CAT # 1 - 5233906
The nurse is caring for a client who is receiving prescribed metoclopramide for gastroparesis. Which of the following findings require immediate notification to the primary healthcare provider (PHCP)? A. Muscle rigidity of the neck B. Hyperactive bowel sounds C. Frequent diarrhea D. Abdominal distention
A Metoclopramide is a dopamine antagonist in treating gastroparesis, nausea, and vomiting. Dopamine antagonists may induce dystonia which is depicted in this option. This finding is highly concerning.
The nurse is assessing a neonate with Hirschsprung's disease. Which of the following would be an expected finding? A. Abdominal distention B. Urinary retention C. Hematemesis D. Palpable abdominal mass
A Neonatal manifestations of Hirschsprung's disease include failure to pass meconium, constipation, abdominal distention, and poor feeding.
A 45-year-old man on the neurology floor can understand instructions but is unable to express himself through talking. Which lobe of the brain controls the expression of speech? A. Frontal lobe B. Parietal lobe C. Temporal lobe D. Occipital lobe
A The expression of speech is controlled by Broca's area in the frontal lobe. Broca's area is in the left hemisphere near the motor strip.
The client has been prescribed a continuous infusion of heparin for multiple venous thromboembolism. The nurse understands that the goal of this treatment is to prolong the A. partial thromboplastin time, 1.5 to 2.5 times the normal control. B. international normalized ratio, 2 to 3 C. prothrombin time, 1.5 to 2.5 times the normal control. D. international normalized ratio, 3 to 4
A The goal for heparin therapy delivered by continuous infusion is to prolong the partial thromboplastin time, by 1.5 to 2.5 times the normal control value. Choices B, C, and D are incorrect. Heparin does not impact these laboratory values. PT and INR is prolonged by warfarin - not heparin.
The nurse is performing medication administration for four clients. Which client and medication should be administered first? See the image below. A. Client one (Prednisone 10mg PO Daily for asthma exacerbation) B. Client two(Acetaminophen 500mg PO x 1 dose for fever) C. Client three (magnesium oxide 250mg PO Daily for chronic alcoholism) D. Client four (glargine insulin 15 units SubQ Daily for diabetes mellitus)
A This medication is prescribed for a client with an asthma exacerbation which is an acute problem. Additionally, this acute problem deals with the client's breathing problem (asthma), prioritizing a fever, diabetes, and chronic alcoholism.
A 90-year-old woman has been bedridden at home for two weeks. Which of the following is not an expected finding due to immobility? A. A decrease in bone density B. Loss of short-term memory C. Atelectasis D. High serum calcium level
B
The nurse is caring for a client with diabetic ketoacidosis (DKA) receiving intravenous (IV) regular insulin. The most recent potassium was 2.9 mEq/L. The nurse should take which priority action Correct Answer(s): B A. Notify the primary healthcare provider (PHCP) B. Stop the regular insulin infusion. C. Obtain a 12-lead electrocardiogram (ECG) D. Assess the client's urine output (UOP)
B The most common complication associated with DKA treatment with regular insulin is hypokalemia and hypoglycemia. Stopping the regular insulin infusion is essential as this is the direct cause of the critically low potassium.
The nurse is performing an initial assessment on a patient being admitted for acute pancreatitis. Which assessment data would support this diagnosis? A. Homan's sign B. Cullen's sign C. Hyperactive bowel sounds D. Kermit's sign
C Cullen's sign refers to the bluish periumbilical discoloration/ecchymosis that is common in acute pancreatitis. The discoloration occurs due to blood-stained exudates seeping from the pancreas. A positive Homan's sign (pain in the calf with foot dorsiflexion) would indicate the presence of a DVT, not pancreatitis. A patient with acute pancreatitis would present with hypoactive (decreased) bowel sounds, not hyperactive. A positive Kernig's sign indicates possible subarachnoid hemorrhage or meningitis. It would not support the patient's acute pancreatitis diagnosis.
You are taking care of a 7-year-old female in the pediatric bone marrow transplant unit. She has been in the hospital for about a year and is working on her school work with the hospital teacher. You note that she is growing increasingly frustrated with her math homework. You know that her successful completion of academic demands is vital to her psychosocial development, as she is in which stage of psychosocial development? A. Industry vs. Inferiority B. Autonomy vs. Shame and Doubt C. Trust vs. Mistrust D. Initiative vs. Guilt
A 6-11 Industry vs inferiority 0-18 trust vs mistrust 2-3 autonomy vs shame and doubt 3-5 initiative vs guilt
A client is scheduled to receive one unit of packed red blood cells (PRBCs) later this morning. While performing morning rounds, the nurse should ask this client which initial question? A. "Have you received a blood transfusion previously?" B. "Do you know why you need this transfusion?" C. "Have you experienced any transfusion-related complication(s) in the past?" D. "Are you aware of the complications and risks associated with blood transfusions?"
A
A client was brought to a psychiatric hospital when police found him walking around the neighborhood at night without shoes in the snow. He looks confused and disoriented. Which should be the priority at this point? A. Assess and stabilize the client medically B. Perform a mental assessment and stabilize the client psychologically C. Locate the nearest family members to get the client's history D. Arrange for a transfer to the nearest medical facility
A
The clinic nurse is preparing to administer vaccinations intramuscularly to a 3-year-old toddler. What is the nurse's first intervention? A. Instruct the mother to immobilize the child's leg. B. Talk to the child about the procedure. C. Swab the area with alcohol. D. Inject the medication in the thigh.
B The nurse must always explain the procedure to the child in words that he/she can understand.
A 42-year-old female client reports colicky abdominal pain that worsens after eating a high-fat meal. The nurse anticipates that this client has which diagnosis? A. Gastric ulcer B. Appendicitis C. Cholecystitis D. Liver cirrhosis
C
A nurse is taking care of a client with acute peritonitis. The current focus of care is the client's nutritional needs. To meet this, the nurse should do which of the following? A. Administer feedings via nasogastric (NG) tube B. Administer gastric enteral feedings C. Feed the client orally D. Administer parenteral nutrition
D
The nurse is instructing the parents of a child with asthma about a peak flow meter. Which statement, if made by the parents, would indicate effective teaching? A. "Before use, I should put the sliding marker at the top of the numbered scale." B. "I should have my child sit at a 45-degree angle while performing this procedure." C. "My child should inhale as quickly as they can through the mouthpiece." D. "I should record the highest of the three readings."
D
Which of the following is a critical and necessary component of a malpractice case? A. An act of omission B. An act of commission C. An intentional act D. A breach of duty
D A breach of duty is a critical and necessary component of a malpractice case. Other vital and essential elements of a malpractice case include an act of commission or omission, an intentional or unintentional act, damages to the client, causation, foreseeability, and causation. Choice A is incorrect. A malpractice case can occur as the result of both acts of omission and commission. Therefore, the commission is not a necessary component of a malpractice case. Choice B is incorrect. A malpractice case can occur as the result of both acts of omission and commission. Therefore, failure is not a necessary component of a malpractice case. Choice C is incorrect. A malpractice case can occur due to intentional and negligent, or unintentional acts; therefore, the intention is not a necessary component of a malpractice case.
The nurse is caring for a client admitted with severe pre-eclampsia. It would be essential for the nurse to have which of the following items at the bedside? A. One liter of 0.9% saline B. Sterile gloves C. Portable ultrasound D. Suction equipment
D A client with severe pre-eclampsia should be monitored closely for seizures which are the hallmark manifestation of eclampsia. The nurse should plan care involving seizure precautions at the bedside, including suction equipment, padded side rails, and oxygen.
When observing a patient on antivirals. The nurse notices the patient has developed bruising. This could indicate which of the following? A. The patient is being abused by a family member. B. The patient is experiencing minor adverse reactions C. The patient is not taking the medications as ordered. D. The patient may be experiencing bone marrow suppression.
D Bruising or bleeding when taking antivirals could indicate possible bone marrow suppression and may require dosage adjustments or a medication change.
The nurse in the psychiatric unit notes that a client with paranoid schizophrenia is yelling and blocking the television. Other psychiatric clients around the yelling client are now becoming agitated. What is the most appropriate action for the nurse? A. Restrain the client B. Escort the other clients from the room C. Administer haloperidol via intramuscular (IM) injection to the client causing a disruption D. Approach the client causing a disruption calmly while accompanied by two additional staff members
D The initial intervention is to approach the client calmly, attempt to de-escalate the situation, and remove this client from the room (preferably on the client's own accord). For the safety of staff and all other individuals in the room, staff members should never make face-to-face contact with an agitated psychiatric client without being accompanied by other trained healthcare personnel.
The nurse is planning a staff development conference about anaphylaxis. Which of the following information should the nurse include? A. 0.9% saline should be infused once vascular access is established. B. The initial treatment is intravenous diphenhydramine. C. The client should carry a prefilled syringe of hydrocortisone. D. If shock occurs, the client should be positioned in reverse Trendelenburg.
A Anaphylaxis quickly causes a loss of vascular tone resulting in hypotension. Establishing intravenous access is essential as the client will require isotonic fluids to restore circulating volume, corticosteroids, and diphenhydramine. Epinephrine, the priority drug to be administered, should be given intramuscular (IM).
When experiencing conflict with another nurse (that is not resolvable between the parties), what is the most appropriate action for the nurse moving forward? A. Report the conflict to the director of nursing over the unit. B. Report the conflict to the nurse manager of the unit. C. Report the conflict to the assigned charge nurse of the unit. D. Discuss the conflict with another nurse to attempt resolution of the issue.
C
Your client was admitted to your medical telemetry unit for acute renal failure. The client is demonstrating mild restlessness while asking numerous questions regarding their diagnosis and treatment. This client is most likely experiencing: A. Hypokalemia B. Hyperkalemia C. Mild to moderate anxiety D. Panic attack
C
Which of the following images represent the visual field of a patient with macular degeneration? A. Loss of peripheral vision (sides) B. Blurred vision C. Central area becomes darker D. Black curtains coming down
C A. End stage of glaucoma B. Cataracts D.Detached retina
A newly registered nurse is caring for a school-aged child with cerebral palsy under the supervision of a senior nurse. Which action by the new RN would warrant the senior nurse to intervene? A. The new RN initiates gentle range-of-motion exercises to the client. B. The new RN lowers the bed to its lowest position. C. The new RN wheels the client to the playroom via wheelchair. D. The new RN feeds the child with the bed elevated at 30 degrees.
D The nurse should position the client with the head of the bed elevated at 60 - 90 degrees to prevent aspiration.
The nurse is taking care of a client with hypoparathyroidism. The nurse understands that patients with hypoparathyroidism have a low serum calcium level. The nurse should be alert for the following signs and symptoms of hypocalcemia, except: A. Kernig's sign B. Trousseau's sign C. Hyperactive deep tendon reflexes D. Chvostek's sign
A Choice A is correct. Kernig's sign is not a sign of hypocalcemia. However, it is a sign that indicates meningeal irritation/infection. Choice B is incorrect. Trousseau's sign is a sign related to hypocalcemia. Spasms of the wrist and hands appear after the upper arm is compressed by a blood pressure cuff. Choice C is incorrect. Hyperactive deep tendon reflexes are a result of severe neuromuscular irritability due to low serum calcium levels. Choice D is incorrect. Chvostek's sign is a sign of hypocalcemia. It can be elicited by tapping over the facial nerve and observing for the spasm of the facial muscles.
The nurse has just finished receiving the shift report from the night nurse. Which patient should the nurse see first? A. A 90-year-old patient with pneumonitis who is getting restless but is currently afebrile. B. A 20-year-old patient with influenza who is febrile and complaining of a headache. C. A 40-year-old patient with hemothorax in the right lung who is attached to a chest drainage system that is tidaling. D. A 27-year-old with sinusitis having green drainage from his nose.
A Elderly clients do not show "typical" symptoms of pneumonia, such as fever. The nurse should watch for altered levels of consciousness or behavioral changes as these may indicate decreased oxygenation to the brain from sepsis. Therefore, the nurse should see this client first.
The nurse is concerned that a child has epiglottitis. Which physical assessment finding is consistent with epiglottitis? A. Absence of spontaneous cough B. Harsh, productive cough C. Generalized skin flushing D. Coarse tremors
A Epiglottitis has an abrupt onset and requires immediate treatment because it can cause progressive obstruction and may lead to respiratory arrest. The absence of spontaneous cough is a common feature of epiglottitis because of severe edema. Edematous epiglottis blocks the airway making it difficult to cough.
The nurse is educating a new nurse working on the pediatric unit about the causes of bacterial tonsillitis in children. Which of the following is the most common cause of bacterial tonsillitis? Correct Answer(s): A A. Group A beta hemolytic streptococcus B. Streptococcus pneumoniae C. Group B Streptococcus D. Neisseria meningitidis
A Group A beta hemolytic streptococcus is the most common cause of bacterial tonsillitis
You have an adult client who has abnormally heightened responses to minor pain like the pain from sitting on a bedpan or a small skin tear. What would you suspect that this client is affected by? A. Hyperpathia B. Drug seeking behavior C. Equianalgesia D. Dysesthesia
A Hyperpathia is synonymous with hyperalgesia and is defined as the abnormal pain processing that can lead to the appearance of neuropathic pain.
The nurse is completing a home assessment for a client receiving oxygen therapy. Which essential piece of equipment should be available? A. Smoke detector B. Extension tubing C. Slip-resistant rugs D. Air humidifier
A It is essential that a client receiving oxygen therapy have smoke detectors and a fire extinguisher as oxygen therapy enhances combustion. Having functional smoke detectors and a fire extinguisher is a priority because it promotes client safety.
The nurse is caring for a client receiving morphine sulfate for severe pain. The nurse should implement all of the following actions, except: A. Administer morphine only when the client complains of pain. B. Ensure naloxone is always available. C. Check the client's respirations before giving morphine
A Morphine should be given at times prescribed by the doctor to ensure adequate serum levels for optimum pain relief. Waiting to give it until the client experiences pain may lead to sub-optimal pain control. When specified by the physician, the nurse can provide morphine for breakthrough pain if the client complains of pain despite receiving round the clock morphine doses.
The nurse prepares to suction a tracheostomy tube to help clear a patient's secretions. After opening the package, filling the cup with sterile water, and putting on sterile gloves, the nurse uses one hand to connect the catheter to the suction. What action would be most appropriate for the nurse to take next? A. Use the contaminated hand to preoxygenate the patient prior to suction. B. Use the sterile hand to slowly insert the catheter while applying intermittent suction. C. Restart the procedure due to contamination after applying sterile gloves. D. Assess the patient's baseline oxygenation status.
A Open suction of a tracheostomy tube requires an aseptic technique. After setting up a sterile field and applying sterile gloves, the nurse would designate one hand as contaminated and ensure the other remains sterile. The contaminated hand should be used to connect/disconnect the catheter tubing, use the resuscitation bag, and operate the suction control. If preoxygenation is indicated, the nurse would use the contaminated hand to administer it.
The nurse assesses a client with damage to cranial nerve III. Which finding would be expected? A. Ptosis B. Anosmia C. Uvula deviation D. Asymmetric facial movement
A Ptosis, or eye drooping, occurs with cranial nerve III (oculomotor) lesions, myasthenia gravis, and Horner syndrome. Dysfunction of cranial nerve III is also associated with dilated pupil, absent light reflex, and impaired extraocular muscle movement.
The nurse reviews a patient's lab results and notes that their potassium level is 5.6 mEq/L. They are looking at the cardiac monitor. The nurse will most likely observe what change first correlating with this lab value? A. Narrow and peaked T waves B. ST elevation C. Peaked P waves D. Noticeable U Waves
A ST-elevation is seen less commonly in hyperkalemia than tall, narrow T waves. Peaked P waves are mostly seen with high right atrial pressure or atrial dilation. U waves is hypokalemia
A client comes to the outpatient clinic complaining of abdominal pain, diarrhea, shortness of breath, and epistaxis. What should the nurse's first action be? A. Ask the client about any recent travel to Asia or the Middle East. B. Screen clients for upper respiratory tract symptoms. C. Review the client's history of recommended immunizations. D. Call an ambulance to take the client immediately to the hospital.
A The client's clinical symptoms suggest possible avian influenza (bird flu). If the client has traveled recently to Asia or the Middle East, where outbreaks of bird flu have occurred, you will need to institute airborne and contact precautions immediately. Nursing priority is always patient safety. This includes not only the patient the nurse is assessing but those who are present within the facility and the staff as well. Determining where a patient has been and any activities he or she has been involved with will help pinpoint the possible source of illness/infection.
The nurse is caring for a client with pneumonia receiving six liters a minute of nasal cannula oxygen. The client has a SpO2 of 81%, and the arterial blood gas (ABG) returns with a PaO2 of 68 mm Hg. Which immediate intervention should the nurse take? A. Notify the rapid response team (RRT). B. Obtain a prescription for a chest radiograph. C. Increase nasal cannula oxygen to seven liters a minute. D. Auscultate the lung fields for adventitious sounds.
A This client demonstrates signs of acute respiratory distress syndrome (ARDS), a complication of pneumonia (hypoxemia). The client's inability to oxygen is highly concerning and is a classic manifestation of ARDS. An RRT should be immediately called to assist with appropriate interventions, including intubation by a qualified provider.
The images below depicts with post-operative surgical complication? A. Wound Evisceration B. Wound Dehiscence C. Diabetic Ulcer D. Tertiary Healing
A This image shows wound dehiscence. Wound dehiscence is a partial or total separation of previously approximated wound edges due to a failure of proper wound healing, sometimes described as "splitting open of the wound." The abdominal muscle layer is intact in wound dehiscence, preventing the internal organs from protruding out. Typically, this occurs five to eight days following surgery when healing is still in the early phases. The causes of wound dehiscence correlate with the causes of poor wound healing, including ischemia, infection, increased abdominal pressure, diabetes, malnutrition, smoking, and obesity. Additional studies have correlated increased findings of dehiscence occurring more often in patients with diabetes, obesity, immune deficiency, malnutrition, or those who utilize steroids.
A 60-year old adult walks into the clinic with a forehead laceration. He was going 45 mph on his motorcycle when he skidded on the gravel and fell off his bike. He isn't sure if he hit his head. After checking for significant bleeding and apparent signs of injury, what is the first intervention the nurse should do? A. Place a c-collar on the patient's neck. B. Take the patient back to a procedure room to stitch the laceration. C. Palpate the patient's abdomen to check for internal bleeding. D. Check the patient's pupils.
A This patient was going faster than 30 mph on a motorcycle. We are not sure if he was wearing a helmet, but with the mechanism of injury, he could have a possible c-spine in
The nurse is participating in a committee reviewing strategies to reduce falls in the older adult. Which of the following recommendations by the nurse would be appropriate to make? A. Increase the number of bedside commodes in the nursing units B. Provide more hand sanitizer stations in high traffic areas C. Standardize administration times of diuretics to the evening hours D. Implement a bedside handoff reporting process for nursing staff
A Utilizing more bedside commodes for older adults may reduce falls because it shortens the distance a client needs to travel to the bathroom. Bedside commodes are especially effective for those receiving medications such as diuretics and undergoing bowel prep. Thus, a bedside commode is an effective intervention to reduce falls for the older adult.
A client with episodes of vertigo who has a fractured leg has been ordered crutches and not to bear weight on the affected extremity. The most appropriate crutch-walking gait the nurse should teach the client is the A. Two-point gait B. Three-point gait C. Four-point gait D. Swing-through gait
B
The nurse is caring for a client with a chest tube for the treatment of a pneumothorax. Which item is essential to have at the bedside? A. Nasal cannula oxygen B. Tracheostomy set C. Bottle of sterile water D. An ampule of Dextrose 50%
B A bottle of sterile water is essential to have at the bedside because if the chest tube becomes disconnected from the chest tube system, the nurse can maintain the patency of the system by putting the end of the tube in sterile water, which will prevent air from reentering the pleural space.
While at work on a medical-surgical floor, you hear an overhead announcement through the speaker system stating "Code Silver" three times, indicating an active shooter in the facility. Which of the following options is the most appropriate initial response for you to take? A. Close all the windows in the clients' rooms. B. Close all the clients' doors to their rooms. C. Perform a horizontal evacuation of your clients to avoid the gunman. D. Conduct a vertical evacuation of your clients to avoid the gunman.
B Active shooter ("Code Silver" or, alternatively, "Code Gray" in some facilities) events are becoming increasingly common in healthcare facilities. Among the options listed, the most appropriate initial response would be to close all the client's doors to their rooms until you receive further instructions from the security officers or police officers. Closing the client's doors keeps the clients (and potentially any visitors) out of the gunman's view.
The nurse is reviewing leadership and management concepts with a student nurse. It would require further teaching if the student nurse made which of the following statements? A. "The Laissez-faire leadership style is a passive leadership approach." B. "A Registered Nurse (RN) may delegate accountability to a Licensed Practical Nurse (LPN)." C. "The rights of delegation include task, circumstance, person, direction, supervision." D. "The State Nurse Practice Act defines roles and responsibilities of nursing professionals."
B An RN may delegate certain responsibilities to an LPN but cannot delegate accountability. The RN retains accountability when delegating patient assignments and tasks but maintains accountability.
A 25-year-old female reports intermittent abdominal pain, bloating, and flatulence that has lasted for several months. Which of the following would the nurse tell the patient to avoid? A. Fiber B. Broccoli C. Yogurt D. Simple carbohydrates
B Broccoli forms gas in the stomach and should be avoided for this patient.
A postpartum client is preparing to be discharged home with her full-term newborn. Prior to discharge, the client verbalizes, "I really should not get pregnant again in the next three years so I can finish college." History reveals that she smokes a pack of cigarettes a day. Which method of contraception would be the most appropriate for this client? A. Medroxyprogesterone acetate injectable suspension B. Condoms and spermicidal contraceptive foam C. Natural family planning D. Oral contraceptives
B Combining condoms and spermicidal contraceptive foam is highly effective in preventing pregnancy. In addition to being easily accessible, this method is also relatively inexpensive (often free if received from a local public health department). This combination is the most appropriate contraceptive method for this client.
Which of the following is the final step that is used during the physical assessment of the abdomen? A. Inspection B. Deep palpation C. Percussion D. None of the above
B Deep palpation is cautiously done after light palpation when necessary because the client's responses to deep palpation may include their tightening of the abdominal muscles. When this occurs, it could make light palpation less effective, particularly if an area of pain or tenderness has been palpated. A complete health assessment may be conducted starting at the head and proceeding systematically downward (head-to-toe evaluation). However, the procedure can vary according to the age of the individual, the severity of the illness, the preferences of the nurse, the location of the examination, and the agency's priorities and procedures.
The nurse is admitting a 72-year-old patient hospitalized for a medical diagnosis of Mycoplasma pneumonia. Which transmission-based precaution is necessary? A. Private room with negative pressure airflow B. Wearing a surgical mask within 3 feet of the patient C. Wearing gloves when in contact with the patient D. HEPA filtration for incoming air
B Droplet precautions are indicated for patients with Mycoplasma pneumonia. Droplet precautions include wearing a surgical mask when within 3 feet of the patient, proper hand hygiene, and placement in a private room or with a cohort of patients. Other examples where droplet precautions are indicated include Pertussis, Influenza, Diphtheria, and invasive Neisseria meningitides.
How should the nurse assess for the presence of thrombophlebitis in a patient who reports having pain in the left lower leg? A. By palpating the skin over the tibia and fibula B. By documenting daily calf circumference measurements C. By recording vital signs obtained four times a day D. By noting difficulty with ambulation
B Inflammation from thrombophlebitis increases the size of the affected extremity and can be assessed by measuring circumference regularly. Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative patients. Manifestations of thrombophlebitis are pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the affected area, elevated temperature, and an increase in the diameter of the involved extremity. Each shift, nurses should assess the legs for swelling and tenderness, measure bilateral calf or thigh circumference, and determine if the patient experiences any chest pain or dyspnea. The patient should be instructed not to massage the legs.
The nurse is caring for a client receiving lactulose. Which of the following finding would indicate a therapeutic response? A. Increased liver enzymes B. Increased level of consciousness C. Decreased urinary calcium D. Increased gastric pH
B Lactulose is indicated for clients with hyperammonemia secondary to cirrhosis of the liver. Increased ammonia levels cause a patient to develop altered mental status (hepatic encephalopathy). A client receiving this medication will have increased bowel movements as that is the primary way of excreting the excess ammonia.
The nurse manager plans to develop a unit-based council to assist in decision-making. The nurse manager is demonstrating which leadership style? A. Authoritative B. Democratic C. Laissez-Faire D. Transactional
B The democratic leadership style is predicated on individuals participating in decision-making. Developing a unit-based council, distributing decision-making responsibilities to individuals, and promoting problem-solving by staff are examples of this leadership style. Choices A, C, and D are incorrect. An authoritative leadership style is when one individual is in complete control. This would be useful during an emergency situation, and clear roles need to be delegated. Laissez-Faire leadership focuses on relying on staff to make decisions, and the manager is viewed as a consultant. This is often viewed as a hands-off approach to leadership. Transactional leadership is when rewards and consequences are based on the actions of an individual. This leadership style is a rigorous approach to managing a team.
Which phase of the nursing process is most foundational for delivery of care? A. Evaluation B. Assessment C. Planning D. Diagnosis
B This assessment determines which diagnoses will be the focus of care, the interventions that will be initiated, and those that will be reevaluated. In this way, the assessments drive care, whereas the reassessments loop back into the further assessments and revision of care planning.
The nurse working on the medical-surgical unit is assigned as a preceptor to work with a newly hired nurse. Which of the following, if performed first by the newly hired nurse, would indicate the ability to prioritize appropriately? A. Teaches a client scheduled for discharge how to ambulate with crutches. B. Witnesses informed consent for a client needing an emergency laparotomy. C. Irrigates a client's ostomy who reports abdominal cramping. D. Calculates the intake and output of a client with diabetes insipidus (DI).
B Witnessing consent is within the scope of an RN. The client needing emergency surgery will require the RN's initial attention to avoid a delay in care. While the primary healthcare provider (PHCP) may override consent, this is usually reserved for clients who cannot communicate because of their condition.
The nurse is caring for a client newly diagnosed with Cushing's disease. Which of the following client statements requires follow-up? A. "I will need to eat more potassium-rich foods." B. "I will need more steroids during periods of stress." C. "I will be at a higher risk for an infection." D. "I should do weight-bearing exercises."
B explanation: A client with Cushing's disease has too many steroids and will have manifestations such as central obesity, weight gain, hypokalemia, hypernatremia, and hypertension. The client will not need more steroids during periods of stress as this is necessary for a patient with Addison's disease to prevent a crisis.
The nurse is reviewing newly prescribed medications for a client taking lithium. Which medication requires further follow-up? A. Venlafaxine B. Hydrochlorothiazide C. Gabapentin D. Verapamil
B A client taking lithium should be instructed to avoid dehydration and hyponatremia. Lithium is a salt, and when the client has decreased fluid volume, the drug will accumulate and raise the lithium level. HCTZ is a thiazide diuretic and is contraindicated for a client taking lithium because of its ability to decrease fluid and sodium levels.
The nurse is educating clients that are attending a prenatal class. Which of the following statements should the nurse include? A. "Chorionic Villous Sampling (CVS) may detect neural tube defects." B. "Maternal serum alpha-fetal protein (MSAFP) may determine gender." C. "Amniocentesis may be used to assess for chromosomal abnormalities." D. "A biophysical profile (BPP) assesses six variables such as fetal glucose."
C Amniocentesis is a widely used antepartum test that may determine the gender of a fetus, the presence of neural tube defects, chromosomal abnormalities, and fetal lung maturity. This test may also be used therapeutically for polyhydramnios as it may remove some excessive amniotic fluid volumes.
The nurse is caring for a client who is experiencing acute mania. Which of the following actions should be prioritized by the nurse? A. Plan structured solitary activities B. Redirect the client's speech and ideas C. Provide high-calorie, small, frequent meals D. Initiate a psychiatry referral
C Choice C is correct. A patient experiencing acute mania manifests symptoms such as inflated self-esteem, flight of ideas, psychomotor agitation, and an expansive affect. The patient experiencing mania often has difficulty sleeping and exerts excessive physical energy. Thus, the nurse needs to focus on ensuring that the patient's need for nutrition is met by offering high-calorie, small, frequent meals. This is the priority based on Maslow's Hierarchy of Needs
The nurse is caring for a 2-year-old client who is intubated and mechanically ventilated. Two hours into the shift, the hospital receives a tornado warning. What is the priority action the nurse should take? A. Clock out, her shift is over, and she is not responsible. B. Remove the child from the ventilator and carry her to a tornado shelter. C. Move the patient as close to the interior of the room as possible. D. Close all of the doors.
C During a tornado warning, the appropriate nursing action is to move patients away from windows and as close to the room's interior as they can safely be moved. This action best protects them in the event of a tornado.
The nurse is preparing to admit a client following lumbar spinal fusion surgery. The nurse should instruct the unlicensed assistive personnel (UAP) to have which equipment at the bedside? A. Overhead trapeze B. Abduction pillow C. Transfer board D. Continuous passive motion (CPM)
C Following a lumbar spinal fusion, the client will need to be log rolled. A transfer board/sheet, along with an ample amount of staff (at least three), will be necessary to facilitate the log roll.
Which is an intrinsic risk factor that increases the risk of patients developing pressure ulcers? A. Shearing B. Friction C. Impaired tissue perfusion D. Pressure
C Intrinsic refers to anything essential or belonging naturally. Impaired tissue perfusion is an internal risk factor. Other intrinsic risk factors associated with skin breakdown include: -Poor nutritional status -Incontinence -Alterations in fluid balance -Altered neurological functioning
The nurse is reviewing the plan of care for a client admitted to the behavioral health unit with anorexia nervosa. The nurse understands that the priority goal for this client is A. to attending scheduled group therapy. B. adhere to the medication regimen. C. gain one pound (half a kilogram) a week. D. demonstrate increased self-esteem.
C Physical needs always prioritize over other needs. For the client with anorexia nervosa, the priority is to stabilize and increase the client's weight. Anorexia nervosa may lead to life-threatening electrolyte disturbances if it goes untreated.
The nurse is teaching a client about newly prescribed tamsulosin. Which of the following statements should the nurse include? Correct Answer(s): C A. "This medication may turn your urine reddish/orange." B. "You will urinate more often with this medication." C. "Change positions slowly while you take this medication." D. "Avoid calcium-containing foods while on this medication."
C Tamsulosin is an alpha-1 antagonist medication indicated in the treatment of benign prostatic hypertrophy. This medication causes vasodilation, and the biggest side effect is orthostatic hypotension. The nurse should educate the client to change positions slowly while taking this medication to reduce the risk of orthostasis.
The mother is concerned about a 2 cm, red rash on her two-month-old infant's back, which blanches with pressure. What teaching should the nurse discuss with the mother regarding this type of lesion? A. Treatment is non-invasive and consists of yellow light laser ablation. B. This marking is due to excessive proliferation of mature capillaries. C. This immature hemangioma requires no intervention. D. The marking is a sign of an infected hair follicle.
C The description is consistent with an immature hemangioma (capillary hemangioma, superficial hemangioma). Because of their bright-red appearance, they are often referred to as "strawberry nevi." They blanch with pressure, which can help differentiate these lesions fromport-wine stains. Immature hemangiomas are common, harmless tumors of blood vessels that occur within the first year of life. They do not require any treatment and typically resolve on their own by 5-7 years of age. They commonly appear on the face, scalp, chest, or back. Occasionally, some immature hemangiomas can interfere with vision or cause other symptoms based on their location. Such hemangiomas may be treated with medications or laser surgery.
The nurse is the guest speaker in a seminar at a local elementary school. She is talking about accident prevention for school-aged children. Which statement by the attendees indicates an understanding of the topic? A. "School-aged children become settled and less adventurous compared to pre-schoolers." B. "School-aged children are less susceptible to home hazards than pre-schoolers." C. "School-aged children understand the dangers when you explain it to them." D. "School-aged kids are less controlled by their parents compared to toddlers."
C The school-aged kids' cognitive levels are now developed to enable understanding of and adherence to rules. They are now susceptible to instruction.
Select the hazard of immobility and complete bed rest that is accurately paired with one of its preventive measures. A. The accumulation of respiratory secretions: Oxygen supplementation therapy B. Dorsiflexion of the foot: Using a foot board or boots to maintain proper positioning C. Venous stasis: The use of a sequential compression device D. Skin breakdown: The use of a tilt table for clients at risk
C Venous stasis, a complication of immobilization and bed rest can be prevented with the use of a sequential compression device (SCD), anti-embolic stockings, client positioning, range of motion exercises, and active leg exercises in bed to promote venous return and to prevent venous stasis, deep vein thrombosis, and pulmonary emboli.
The nurse is educating a patient with glaucoma. Which of the following classifications of medications should the nurse instruct the patient to avoid? A. Osmotic diuretics B. Beta-adrenergic blockers C. Anticholinergics D. Alpha-2 adrenergic blockers
C Anticholinergic medications can increase intraocular pressure (IOP) and worsen the condition of patients with glaucoma. Anticholinergic agents also have the potential for producing central side effects, such as confusion, unsteady gait, or drowsiness in adults. Children may become restless or spastic. Glaucoma is one of the leading causes of blindness in the United States. In some cases, it is genetic. In others, it may occur due to eye injury or disease. Some medications may contribute to the development of glaucomas, such as long-term use of topical glucocorticoids, some antihypertensives, antihistamines, and antidepressants. The primary risk factor associated with glaucoma includes high blood pressure.
The nurse is caring for a newly diagnosed abdominal aortic aneurysm patient. The nurse should anticipate a prescription for which of the following medications? Correct A. Naproxen [11%] B. Digoxin [15%] C. Prednisone [14%] D. Atenolol
D An abdominal aortic aneurysm (AAA) is a severe condition that may lead to potential rupture. Depending on the size of the aneurysm, patients may be taken in for emergent or elective surgery. Priority action is to maintain the blood pressure appropriately. Hypertension is a potential risk factor for abdominal aorta aneurysms. In patients with AAA, hypertension should be aggressively treated with a blood pressure goal of < 140/90 mmHg. Apart from controlling blood pressure, beta blockers have another advantage of reducing the rate of expansion of an AAA. Thus, beta-blockers such as atenolol are used to lower blood pressure and decrease the risk of aneurysm progression and the risk of rupture.
A client who has sustained a sports injury just underwent a diagnostic arthroscopy of the left knee. Which of the following should the nurse prioritize assessing after the procedure? A. Wound and skin integrity B. Mobility assessment C. Skin and vascular assessment D. Circulatory and neurologic assessments
D Following the client's knee arthroscopy, the nurse should prioritize performing circulatory and neurologic assessments. As with all orthopedic procedures, compartment syndrome is one of the most severe post-procedure complications. Following an arthroscopy, swelling may occur in the affected limb due to the extravasation of fluid into the leg. This fluid accumulation increases the compartment pressure, leading to decreased or impaired vascular flow to the tissues. Compartment syndrome is a medical emergency, as it may cause irreversible neurological and circulatory impairments of the limb. Typically, the earliest symptom of compartment symptom is a client reporting pain that is out of proportion to the severity of the injury. Early signs of compartment syndrome include swelling, pallor, paresthesia, coolness, numbness, and weak pulses. Late symptoms include pulselessness and paralysis. Therefore, the nurse's priority is to perform circulatory and neurological assessments on the affected extremity. Once circulatory and neurological integrity is established, the nurse may then perform any additional assessments or interventions required.
A common prerenal cause of acute kidney injury is: A. Nephrotoxicity B. Bladder cancer C. Contrast media D. Hypovolemia
D Hypovolemia is a common prerenal cause of acute kidney injury (AKI). Prerenal reasons are those factors that are external to the kidney. Hypovolemia causes a decrease in blood flow to the organs. Hypovolemia can lead to intrarenal kidney disease.
A nurse educates a client who just had a skin test for hypersensitivity reactions. The nurse should teach the client which of the following? A. Ensure that the tested areas are kept moist with a mild lotion B. Keep the tested skin regions out of direct sunlight until after the test has been read C. Wash the test sites daily with mild soap and water D. To return on a specific date to have the test results read
D It is essential for the nurse to teach the client to return on a specified date to have the test results read by the health care provider (HCP). For a client undergoing skin hypersensitivity testing, test outcomes are determined based on specific hypersensitivity changes (i.e., erythema, wheals, and induration). Therefore, an essential aspect of skin hypersensitivity testing is ensuring the results are read at the appropriate intervals. Although the health care provider (HCP) can analyze immediate hypersensitivity reactions soon after the test is performed, delayed hypersensitivity reactions must be interpreted at a follow-up appointment specified by the HCP (typically 48-72 hours after the initial appointment). Interpretation of the test results before or after this particular timeframe would yield inaccurate and unreliable results. Therefore, the nurse should ensure the client is aware of the date and time of the follow-up appointment and understands the importance of adhering to the appointment to ensure their test results are correctly interpreted.
There is a massive airline crash near your acute care facility. As the victims of this massive external disaster arrive at your facility, your new graduate nurse asks you what the black-colored triage tags on the incoming victims indicate. How should you respond to this new nurse? A. The victims are the lowest priority for care. B. The victims have life-threatening injuries and are in need of immediate care. C. The victims are always dead. D. The victims are in a severe medical crisis, and they have little chance of survival.
D Red tags - IMMEDIATE and have a high change of survive. Ex: Pneumothorax, cardiac tamponade, massive hemorrhage Yellow tags - DELAYED medium priority. No immediate danger of death. Ex: femur fracture Green Tag - MINOR lowest priority, those with minor injury, ambulating, Ex: abrasions sprain Black tags - EXPECTANT keep comfortable, pain meds until death. Ex: massive head injury with fixed pupils, 3rd degree burns 95% body surface
The nurse is triaging clients in the emergency department (ED). Which client should the nurse triage as emergent? A client A. reporting pleuritic chest pain with a productive cough. B. who is pregnant and reporting intermittent nausea and vomiting. C. who has an isolated area of reddened vesicles and malaise. D. with sudden onset of ataxia and dysarthria.
D Sudden onset of dysarthria and ataxia concerns for stroke. These manifestations require emergent prioritization because treatment is necessary to prevent further tissue damage.
A nurse is conducting infection control assessments on the nursing unit. Which client is at the greatest risk for infection? A client A. withdrawing from alcohol and is malnourished. B. receiving methylprednisolone for an asthma exacerbation. C. has an external urinary catheter device for urinary incontinence. D. receiving total parenteral nutrition (TPN) via a central line.
D TPN is a risk factor as the high glucose content makes the client more likely to develop a bacterial or fungal infection. Also inappropriate dressing changes.
Today, you are the charge nurse for the nursing care unit overseeing RNs, LPNs, and unlicensed assistive personnel (UAPs). As you prepare the staff assignments prior to the shift, which of the following legal documents must you consider as you are making staff assignments and delegating tasks for the day? A. Competency checklists for all the team members scheduled for the shift B. Job descriptions of all team members on the unit for today's shift C. The scope of practice for both RNs and LPNs as established by the American Nurses Association D. The state's scope of practice documents for RNs, LPNs, and any applicable unlicensed assistive personnel (UAP)
D The state's scope of practice documents for RNs, LPNs, and applicable unlicensed assistive personnel are the legal documents that must be considered when creating assignments or delegating tasks for the day. These legal documents abide by specific state regulations differentiating what healthcare team members may or may not do under the licensure they possess (or, in the case of an UAP, the lack of licensure).
You are administering IV magnesium to a patient with a magnesium level of 1.5 mEq/L. You check on them halfway through the infusion, and they report that their face feels flushed. What is the priority nursing intervention? A. Slow down the infusion rate. B. Notify the healthcare provider. C. Reassess the patient when the infusion finishes. D. Stop the infusion.
D This is the priority nursing action and should be completed first. The infusion should immediately be turned off to minimize any further reaction. As soon as the injection is stopped, the provider can be notified. In priority nursing questions, the priority will always be whatever action you can take that immediately helps the patient. In this question, turning off the infusion will help stop/prevent further reactions to the magnesium infusion, so it is the priority.
The nurse is providing teaching to a student nurse who needs to instill ear drops in the ear of a 6-year-old patient. Which of the following methods is the best way to administer ear drops in this patient? A. Tilt the child's head to the side and instill the medication at a 90-degree angle. B. Pull the pinna down and back before instilling the drops. C. Use a spray bottle to instill the medication in the ear. D. Pull the pinna up and back before instilling the medication.
D When administering ear drops in children older than three years of age, the best way to give this medication is to pull the patient's pinna upwards and back before instilling the drops.