hesi test 1 redone

Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection? You answered this question Incorrectly 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. Correct: Cleaning from front to back will decrease the risk of infection by reducing the number of microorganisms at the urethral meatus. Keeping the umbilical cord clean and dry will decrease the risk of infection and will allow it to fall off.

A nurse from the pediatric unit is transferred to the adult medical-surgical unit. Which client assignment should the nurse accept from the charge nurse? You answered this question Correctly 1. Undergoing surgery for tonsillectomy and adenoidectomy. 2. Diagnosed with leukemia, hospitalized for induction of chemotherapy. 3. Prescribed IV heparin for left leg thrombosis. 4. Admitted with a cerebrovascular accident.

1. Correct: This is the most stable client to give to the nurse who was transferred from the pediatric unit. A pediatric nurse cares for postop T&As daily in this specialty area and can transfer this knowledge to the adult client.

A client diagnosed with cancer is being discharged home to live with an adult child. What action should the nurse take to participate in the continuity of care? You answered this question Incorrectly 1. Identify community services available for the client and family. 2. Discuss hospice care for the client. 3. Advise family that client would benefit more from nursing home placement. 4. Make arrangements for around the clock home health aides.

1. Correct: The nurse promotes continuity of care at discharge by providing a smooth transition from one level of care to another. The nurse should include in the discharge plan appropriate community support services available to the client and family so that they can obtain support as needed.

A client in the manic phase of bipolar disorder is constantly interrupting a group session. What should the nurse do? You answered this question Correctly 1. Engage the client to walk with the nurse to make another pot of coffee 2. Ask the client to reflect on behavior to determine if it is appropriate 3. Ask the group to tell the client how they feel when interrupted 4. Instruct the client to perform jumping jacks and count aloud to get rid of some energy.

1. Correct: Yes! Get them away and doing something purposeful.

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

The nurse, caring for a client on the medical unit, receives a primary healthcare provider prescription for penicillin 100,000 units IM. The drug label reads penicillin 300,000 units/mL. How many mL of this medication should the nurse administer? Round answer using two decimal points.

0.33

Which assignment would be most appropriate for the LPN/VN to accept from the charge nurse in the Labor, Delivery, Recovery and Postpartum Unit (LDRP)? You answered this question Incorrectly 1. Primipara needing assistance with breastfeeding. 2. Multipara reporting a headache and epigastric discomfort. 3. Primipara who is two days post op cesarean section. 4. Primipara who is preeclamptic in active labor. 5. Multipara post op cesarean section with a PCA pump.

1. & 3. Correct: These are stable clients whose care is within the scope of practice of an LPN/VN.

A client calls the clinic to ask the nurse if it would be okay to take the herbal medication kava-kava to help reduce anxiety. What is the nurse's best response? You answered this question Correctly 1. "Why do you want to take kava-kava?" 2. "I really doubt your primary healthcare provider will approve you taking kava-kava." 3. "Kava-kava can cause liver damage, so we need to consult your healthcare provider." 4. "Do not take Kava-kava for more than a year without a primary healthcare provider's supervision."

3. Correct: Kava-kava can cause liver damage. It is recommended that if if taking kava-kava the client should be under the direct supervision of a primary healthcare provider.

A client is receiving a unit of whole blood. The client begins to complain of lower back pain. What is the nurse's first action? You answered this question Correctly 1. Identify the client's pain level 2. Log roll the client to their side 3. Stop the transfusion 4. Take the client's vital signs

3. Correct: Low back pain is a sign of an acute hemolytic reaction. This is the most dangerous and potentially life-threatening type of transfusion reaction. It occurs when the donor blood is incompatible with that of the recipient.

The nurse is preparing to provide oral care to an unconscious client. What is the most important step for the nurse to provide? You answered this question Incorrectly 1. Performing hand hygiene. 2. Explaining the procedure to the family. 3. Positioning the client in side-lying position. 4. Raising the head of bed 30 degrees.

3. Correct: Positioning the client in a side-lying position allows secretions to drain from the mouth and prevents aspiration. The most important aspect of care is the protection of the airway of this unconscious client. This is accomplished through proper positioning of the client in a side-lying position.

The nurse is collecting data on a client who is having a breast augmentation. Which client information would be most important for the nurse to report to the surgeon before surgery? You answered this question Incorrectly 1. Client is concerned about who will care for her two children while she recovers. 2. There is a history of postoperative dehiscence after a previous C-section. 3. Client's last menstrual period was 8 weeks ago. 4. Client is concerned over pain control postoperatively.

3. Correct: The client may be pregnant, so a pregnancy test will need to be completed prior to administering anesthetic agents. As you look at these options, they are all possible but only one is a priority and, in this case, life threatening.

The nurse overhears two nursing students talking about a client in the cafeteria. What should the nurse do first? You answered this question Incorrectly 1. Report the incident to the nursing supervisor. 2. Write up a variance report about the incidence. 3. Instruct the students that this is a violation of HIPAA. 4. Notify the students' faculty regarding the violation.

3. Correct: The students should first be told of their violation of HIPAA and that they should stop immediately. Then the nurse should follow policy as to whether anyone else should be notified.

A client's vital signs, following a bowel resection are: Blood pressure 116/74; heart rate 102 and regular; respirations 26 and shallow. The ABGs are: pH 7.48; PCO2 30; HCO3 24. What disorder do these findings indicate? You answered this question Incorrectly 1. Metabolic alkalosis 2. Metabolic acidosis 3. Respiratory alkalosis 4. Cardiovascular shock

3. Correct: With increased respiratory rates, more PaCO2 is exhaled (blown off), decreasing the PCO2 level. PCO2 is an acid. If the client is blowing off CO2, an acid, this leaves them more alkaline. In this case, we see respiratory alkalosis because the lungs are the problem. The pH is high, indicating alkalosis.

What foods should the nurse reinforce to the client to avoid for three days prior to a guaiac test? You answered this question Correctly 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.

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? You answered this question Incorrectly 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.

A client has returned to the burn unit after an escharotomy of the forearm. What is the priority nursing intervention? You answered this question Incorrectly 1. Roll sterile q-tip over the wound 2. Elevate the affected arm 3. Ask the client to rate pain level 4. Monitor bilateral radial pulses

4. Correct: An escharotomy is an incision of the eschar of a burned arm to decrease the tension in the proximal tissue. This will result in increased circulation to the proximal tissue. The monitoring of bilateral radial pulses needs to be done to check for adequate circulation.

The nurse is caring for a client with jaundice, elevated liver enzymes and an elevated serum bilirubin. What color urine does the nurse expect to find? You answered this question Correctly 1. Pink tinged 2. Straw colored 3. Clear 4. Dark amber

4. Correct: Yes! The bilirubin will be excreted in the urine and discolor it dark.

The unlicensed assistive personnel (UAP) reports to the nurse that a client with Alzheimer's disease has been walking into rooms on the unit and stating, "This is my room, so get out!" What is the best instruction the nurse can give to the UAP? You answered this question Correctly 1. Calmly sit with the client and have the client repeat the room number at frequent intervals. 2. Have the client remain in own room so the client can become familiar with it. 3. Place a sign on the client's door with the client's name. 4. Hang a familiar object on the door to enhance room recognition.

RationaleStrategies 4. Correct: A client with Alzheimer's is likely to recognize a familiar object before reading the name on the door.

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.

(150/60)x15=38

The nurse walks into a client's room and finds the client exposed while the unlicensed assistive personnel (UAP) is giving the bath. After covering the client with a sheet, what should the nurse do first? You answered this question Incorrectly 1. Tell the UAP to keep the client covered at all times. 2. Talk with the UAP about providing appropriate care for all clients. 3. Provide teaching to the UAP about privacy for clients. 4. Use the call light to ask for additional assistance in the room.

1. Correct: A comment should be made about keeping the client covered. This instruction is the first action after covering the client.

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? You answered this question Correctly 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.

What's the most important information for the nurse to reinforce in the teaching plan of a client with aplastic anemia? You answered this question Correctly 1. Use a soft toothbrush or swab for mouth care. 2. Plan a high intake of raw fruits and vegetables. 3. Include a generous amount of red meats in the diet. 4. Return to the normal routines of living as quickly as possible.

1. Correct: With aplastic anemia, the client experiences pancytopenia (decrease in all the blood components). Platelets will be low and this places the client at risk for bleeding. Measures to reduce the risk of bleeding is the priority answer because the bleeding risk is the most life threatening to the client.

The nurse is providing care to a client who has a history of violent episodes against his wife. The client has made a specific threat that he plans to kill his wife when he gets out of the hospital. What should the nurse do first? You answered this question Correctly 1. Report the threat with the treatment team immediately. 2. Call the wife immediately to report her husband's intention. 3. Reinforce client teaching on violence prevention. 4. Tell the client that he shouldn't make threats like that.

1. Correct: Yes, immediately discuss the threat with the treatment team. The duty to warn is an obligation of healthcare providers. The threat should be discussed with the treatment team, and agency policy for notification of the threatened party should be followed.

A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual? You answered this question Incorrectly 1. Attend an activity with the client who is reluctant to go alone. 2. Allow the client to break an insignificant rule. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when the client is hungry.

1., 3., 4. & 5. Correct: Trust is demonstrated through nursing interventions that convey a sense of warmth and care to the client. These interventions are initiated simply, concretely, and directed toward activities that address the client's basic needs for physiological and psychological safety and security. Concrete thinking focuses thought processes on specifics, rather than generalities, and immediate issues, rather than eventual outcomes. Examples of nursing interventions that would promote trust in an individual who is thinking concretely include such things as: providing a blanket when the client is cold, providing food when the client is hungry, keeping promises, being honest, providing a written, structured schedule of activities, attending activities with the client who is reluctant to go alone, being consistent in adhering to unit guidelines, and taking the client's preferences, requests, and opinions into consideration when possible in decisions concerning care.

A homeless person has been admitted to the medical unit and placed on airborne precautions for suspected Pulmonary Tuberculosis (TB). The nurse will monitor for which signs and symptoms? You answered this question Correctly 1. Weight gain 2. Fatigue 3. Bloody sputum 4. Diaphoresis during sleep 5. Anorexia

2., 3., 4. & 5. Correct: Feeling tired all the time or fatigue, weight loss rather than weight gain, loss of appetite, fever, coughing up blood and night sweats are the most common signs and symptoms of active TB.

What is the priority nursing intervention for a client with carbon monoxide poisoning? You answered this question Correctly 1. Connect to an O2 saturation monitor. 2. Hyperventilate with an ambu bag. 3. Send to radiology for a ventilation/perfusion scan. 4. Administer 100% O2 per nonrebreather mask.

4. Correct: How do you treat carbon monoxide poisoning? It is treated with 100% oxygen.

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? You answered this question Correctly 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.

A nurse on a psychiatric unit overhears an unlicensed assistive personnel (UAP) tell a client who is very restless and continually pacing, "I am going to put you in restraints if you do not go to your room and sit down." The nurse should inform the UAP that this comment could lead to which legal action being taken against the UAP? You answered this question Correctly 1. Assault 2. Battery 3. False imprisonment 4. Invasion of privacy

1. Correct: Assault is an act that results in a person's genuine fear and apprehension that he or she will be touched without consent. 2. Incorrect: Battery is the unconsented touching of another person. These charges can result when a treatment is administered to a client against his or her wishes and outside of an emergency situation. Harm or injury need not have occurred for these charges to be legitimate. 3. Incorrect: For confining a client against his or her wishes, and outside of an emergency situation, the nurse may be charged with false imprisonment. Examples include locking a person in a room; taking a client's clothes for purposes of detainment against his or her will; and retaining in mechanical restraints a competent voluntary client who demands to be released. 4. Incorrect: This is a charge that may result when a client is searched without probable cause. You need a healthcare provider's prescription and written rationale showing probable cause for this intervention.

Which nursing intervention is most important for the nurse to perform prior to the administration of diltiazem? You answered this question Incorrectly 1. Note the rate and character of the apical pulse. 2. Ausculate the anterior and posterior breath sounds. 3. Check the morning results of serum electrolytes. 4. Review the last 24 hour urine output.

1. Correct: Diltiazem is used to treat hypertension, angina, and certain heart rhythm disorders. So prior to giving this medication, the nurse should monitor blood pressure and pulse. Diltiazem causes systemic vasodilation and suppresses arrhythmias.

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?" You answered this question Incorrectly 1. It will regulate a neurotransmitter called serotonin 2. It will help you feel less depressed 3. It will raise your level of the brain hormone norepinephrine. 4. It will balance blood glucose and dopamine levels in your head.

1. Correct: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI), which regulates serotonin levels in the brain. The drug action is explained in a manner that the client will understand.

A client with sleep apnea has been ordered a Continuous Positive Airway Pressure (CPAP) machine. Which action could the nurse assign to an unlicensed assistive personnel (UAP)? You answered this question Incorrectly 1. Reminding the client to apply the CPAP at bedtime 2. Obtaining oxygen saturation levels every three hours 3. Teaching the client how to turn on the CPAP machine 4. Assessing for fatigue or depression caused by poor sleep

1. Correct: It is appropriate delegation for a UAP to remind the client to do a previously taught intervention. The UAP cannot perform actual teaching because this is outside the scope of practice, but reminding the client about what was taught may help with compliance.

A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. A complete client evaluation has not identified a physical reason for the symptoms. The client tells the nurse, "The doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad some times that I can't function!" What is the nurse's most appropriate response? You answered this question Correctly 1. "The pain you feel is real." 2. "The primary healthcare provider is right. Your pain is not real." 3. "Let me get you an appointment with the psychiatrist." 4. "Don't worry. Everything will be ok."

1. Correct: Pain is real even if it is psychological pain. The client is expressing anxiety and stress through stomach pain. The nurse should use a therapeutic communication technique that is client centered and empowers the client.

A new mother brings her infant to the clinic for a well-baby checkup. While at the clinic, the mother asks the nurse if there are any reasons why her infant should not have the measles, mumps, rubella (MMR) vaccine. The nurse's response is based on evidence that the MMR vaccine is contraindicated under which condition? You answered this question Correctly 1. A known allergy to gelatin. 2. A family history of autism. 3. In infants with diarrhea. 4. A known allergy to sulfonamides.

1. Correct: The MMR vaccine is grown using chicken embryos and manufactured with the use of gelatin. Known allergies to gelatin would be a contraindication for administration. 2. Incorrect: The Centers for Disease Control does not recognize a link between the administration of the MMR vaccine and the development of autism. 3. Incorrect: Diarrhea is not a contraindication specifically for the MMR vaccine. Diarrhea may result in hypovoemia and electrolyte imbalance which would need to be addressed. 4. Incorrect: Sulfonamides are not used in the development of the MMR vaccine. Neomycin is used in the development of the MMR vaccine. Neomycin is the only antibiotic allergy that would contraindicate the administration of the MMR vaccine.

What action should the nurse take when a client receiving 40 mL/hr of enteral feedings has a gastric residual volume of 250 mL? You answered this question Incorrectly 1. Recheck gastric residual volume in 1 hour. 2. Reduce the infusion rate and reevaluate residual volume in 4 hours. 3. Change the feeding schedule from continuous to intermittent delivery. 4. Discard the 250 mL and continue the feedings at the same rate.

1. Correct: The action is to recheck gastric residual in 1 hour. This may be a sign of intolerance. Reasons for delayed gastric emptying must be determined if 250 mL or more remains on 2 (1 hour apart) checks.

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? You answered this question Correctly 1. Ensure a do-not-resuscitate prescription has been provided. 2. Report client wishes during the end-of-shift report. 3. Have the client sign an advanced directive. 4. Ask the client who holds the durable power of attorney for health care decisions.

1. Correct: The nurse should check the medical record for a DNR order. By law, a person who does not have a do-not-resuscitate (DNR) prescription, must be provided CPR in the event of a cardiac/respiratory arrest. This action will ensure the client's end-of-life wishes have been communicated and will honor the client's wishes.

Which food selection would need to be removed from the tray by the nurse for a client recovering from thyroidectomy? You answered this question Correctly 1. Roasted almonds 2. Mashed vegetables 3. Scrambled eggs 4. Ice cream

1. Correct: 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. 2. Incorrect: Mashed vegetables will be soft and easy to swallow. No need to remove this food selection. 3. Incorrect: This would be good for the client. The food is soft and easy to swallow. No need to remove this food selection. 4. Incorrect: Ice cream with neck surgery. Cold and soft. No need to remove this food selection.

Which behavior by the nurse indicates proper use of standard precautions? You answered this question Correctly 1. Wearing clean gloves while performing a heel stick on an infant. 2. Wearing the same gloves for assessment of clients in the same room. 3. Wearing sterile gloves when changing the urine bag and nasogastric canister of an infected client. 4. Donning a gown when responding to a request by the family to check the IV pump on a client with rotovirus.

1. Correct: When drawing blood, a precaution is to wear gloves, so blood will not get on the nurse's hands. Clean gloves are appropriate here.

How should the nurse respond to a pregnant client who asks, "How will I know when it is time to go to the hospital?" You answered this question Correctly 1. "Go to the hospital immediately if your membranes rupture." 2. "You should leave for the hospital as soon as you lose your mucus plug." 3. "Go to the hospital when you have a burst of energy followed by a backache." 4. "You need to go to the hospital when contractions are 2 minutes apart."

1. Correct: Yes! This is the appropriate information. A gush or trickle of fluid from the vagina should be evaluated regardless of whether contractions are occurring. Infection and compression of the umbilical cord are possible complications. 2. Incorrect: No. The mucus plug is lost prior to the beginning of active labor, so too early to go to the hospital. Some women lose their mucus plug weeks before labor begins, others lose it right as labor starts. 3. Incorrect: Nesting? That's too early and not specific enough. This is not labor. 4. Incorrect: The client should go when contractions are 5 minutes apart, for 1 hour if it is her first pregnancy. Labor may be faster for the woman who has given birth before than for the nullipara. Multiparas are instructed to go to the hospital when contractions are regular, 10 minutes apart, for 1 hour.

A client who has been trying to lose weight reports to the nurse that it is just easier to stop by the fast food restaurant on the way home from work than to go home and prepare a meal. Which suggestions should the nurse provide to help the client stay on track? You answered this question Incorrectly 1. Eat yogurt and a piece of fruit upon returning home. 2. Order low fat options at the restaurants. 3. Pack a healthy snack to eat on the way home from work. 4. Fast foods do not contain healthy options. 5. Alter route home from work in the evenings.

1., 2. & 3. Correct: The client is describing lack of convenience, a barrier to making better choices. The client can consume yogurt and fruit on the way home and still be making a good choice for dinner. Accessibility of healthier items will help the client stay on track. Availability of healthy foods will help the client stay on the food plan.

Which health promotion strategies are best for the nurse to reinforce for a single parent of young children who is trying to increase personal physical activity level but expresses a lack of time? You answered this question Incorrectly 1. Suggest walking up and down steps at home several times each morning and evening. 2. Suggest parking further away from the grocery store and work. 3. Walk with the children in the evening instead of watching TV with them. 4. Suggest waking one hour earlier in the morning to go to the gym. 5. Suggest walking for 30 minutes with a buddy each afternoon before leaving work.

1., 2. & 3. Correct: These strategies will allow the parent to stay home without adding further time demands to the day. Parking farther away is one plan to get more steps into the day without increasing time demands drastically. Walking with the children allows the parent to spend quality time with the children as well as offers them a good example.

The nurse is caring for a client diagnosed with paranoid personality disorder. Which interventions would be appropriate for the nurse to initiate? You answered this question Incorrectly 1. Develop a trusting relationship. 2. Be honest when communicating with the client. 3. Encourage the client to participate in group therapy. 4. Encourage the client to clean the day room daily. 5. Give clear explanations of procedures beforehand.

1., 2. & 5. Correct: This disorder is characterized by distrust and suspicion towards others. The nurse should use open communication techniques to increase the client's trust in the nurse. Clear explanations of procedures will decrease the anxiety of the client.

Which safety interventions would be appropriate for the nurse to reinforce to parents of school aged children? You answered this question Correctly 1. Encourage bicycle helmet use when riding bikes. 2. Teach children to swim at an early age. 3. Teach children to not be afraid of playing with neighborhood dogs. 4. Keep firearms in the home locked and unloaded. 5. Teach "stop, drop, and roll" in case clothing catches on fire.

1., 2. 4., & 5. Correct: Wearing a helmet when bike riding may prevent head injury in case of a bike accident. Children should learn to swim at early ages. Children may drown in home or neighborhood pools. Children are curious about firearms, which should be safely locked away and unloaded. Fire safety is important. Being able to extinguish a fire quickly can save a life.

Which client data should the nurse anticipate when caring for a client with acute cholecystitis? You answered this question Correctly 1. Chills 2. Fever 3. Nausea and vomiting 4. Increased appetite 5. Rigidity of upper right abdomen

1., 2., 3. & 5. Correct: Many clients with acute cholecystitis present with acute onset of right upper quadrant pain associated with nausea and vomiting. Epigastric pain may also be present as well as fever, chills, and anorexia. A physical examination often reveals rigidity of the upper right abdomen that may radiate to midsternal area or right shoulder. Rebound and guarding are present in some cases.

Which interventions should the nurse initiate to lessen acid reflux in a client diagnosed with gastroesophagel reflux disease (GERD)? You answered this question Correctly 1. Provide small, frequent meals. 2. Avoid carbonated beverages. 3. Administer omeprazole as prescribed. 4. Assist with smoking cessation. 5. Place in left lateral position for 2 hours after eating.

1., 2., 3., & 4. Correct: All of these actions are correct to help alleviate GERD. When a client has GERD, the stomach's contents reflux into the esophagus. Small frequent meals will decrease possible reflux by decreasing the stomach content. Smoking can relax the lower muscle of the esophagus. Drinking a carbonated drink may cause the stomach to expand. Both smoking and drinking a carbonated drink increase the potential of reflux. The action of omeprazole is to reduce the acid that is produced in the stomach.

A nurse has just inserted an indwelling urinary catheter in a client scheduled for surgery. What should the nurse document? You answered this question Incorrectly 1. Size of catheter. 2. Color of urine. 3. Date and time of insertion. 4. Type catheter inserted. 5. Infusing rate of IV fluid.

1., 2., 3., & 4. Correct: The following documentation is appropriate after inserting an indwelling catheter: Color of the urine, date and time of the insertion, the type of catheter inserted, and the catheter size.

The nurse is caring for a client with a perineal burn. The skin is not intact. How will the nurse know if a perineal infection is occurring? You answered this question Correctly 1. Color changes 2. Drainage 3. Odor 4. Fever 5. Bleeding 6. Increased pain

1., 2., 3., 4. & 6. Correct: Infection may cause color changes, drainage, odor, fever and increased pain.

Which documentation entries by the LPN would be appropriate to place in a client's electronic record? You answered this question Correctly 1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. 2. Appears to be having abdominal discomfort. 3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. 4. Pre op Diazepam 10.0 mg given po. 5. Transferred to surgical suite per stretcher with side rails up, in stable condition.

1., 3, & 5. Correct: These are written correctly with complete, concise and objective information for each statement pertaining to the client.

The nurse is reinforcing discharge education to a client after a concussion. What should the nurse emphasize to report to the primary healthcare provider? You answered this question Incorrectly 1. Difficulty waking up 2. Headache (3/10 on the pain scale) 3. Blurry vision 4. Achy feeling all over 5. Vomiting

1., 3. & 5. Correct: Increased intracranial pressure (ICP) is a result of increased pressure around the brain or blood in the brain. These are signs of increasing intracranial pressure (post-concussion syndrome). This is a medical emergency, and the primary healthcare provider should be notified immediately.

Which comments made by the nurse indicate an understanding of confidentiality as it relates to mental illness? You answered this question Incorrectly 1. "Client approval is needed prior to talking with family members." 2. "My computer screen is left open for the next nurse to chart." 3. "Client situations can be discussed in the care planning meeting." 4. "Discussion about clients while in the elevator is prohibited." 5. "In the home setting, I can be more casual in discussing client information with others."

1., 3., & 4. Correct. The nurse should be the client advocate and protect the client's confidential information. A client's personal data and identifiable health information should be shared only with persons approved by the client. 2. Incorrect: The nurse's computer screen should not be viewed by unauthorized persons. Also each nurse should log off the computer to ensure client confidentiality. 5. Incorrect. The confidentiality of the client information is to be maintained in the home setting. The nurse is the client advocate.

The nurse is assisting with a plan to teach a group of young women who want to become pregnant. What information should be included to increase the chances of having a healthy baby? You answered this question Correctly 1. Take 400 micrograms of folic acid every day. 2. Limit alcohol to 1 glass per day. 3. Avoid smoking. 4. Take the flu vaccine during flu season. 5. Start prenatal care by 3 months of pregnancy

1., 3., & 4. Correct: Folic acid is a B vitamin. If a woman has enough folic acid in her body at least a month before and during pregnancy, it can help prevent neural tube defects. Smoking can lead to premature birth, cleft lip or cleft palate, and infant death. The flu shot given during pregnancy has been shown to protect mom and baby (up to 6 months old) from flu.

An elderly client tells the nurse, "I noticed that my skin is drier". What should the nurse tell the client about skin changes associated with aging? You answered this question Correctly 1. The oil glands don't work as effectively as one ages. 2. There is increased vascularity of the skin in the elderly making it appear red. 3. There is a loss of elasticity in the skin with advancing age. 4. One loses the fat under the skin as one ages. 5. Skin tears more easily as one gets older.

1., 3., 4. & 5. Correct. There is a decrease in sebaceous gland activity in the elderly. Elasticity of the skin decreases with aging. Subcutaneous fat diminishes as one ages resulting in sagging and wrinkling of the skin. The skin becomes fragile and tears easily in the elderly.

The primary healthcare provider is preparing to drain a large abdominal abscess. The client has dementia and moves about on the bed frequently. Which personal protective equipment (PPE) should the nurse wear while holding the client for the procedure? You answered this question Correctly 1. Face shield 2. Sterile Gloves 3. Gown 4. Mask 5. Regular exam gloves

1., 3., 4. & 5. Correct: The nurse should implement transmission based contact precautions. During drainage of an abscess, the nurse may come into direct and indirect contact of the contaminated body fluids. The nurse needs the protection of a gown, mask, face shield, and regular exam gloves. Since the nurse is not directly assisting with the wound care, regular exam gloves are appropriate.

What statement by a new LPN would indicate an understanding of how to maintain skin integrity for a client on bedrest? You answered this question Incorrectly 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. Skin should be monitored every 2hrs.

What nursing actions 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. A calm environment may promote relaxation. Light therapy may reduce agitation and confusion during the day, so open the blinds. Caregivers should remain calm and avoid confrontation. Routine helps the client feel secure.

What factors should a licensed practical nurse (LPN) consider when deciding to accept a delegated task or responsibility from a registered nurse (RN)? You answered this question Correctly 1. The stability of the client's condition. 2. The workload of the RN on the unit. 3. The number of years that the LPN has worked on the unit. 4. One's knowledge related to the delegated task or responsibility. 5. One's own competence to perform the delegated task or responsibility.

1., 4. & 5. Correct: When deciding to accept a delegated task or responsibility, the stability of the client's condition should be considered. Since client assessment is performed by the RN, unstable or critically ill clients should remain the RN's responsibility. The LPN should also consider his or her own knowledge related to the assigned task or responsibility. Do not accept the assignment if you do not know how to handle the situation or perform the task. Ask for additional information or instruction before accepting the assignment. The LPN should evaluate his or her own competence to perform the delegated task or responsibility. Client safety is always the priority. Be familiar with the Nurse Practice Act in your state.

Which tasks would be appropriate for the LPN/VN to accept from the RN? You answered this question Incorrectly 1. Administer antibiotic via intravenous piggyback (IVPB). 2. Teach insulin self administration to a diabetic client. 3. Administer IV pain medication to a two day post op client. 4. Check for urinary retention. 5. Remove wound sutures.

1., 4., & 5. Correct. These tasks are within the PNs practice scope. The PN can administer antibiotics by IVPB, monitor for urinary retention and remove wound sutures.

Which interventions are most appropriate for the nurse to provide for the client diagnosed with late onset Alzheimer's disease? You answered this question Incorrectly 1. Make sure the client's room is dark at bedtime to ensure sleep. 2. Offer fluids every 2 hours during the day and restrict fluids after 6 pm. 3. Teach client to dress self within 30 minutes. 4. Speak loudly and clearly while looking into the client's face. 5. Store frequently used items within easy reach of the client.

2. & 5. Correct: Offering fluids every 2 hours during the day and restricting fluids after 6 pm will ensure adequate hydration but will also minimize nighttime wetness, incontinence, and having to get up frequently at night. Storing frequently used items within easy reach helps to ensure client safety.

The LPN/VN is collecting health assessment data from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider? You answered this question Correctly 1. "When I was 8 years old I had chickenpox." 2. "I had rheumatic fever when I was 10 years old." 3. "There is a strong history of gastric cancer in my family." 4. "I have pain in my hip with any movement."

2. Correct: After having rheumatic fever, a client would need to be pre-medicated with antibiotics prior to any surgical or dental procedure to prevent the development of infective endocarditis.

Which finding should a nurse expect when collecting data on a healthy 65 year old client? You answered this question Correctly 1. Anomia 2. Presbyopia 3. BP 156/88 4. Apraxia

2. Correct: As the lens becomes less flexible, the near point of focus gets further away. This condition, presbyopia, usually begins in the 40s. Reading glasses to magnify objects are required.

The client has been prescribed a topical anticholinergic medication for the treatment of glaucoma. Which report by the client indicates a common side effect? You answered this question Incorrectly 1. Constriction of the iris sphincter 2. Blurred vision 3. Pain 4. Confusion

2. Correct: Blurred vision is a common side effect of the medication due to the dilatation of the iris sphincter.

The nurse assigned feeding of a client to the unlicensed assistive personnel (UAP). Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. What should the nurse do first? You answered this question Correctly 1. Feed the client after warming the food. 2. Speak to the UAP to determine what happened with the feeding. 3. Pick up the tray and tell the UAP the task was not done. 4. Provide a between meal supplement to the client.

2. Correct: Communication is important in assigning tasks, as is follow-up. There may be a good reason that the tray was not served. The key word in the stem is first. The other options may be correct but are not the best first action.

A client reports to the nurse, "I just do not feel well. Something is wrong." The client's vital signs are BP: 130/88, HR: 102, RR: 28. What should the nurse do next? You answered this question Correctly 1. Administer PRN anxiolytic. 2. Connect to oxygen saturation monitor. 3. Reassure the client that everything is okay. 4. Assist with relaxation technique.

2. Correct: Everything is pointing toward hypoxia. Look at HR and RR. This data is telling you that the client is restless and has tachycardia...think hypoxia FIRST when you see these 2 symptoms.

The nurse is caring for a client reporting intense headaches with increasing pain for the past month. An MRI is prescribed. In reviewing the client's information, which piece of information is of concern to the nurse? You answered this question Correctly 1. Allergy to iodine 2. Internal cardiac defibrillator 3. Diabetic 4. Stroke a year ago

2. Correct: If a client with a cardiac pacemaker and internal defibrillator has an MRI, the pacemaker is turned off and the client could die. The MRI uses a magnet. Magnets turn off pacemakers. This needs to be reported to the primary healthcare provider.

Immediately following a below-the-knee amputation (BKA), the nurse positions the client to prevent complications. What intervention related to position of the residual limb is a priority at this time? You answered this question Incorrectly 1. Flat on the bed 2. Elevate foot of the bed 3. Position of comfort 4. Dependent position

2. Correct: It is normal to experience post-operative swelling after a BKA. Immediately after surgery, the foot of the bed should be elevated to reduce swelling. An ACE compression bandage will be used to reduce swelling and prevent hemorrhage. The other positions would not be as appropriate since swelling is an issue after a below the knee amputation.

The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate to the nurse that the client should not be advanced to the next level? You answered this question Correctly 1. Facial flushing 2. Report of chest heaviness 3. Heart rate increase of 10 beats/min. 4. Systolic blood pressure increase of 10 mm Hg

2. Correct: Onset of chest pain indicates myocardial ischemia which can be life threatening. The client should not be advanced to the next level of activity.

The nurse is preparing to administer oxycodone with acetaminophen for pain control as prescribed by the healthcare provider. The nurse checks the client's arm band and notes that the client is allergic to acetaminophen. What action should the nurse take? You answered this question Correctly 1. Give the medication as prescribed. 2. Return to the nurse's station and notify healthcare provider of allergy. 3. Ask the client about allergies to acetylsalicylic acid 4. Ask client to rate pain on a scale of 1 to 10.

2. Correct: Oxycodone and acetaminophen cannot be given if the client is allergic to acetaminophen. Call the primary healthcare provider for another medication.

A client received a leg cast that was applied following fracturing the left femur. What observation would be a priority for the nurse to report to the primary healthcare provider? You answered this question Correctly 1. Reports of a feeling of warmness under the cast after application. 2. Pain not relieved by elevation, cold packs, and pain medication. 3. Reports of itching under the cast not relieved by cool air. 4. Slight swelling of the toes of the affected extremity.

2. Correct: Pain that is disproportionate to the injury, becomes severe, and/or is not relieved by elevation, cold packs, and pain medication could indicate a complication such as compartment syndrome. Failure to detect this could lead to neurovascular damage and possible amputation.

An elderly client with vomiting and diarrhea for three days, is receiving IV fluids at 200 mL/hr via pump. What is the priority nursing action? You answered this question Incorrectly 1. Intake and output every shift. 2. Auscultate lungs every 2-4 hours. 3. Vital signs every shift. 4. Monitor IV site every 2-4 hours.

2. Correct: The IV is infusing at 200 mL/hr which is a rapid infusion rate for an elderly client. The lungs should be auscultated every 2-4 hours to monitor for potential fluid volume excess (FVE). 1. Incorrect: Input and Output (I&O) are important, but are a less priority than lung auscultation in the elderly client to monitor for FVE. 3. Incorrect: Vital signs should probably be more frequent than every shift on the elderly client with dehydration. In addition, the client's IV rate is 200 mL/hr which may result in FVE. 4. Incorrect: The site should be monitored but will not be the priority over lung auscultation in the elderly client to monitor for FVE.

When arterial blood gases (ABGs) are drawn by lab personnel, which information is important for the nurse to document? You answered this question Incorrectly 1. That the client had not been NPO prior to the test. 2. The client was on 2 L of oxygen by nasal canula. 3. Lung sounds are wet. 4. Client is in semi fowler's position.

2. Correct: The fact that the client is on 2 Liters of oxygen will affect the analysis of the ABG results.

An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse respond to this? You answered this question Correctly 1. Encourage the family to accept nursing home placement as the best option for their loved one. 2. Listen to the family's concerns and report those to the primary healthcare provider. 3. Determine what the client wants to do and tell the family to abide by the client's wishes. 4. Realize that the nurse does not need to be involved in this decision.

2. Correct: The nurse should listen to the concerns of the family. The Asian culture tends to be opposed to nursing home placement and see it as their duty to care for their elders in the home. The nurse should listen and serve as an advocate.

The nurse is talking with the spouse of a client who has alcoholism and determines that the spouse is exhibiting co-dependent behavior. What comment by the spouse confirms this behavior? You answered this question Correctly 1. "I frequently tell my spouse that drinking alcohol is ruining our relationship." 2. "I go and pick my spouse up from the bar when not home by midnight." 3. "I do not go out drinking with my spouse, and will not drink at home either." 4. "I have told my spouse that I am willing to attend a counseling session when my spouse wants to stop drinking."

2. Correct: The spouse is attempting to please the alcoholic client. Codependent people are people pleasers, and they make excuses for others. The spouse is enabling the client to continue to drink. The spouse may feel keeping the client from driving while intoxicated will keep people safe.

A client has been prescribed chlorpromazine for the treatment of schizophrenia. The nurse makes afternoon rounds and finds the client's temperature to be 104.7º F/40.4º C. The client has extreme muscle rigidity, and the vital signs have been fluctuating for the last four hours. What should the nurse do first? You answered this question Incorrectly 1. Provide a tepid sponge bath. 2. Notify the primary healthcare provider immediately. 3. Administer an antipyretic immediately. 4. Administer the chlorpromazine as prescribed.

2. Correct: These symptoms are consistent with neuroleptic malignant syndrome (NMS), which is an adverse reaction to antipsychotic drugs. The symptoms of NMS are fever, altered mental state, muscle rigidity, and autonomic dysfunction. This is a medical emergency, and immediate action should be taken.

A client who must use crutches, is being assisted by the nurse while performing a three-point gait. What information should the nurse provide? You answered this question Correctly 1. Move right crutch forward, then left foot. Next move left crutch forward, then right foot. 2. Move both crutches forward without bearing weight on the affected leg, then move the unaffected leg forward. 3. Move left crutch and right foot forward together, then move the right crutch and left foot forward together. 4. Move both crutches ahead together, then lift body weight by the arms and swing both legs to the crutches.

2. Correct: This method is correct for the three-point gait. Client has to bear weight on the unaffected foot and both crutches. The affected leg does not touch the ground.

An unresponsive client begins to vomit. What intervention by the nurse would have the highest priority? You answered this question Correctly 1. Suction the client's mouth. 2. Turn the client onto their side. 3. Apply oxygen per face mask. 4. Insert an oropharyngeal airway.

2. Correct: To prevent aspiration, the first thing to do is turn the client onto their side. Leaving the client in the supine position will allow vomitus to get into the lungs when the client breathes.

The nurse is gathering data on a health history with a client who is 10 weeks pregnant. During the interview, the client states, "I'm not so sure I'm really happy about this pregnancy". Which response by the nurse is most appropriate? You answered this question Incorrectly 1. Many women feel ambivalent about being pregnant. 2. Tell me more about how you are feeling. 3. Why do you feel this way? 4. It seems there is never a good time to get pregnant.

2. Correct: Use of the open ended statement provides the client an opportunity for clarification of her feelings, ideas and perceptions. This also emphasizes the importance of the client's interaction.

Which action should the nurse perform first when a chest tube is accidentally disconnected from the water-seal system? You answered this question Correctly 1. Auscultate the lung sounds. 2. Re-connect the tubing. 3. Notify the primary healthcare provider. 4. Place the client on oxygen.

2. Correct: You do whatever you can to re-establish the water seal. The water seal must be re-established to prevent tension pneumothorax.

A licensed practical nurse (LPN) is planning client assignments prior to the beginning of a shift. Which tasks would be appropriate for the LPN to assign to an unlicensed assistive personnel (UAP)? You answered this question Incorrectly 1. Change dressing on a new postoperative client. 2. Ambulate a 3 day postoperative client. 3. Provide insulin to a diabetic client before breakfast. 4. Collect urine for a 24-hour urine collection. 5. Monitor client expressing suicidal thoughts hourly.

2.& 4. Correct: It is appropriate for the UAP to attend to a stable client who requires frequent ambulation. The UAP has been trained to safely ambulate clients. It is appropriate for the UAP to collect a 24-hour urine specimen. The UAP is skilled at this task.

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? You answered this question Correctly 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. Correct: A client going through a normal grieving process will experience a mixture of good and bad days. The client can enjoy their family. The client experiences moments of pleasure and cries less.

Which signs and symptoms would the nurse expect to observe in a client who has taken prednisone for two months? You answered this question Incorrectly 1. Weight loss 2. Decreased wound healing 3. Hypertension 4. Decreased facial hair 5. Moon face

2., 3. & 5. Correct: Decreased wound healing is a side effect with prolonged steroid use due to the immunosuppressive effects. All steroid medications, such as prednisone, can lead to sodium retention which then leads to dose related fluid retention. Hypertension is seen due to this fluid and sodium retention. Cushingoid appearance (moon face) is a side effect that is created from the abnormal redistribution of fat from prolonged steroid use. 1. Incorrect: Within one month after corticosteroid administration, weight gain is seen rather than weight loss. 4. Incorrect: Facial and body hair increase with prolonged steroid use. This excessive growth of body hair, known as hirsutism, is one of the numerous potential side effects of prednisone.

Post thyroidectomy, the nurse monitors the client for complications by performing which action? You answered this question Incorrectly 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 intervention should be made by the nurse to minimize risk of infection from an indwelling urinary catheter? You answered this question Incorrectly 1. Check to see if drainage receptacle is at the level of the bladder 2. Position the catheter below the level of the bladder. 3. Check tubing to assure that there is no tension on the catheter tubing. 4. Make sure that gravity drainage is maintained. 5. Cleanse around urinary meatus three times per day with antiseptic solution.

2., 3., & 4. Correct: Observing urine flow is important as is notation of color, odor and any sediment or blood in the urine. Stagnant urine is prone to infection. Tubing should be free of kinks and without tension on the tubing. Gravity drainage should be maintained at all times. The drainage receptacle should be below the level of the bladder to allow for gravity drainage, with no loops in the tubing below the level of the drainage receptacle.

The client has suicidal ideations with a vague plan for suicide. The nurse, who is reinforcing teaching to the family about caring for the client at home, should emphasize which points? You answered this question Correctly 1. Family members are responsible for preventing future suicidal attempts. 2. When the client stops talking about suicide, the risk has increased. 3. Warning signs, even if indirect, are generally present prior to a suicide attempt. 4. One suicide attempt increases the chance of future suicide attempts. 5. Report sudden behavioral changes.

2., 3., 4. & 5. Correct: A common myth is that the person who doesn't talk about suicide will not attempt it, but this may be a warning sign that the person has a well thought out plan. Warning signs generally exist but may not be recognized by others until after the suicide or attempted suicide. Once a person has made a suicidal attempt, the chances increase that they will attempt it again at a later time. Sudden behavioral changes can signal suicidal intentions, especially if that is the primary focus of their thoughts and feelings.

Which data collected by the nurse would support a client history of chronic emphysema? You answered this question Incorrectly 1. Atelectasis 2. Increased anteroposterior (AP) diameter 3. Breathlessness 4. Use of accessory muscles with respiration 5. Leans backwards to breathe 6. Clubbing of fingernails

2., 3., 4., & 6. Correct: Emphysema is described as a permanent hyperinflation of lung beyond the bronchioles with destruction of alveolar walls. Airway resistance is increased, especially on expiration. Inspection reveals dyspnea on exertion, barrel chest (anteroposterior diameter is equal to transverse diameter), tachypnea, and use of accessory muscles with respiration. Clubbing of fingernails is due to chronically decreased oxygen levels.

Which data collected by the nurse would support a client history of chronic emphysema? You answered this question Incorrectly 1. Atelectasis 2. Increased anteroposterior (AP) diameter 3. Breathlessness 4. Use of accessory muscles with respiration 5. Leans backwards to breathe 6. Clubbing of fingernails

2., 3., 4., & 6. Correct: Emphysema is described as a permanent hyperinflation of lung beyond the bronchioles with destruction of alveolar walls. Airway resistance is increased, especially on expiration. Inspection reveals dyspnea on exertion, barrel chest (anteroposterior diameter is equal to transverse diameter), tachypnea, and use of accessory muscles with respiration. Clubbing of fingernails is due to chronically decreased oxygen levels. 1. Incorrect: Atelectasis is collapse of alveolar lung tissue, and findings reflect presence of a small, airless lung. This condition is caused by complete obstruction of a draining bronchus by a tumor, thick secretions, or an aspirated foreign body, or by compression of lung. 5. Incorrect: Client tends to sit up and lean forward to relieve or prevent orthopnea and uses accessory muscles of respiration to breathe.

Which actions should the nurse perform to prevent injury from a needle stick? You answered this question Correctly 1. Recap the needle after use to prevent injury. 2. Clean used instrument trays carefully after every procedure. 3. After drawing up saline to flush an IV, place the syringe in a pocket to prevent possible injury. 4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible.

2., 4. & 5. Correct: Instrument trays should be cleaned carefully after every procedure as sharps may have been left behind. Puncture resistant biohazard containers should be replaced when three-quarters full to prevent hand injury when disposing of sharps. Use of "needleless" devices reduces the risk of needle stick injuries.

The nurse is providing care to a client who is infected with Clostridium difficile (C. diff). Which interventions will lessen the likelihood of transmission? You answered this question Incorrectly 1. Wash hands with alcohol-based hand rub. 2. Use soap and water to perform hand hygiene 3. Remove gown after exiting the room. 4. Change gloves before touching non-contaminated articles. 5. Place client in room with client who has the same microorganism.

2., 4., & 5. Correct: Using soap and water is the only acceptable way to perform hand hygiene since this is more effective against the microorganism than are alcohol scrubs. Care should be taken not to transfer microorganisms from contaminated gloves to non-contaminated areas. If a private room is unavailable, clients who are infected with the same microorganism may be placed in the same room.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a rehabilitation unit. Which nursing tasks would be most appropriate for the nurse to assign to the UAP? 1. Take initial vital signs on client receiving blood. 2. Insert an indwelling urinary catheter. 3. Assist a client to the bathroom during bladder training. 4. Transfer a client from wheelchair to bed. 5. Feed lunch to the client who gagged on food at breakfast.

3. & 4. Correct: The UAP can assist client to the bathroom as part of bladder or bowel training. The nurse is responsible for the training but can delegate this part of the training. Transferring a client from bed to wheelchair and wheelchair to bed is within the scope of practice for the UAP

What is priority for the nurse to determine about a client who is scheduled for a tubal ligation in the outpatient surgical center? You answered this question Incorrectly 1. Client's prior experiences with outpatient surgery. 2. Medical plan and the extent of insurance coverage for outpatient surgery. 3. Client's plan for transportation and care at home. 4. Client's plan to spend the night at the surgical center.

3. Correct: After outpatient surgery, the client should not be allowed to drive home. A driver and assistance at home are necessary prior to discharge.

Which observation of a six month old infant would concern the nurse? You answered this question Incorrectly 1. Able to sit unsupported for a few seconds. 2. Posterior fontanel is closed. 3. Head lags when pulled to sitting position. 4. Birth weight has doubled.

3. Correct: At 6 months, the infant should be able to lift head when pulled to a sitting position.

A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What information is essential for the nurse to emphasize concerning safe needle disposal? You answered this question Correctly 1. Syringes are placed in a garbage bag. 2. A hospital issued biohazard container must be used. 3. Any hard plastic container with a screw-on cap may be used. 4. The needles must be taken to the nearest hospital for disposal.

3. Correct: At home, needles, syringes, and sharps may be disposed of in a hard plastic container placed into the regular trash. Clients should follow their community guidelines for sharps container disposal. This protects the sanitation engineers from becoming injured by the sharps.

An 8 year old smiles when mom places the "B" paper on the refrigerator. Which Erikson developmental stage is this child displaying? You answered this question Incorrectly 1. Autonomy vs. Shame and Doubt 2. Initiative vs. Guilt 3. Industry vs. Inferiority 4. Identity vs. Role Confusion

3. Correct: Children need to cope with new social and academic demands. Success leads to sense of competence, while failure results in feelings of inferiority.

Which client assignment would be appropriate for the nurse to accept from the charge nurse? 1. Client admitted one hour ago with a diagnosis of leukemia. 2. Client who has developed Addison's disease. 3. Client who has gastroenteritis. 4. Client post transsphenoidal hypophysectomy.

3. Correct: Gastroenteritis involves an irritated and inflamed stomach and intestines, typically caused by a viral or bacterial infection. Of the four clients, this one would be the most stable client.

A middle-aged client has a strong positive family history of type 2 diabetes mellitus. What is the best recommendation the nurse can reinforce to decrease the client's risk of developing this disease? You answered this question Correctly 1. Test serum glucose values monthly. 2. Avoid starches and sugars in the diet. 3. Obtain a normal body weight and exercise regularly. 4. Maintain a normal serum lipid panel.

3. Correct: Genetics and body weight are the most important factors in the development of type 2 diabetes mellitus. The client cannot alter genetics. Therefore, a normal body weight is imperative. Regular exercise reduces insulin resistance and permits increased glucose uptake by cells. This serves to lower insulin levels and reduce hepatic production of glucose.

Which action would the nurse need to perform to increase stability while initiating a client transfer? You answered this question Correctly 1. Lift with the back. 2. Put on a back belt. 3. Spread feet to width of the shoulders. 4. Lean forward slightly.

3. Correct: In order to increase stability, the nurse will need to increase the base of support. This can be done by spreading the legs to the width of the shoulders.

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? 1. Akinesia 2. Neuroleptic malignant syndrome 3. Pseudoparkinsonism 4. Oculogyric crisis

3. Correct: Pseudoparkinsonism may appear 1 to 5 days following initiation of antipsychotic medications and occurs most often in women, the elderly, and dehydrated clients. Symptoms include tremor, shuffling gait, drooling, and rigidity.

The nurse is preparing to leave the client's room where personal protective equipment has been necessary. What should the nurse do first? You answered this question Incorrectly 1. Remove the gown. 2. Remove the protective eyewear. 3. Remove the gloves. 4. Wash hands.

3. Correct: Removing the most contaminated item first is the most effective way to prevent spread of contamination or infection. The gloves should be removed first, followed by hand washing, removal of the protective eyewear, and finally removal of the gown.

Which statement by an LPN/LVN student indicates to the nurse educator that teaching regarding witnessing consent signatures has been successful? You answered this question Correctly 1. "Two people must witness a consent signature." 2. "An RN must witness a consent signature." 3. "Signing as a witness implies that the client willingly signed the consent." 4. "A witness must be over the age of 21."

3. Correct: Signing as a witness implies that the witness has observed the client personally signing the consent form with no coercion.

Which pediatric client should the nurse see first? You answered this question Incorrectly 1. Six year old with a femur fracture. 2. Two year old with a fever of 102 ° F (38.8 ° C) 3. Three year old with wheezes in right lower lobe. 4. Two year old whose gastrostomy tube came out.

3. Correct: The child having respiratory difficulty should be seen first. This is an example of using Maslow to set priorities. Airway will always be first, followed by breathing and circulation. This client is not stable.

A client, diagnosed with schizophrenia, tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for the nurse to initiate with this client? You answered this question Correctly 1. Watching TV with two other clients in the day room. 2. Watching TV alone in a conference room. 3. Spending time in brief one on one interactions with the nurse. 4. Sitting in the day-room away from other clients.

3. Correct: The interaction with the nurse can keep the conversation reality based and provide interaction with someone. Clients with schizophrenia may be very withdrawn and need the presence of the nurse.

A frightened client comes to the nurses' station during the night and reports hearing the voice of the devil speaking to them. Which response by the nurse is priority? 1. "Could you have overheard the staff talking at the desk?" 2. "I will get you some medication for anxiety." 3. "What did the voice tell you? " 4. "You do not have to worry about this. You are safe."

3. Correct: The most important thing the nurse needs to find out is what the voice was telling the client. This is a safety issue. The nurse needs to know if the voice was telling the client to harm themselves or others.

A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM). The newborn weighs 6 lbs (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What action should the nurse take? You answered this question Incorrectly 1. Administer the drug intravenously (IV) since a large volume is required. 2. Choose three injection sites and give the medication as prescribed. 3. Consult with the pharmacy for a different medication concentration. 4. Read the available drug information to determine how to administer the medication.

3. Correct: The nurse must consult with the pharmacy to receive further instructions. The dose is greater than the allowed volume to be given IM, which warrants clarification by the pharmacy.

Which statement would demonstrate to the nurse the highest risk for suicide or self-directed injury? You answered this question Correctly 1. "I can't do anything right anymore." 2. "I am not sure what to do anymore." 3. "I just cannot take this loneliness anymore." 4. "No one cares about me."

3. Correct: This statement indicates that the person cannot tolerate the current situation. The client is at risk for harm self.

Which home safety intervention should the nurse advise parents of a toddler? You answered this question Correctly 1. Place the child in the center of an adult size bed when napping. 2. Buckle the child into the high chair if parents leave the room during a meal. 3. Anchor top-heavy furniture or fish tanks so that they cannot be pulled over. 4. Allow the toddler to explore stairs in the home if supervised.

3. Correct: Top-heavy furniture, TVs and fish tanks can be pulled over by the toddler, especially if the child is trying to reach something on top of them.

A client develops pernicious anemia after a Billroth II procedure and is to receive vitamin B12 intramuscularly. What should the nurse include when reinforcing discharge instructions? You answered this question Incorrectly 1. B12 can be stored in a lighted area. 2. The B12 injections will be stopped when symptoms disappear. 3. The B12 injections will be continued for the client's life. 4. Vitamin B12 will be taken by mouth once the maintenance dose is determined.3. Correct: With pernicious anemia, the client lacks the intrinsic factor. Without the intrinsic factor, B12 cannot be absorbed. The client will require B12 shots throughout the lifespan.

3. Correct: With pernicious anemia, the client lacks the intrinsic factor. Without the intrinsic factor, B12 cannot be absorbed. The client will require B12 shots throughout the lifespan.

Which intervention can the nurse safely assign to an unlicensed assistive personnel (UAP)? You answered this question Correctly 1. Irrigate a colostomy in a client who is 2 days postoperative. 2. Remove a fecal impaction in a client. 3. Apply a condom catheter to an incontinent client. 4. Insert a urinary catheter to obtain a urine sample.

3. Correct: With proper instruction a UAP may be delegated to apply a condom catheter. This is not an invasive procedure.

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? You answered this question Correctly 1. Pain 2. Airway 3. Fluid volume status 4. Risk for injury

3. Correct: Yes! The client will have lots of fluid loss through the burn wound and also the fluid shift.

Which activities can the nurse safely assign to an unlicensed assistive personnel (UAP)? You answered this question Correctly 1. Administer a nebulizer treatment to a client diagnosed with pneumonia. 2. Obtain vital signs on a postoperative client who required naloxone 5 minutes ago. 3. Report a urinary output (UOP) less than 50 mL/hr on a post-op client. 4. Assist a client with obtaining a clean catch urine sample. 5. Remove an indwelling urinary catheter from a client.

3., & 4. Correct: The UAP can report the amount of UOP but cannot interpret it. A clean catch urine sample is a noninvasive procedure. Therefore, the UAP can assist the client to obtain the clean catch urinary sample. Both activities are the right person and right tasks for assigning to the UAP.

The nurse is reinforcing teaching about proper foot care to a client who has diabetes. Which statements by the nurse are correct? You answered this question Correctly 1. Cut the toenails in a rounded fashion. 2. Wash the feet with warm water and betadine. 3. Wear appropriate fitting shoes at all times. 4. View the bottom of the feet daily. 5. Protect feet from hot and cold.

3., 4., & 5. Correct: Shoes should be worn at all times to prevent injury. The client may step on something and not know that the foot has been injured. Inspection should be done daily, since many diabetics cannot feel if their feet have been injured. Feet may not be sensitive to hot and cold, which could cause injury. 1. Incorrect: Toe nails should be cut straight across to avoid an ingrown toenail. Additionally, any skin cuts on the toes may result in infection. 2. Incorrect: Do not put harsh chemicals, such as betadine, on the feet. Betadine will dry the skin which may lead to cracks in the skin. This creates potential portals for infection to occur.

Which home routines help reduce the risk for skin damage in a client with impaired sensation? 1. Using a hot water bottle to help warm up when first going to bed. 2. Hot water heater set at a temperature of 140 degrees. 3. Open flame heaters in the living areas of the home. 4. Testing the water with the back of the wrist and forearm before getting in the shower. 5. Wear shoes when out of bed.

4. & 5. Correct: This practice actually is a safeguard for skin damage from burns. Shoes will protect feet from injury.

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? You answered this question Correctly 1. Available support system 2. Perception of the situation 3. Desire to return to work 4. Coping mechanisms

4. Correct. 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.

Which dietary consideration is most important for the nurse to reinforce to a client with hypothyroidism? You answered this question Correctly 1. Increase carbohydrate intake. 2. Decrease fluid intake. 3. Avoid shellfish. 4. Increase fiber.

4. Correct: A symptom of hypothyroidism is constipation due to the decreased mobility of the intestinal tract. Client's with hypothyroidism should increase their dietary fiber to prevent constipation.

Which client must the nurse assign to a private room? You answered this question Incorrectly 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.

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? You answered this question Incorrectly 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. Correct: When drawing blood, a precaution is to wear gloves, so blood will not get on the nurse's hands. Clean gloves are appropriate here. 1. "My fingers and feet are swollen." 2. "My weight is up 1 pound (0.45 kg)." 3. "There is blood in my urine." 4. "I am having trouble with my vision."

4. Correct: Did you see the sign of Dig toxicity? Good Job! Digoxin toxicity happens when you have too much digoxin in the body. Certain medical conditions like heart disease and medications like diuretics increase the risk of digoxin toxicity. Changes in vision is one symptom of digoxin toxicity.

Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is in the acute phase of mania? You answered this question Correctly 1. Sit with the client during meals and encourage the client to eat all foods on the tray. 2. Assess the client's food preferences and provide only those foods for the client at meal time. 3. Allow the client to eat in the dining room with other clients. 4. Provide high protein, high calorie snacks to the client between meals.

4. Correct: Having nutritious foods available between meals may help to increase the client's food intake. Nutritious intake is required on a regular basis to compensate for increased caloric requirements due to the hyperactivity during the manic phase.

What is most important for the nurse to have at the client's bedside when a large orogastric tube for rapid gastric lavage is being inserted by the primary healthcare provider? 1. Emesis basin 2. Portable x-ray machine 3. Oxygen 4. Suction equipment

4. Correct: Insertion of a large orogastric tube designed for rapid lavage often causes gagging and vomiting, so suction equipment should be readily available to reduce the risk of aspiration. Maintaining the client's airway is the priority.

The nurse enters a client's room and finds the client masturbating. Which action by the nurse would be most appropriate for the nurse to take? You answered this question Incorrectly 1. Ask the client to stop 2. Remain in the room until client has finished. 3. Document the activity in the client's chart. 4. Quietly leave the room

4. Correct: Leaving the client's room allows the client to have privacy. The client has the right to express self sexually in private.

When should the nurse tell the client to take Lispro insulin? You answered this question Incorrectly 1. Thirty minutes before bedtime. 2. Twice daily in AM and PM. 3. One hour before meals. 4. With meals.

4. Correct: Lispro is a rapid-acting insulin that should only be taken with food or within 15 minutes of a meal.

A client with Bell's palsy is having difficulty eating. Which action by the nurse will be most helpful? You answered this question Incorrectly 1. Perform active facial exercises several times a day. 2. Provide a liquid diet high in protein and calories that will be easily swallowed. 3. Provide oral hygiene after eating. 4. Have the client chew food on the unaffected side of the mouth.

4. Correct: Maintenance of good nutrition is most important. Having the client chew on the unaffected side will help the client avoid food trapping. This will decrease the risk of aspiration which prioritizes higher than the other options.

A nurse enters a client's room to find the client on the floor having a grand mal seizure. What action should the nurse take? You answered this question Correctly 1. Wrap the client tightly in a blanket as a restraint. 2. Insert a padded tongue blade in the client's mouth. 3. Assist the client back into the bed. 4. Place a towel or sheet under the client's head.

4. Correct: Placing a towel or sheet under the client's head prevents further injury to the client.

Which task can the LPN/LVN assign to an unlicensed assistive personnel (UAP) when caring for a client who has had a stroke? You answered this question Correctly 1. Assess a client's ability to swallow. 2. Insert a foley catheter. 3. Instruct the client how to use a walker. 4. Take the client's temperature.

4. Correct: The UAP can obtain routine vital signs, such as a temperature.

The nurse is caring for a client while an antibiotic is being infused. The client reports burning at the intravenous (IV) site and the nurse notes that there is no blood return after lowering the IV bag. Which nursing intervention should the nurse implement? You answered this question Correctly 1. Apply ice compresses. 2. Slow the infusion. 3. Inspect the IV site again in 15 minutes. 4. Stop the infusion.

4. Correct: The infusion should be stopped. The IV fluid will move into subcutaneous tissue and can cause damage to the tissue.

The nurse is bathing a confused client in the acute care unit. The nurse talks with the client and explains each procedure. During the bath, the client becomes very agitated. What should the nurse do? You answered this question Incorrectly 1. Complete the bath as quickly as possible. 2. Reassure the client and request them to stop acting out. 3. Continue bathing with assistance from an unlicensed assistive personnel. 4. Stop the bath, dress and reassure the client.

4. Correct: The nurse should not continue bathing if the client is becoming so distressed. Perhaps the bath can be completed at a later time. Safety is the priority.

After a heart catheterization, a client reports severe foot pain on the side of the femoral insertion site. The nurse notes pulselessness, pallor, and a cold extremity. What should be the nurse's first action? You answered this question Correctly 1. Administer an anticoagulant. 2. Warm the room. 3. Increase intravenous fluids. 4. Notify the primary healthcare provider.

4. Correct: This is an emergency, and the primary healthcare provider (PHP) is the only one that can save this foot from ischemia. Don't delay.

Which health problem does the nurse recognize as putting the client at risk for hypomagnesemia? You answered this question Correctly 1. History of heart disease 2. Ingesting magnesium based antacids 3. Parathyroid disorder 4. Alcohol abuse

4. Correct: 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.

A client is prescribed 1.5 grams of levodopa daily. Available forms of this drug include tablets of 250 milligrams. How many tablets should this client be given to receive the proper amount of medication? Round answer to the nearest whole number.

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