

The client was on 2 L of oxygen by nasal canula

When should the nurse tell the client to take Lispro insulin?

With meals

Neuroleptic Malignant Syndrome (NMS)

fatal complication of neuroleptic drugs. Routine assessments should include temperature and observation for NMS symptoms (Hyperpyrexia up to 107 degrees F or 41.67 degrees C, tachycardia, tachypnea, fluctuations in BP, diaphoresis, and coma)

Diltiazem (Cardizem)

hypertension

acute cholecystitis

inflammation of the gallbladder chills fever nausea vomiting rigidity of upper right abdomen

Dysphoria

is a mood of general dissatisfaction, restlessness, depression, and anxiety. This is often seen in clinical depression

Anhedonia

is the inability to experience pleasure, and is a symptom of clinical depression. This would not be a positive sign of normal grieving in a client

oculogyric crisis

is uncontrolled rolling back of the eyes and may appear as part of dystonia (Involuntary muscular movements of face, arms, legs, and neck)

Naloxone (Narcan)

opioid antagonist