LPN Adaptive questions Fundamentals

A physician orders guaifenesin (Humibid) 300 mg four times a day. The dosage strength is 200 milligrams/5 milliliters. To ensure the patient's safety, how many milliliters should the nurse administer for each dose? Record your answer using one decimal place. mL

** 7.5** 300mg/x = 200mg/5mL X = 7.5 mL

A child is to receive 60 mg of phenytoin (Dilantin). The medication is available as an oral suspension that contains 125 mg/5 mL. How many milliliters should the nurse administer? Record the answer using one decimal place. mL

**2.4** 2.4 mL. Use the "Desire over Have" formula to solve this problem. Desire 60 mg = x mL Have 125 mg 5 mL 125x = 300 X = 300 ÷ 125 = 2.4 mL

A pain scale of 1 to 10 is used by a nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. What conclusion should the nurse make regarding the client's response to pain medication? Multiple choice question Client has a low pain tolerance. Medication is not adequately effective. Medication has sufficiently decreased the pain level. Client needs more education about the use of the pain scale.

**Medication is not adequately effective.** The expected effect should be more than a 1-point decrease in the pain level. Identifying whether a client has a low pain tolerance cannot be determined with the data available. The medication has not achieved an adequate response; pain generally is considered to be tolerable if it is 4 or below on a pain scale of 1 to 10. Determining that the client needs more education about the use of the pain scale cannot be determined with the data available.

When monitoring a client 24 to 48 hours after surgery, the nurse should assess for which problem associated with anesthetic agents? Multiple choice question Colitis Stomatitis Paralytic ileus Gastrocolic reflux

**Paralytic ileus** After surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis , and gastrocolic reflux are not postoperative complications related to anesthetic agents.

A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include in the teaching? Multiple choice question Maligning a person's character while threatening to do bodily harm. A legal wrong committed by one person against property of another. The application of force to another person without lawful justification. Behaving in a way that a reasonable person with the same education would not.

**The application of force to another person without lawful justification ** Battery means touching in an offensive manner or actually injuring another person. Battery refers to actual bodily harm rather than threats of physical or psychological harm. Battery refers to harm against persons instead of property. Behaving in a way that a reasonable person with the same education would not is the definition of negligence.

A client diagnosed with tuberculosis is taking isoniazid (INH). To prevent a food and drug interaction, the nurse should advise the client to avoid: Multiple choice question Hot dogs Red wine Sour cream Apple juice

**red wine** Clients taking isoniazid (INH) should avoid foods containing tyramine, such as red wine, tuna fish, and hard cheese. Frankfurters do not contain tyramine and therefore are not contraindicated. Sour cream does not contain tyramine and therefore is not contraindicated. Apple juice does not contain tyramine and therefore is not contraindicated.

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? Multiple selection question Oral temperature 98.2° F Apical pulse 88 beats per minute and regular Respiratory rate of 30 per minute Blood pressure 116/78 mm Hg while in a sitting position Oxygen saturation of 92%

(all norm) **Oral temp apical pulse blood pressure** The client's temperature, pulse, and blood pressure are within normal ranges for a 50-year-old female. The client's respirations are mildly elevated and the oxygen saturation level is below normal (5). A normal respiratory rate for a female client in this age-group would be 12 to 20 per minute, and oxygen saturation level should be 95%.

When should the practical nurse (PN) evaluate the client's pain level? (Select all that apply.) A Routinely with measurement of vital signs B When the client initially complains of pain C At the beginning and end of each shift D Every 4 hours around the clock E Thirty to 60 minutes after administration of an analgesic

** A Routinely with measurement of vital signs B When the client initially complains of pain C At the beginning and end of each shift E Thirty to 60 minutes after administration of an analgesic** The client's pain level should be assessed routinely with measurement of vital signs, when the client initially complains of pain, at the beginning and end of a shift. Assessment of effectiveness should occur 30 to 60 minutes after administration of an analgesic. The client should not be awakened while sleeping for assessment of his/her pain level

The nurse is caring for a client that is hyperventilating. The nurse recalls that the client is at risk for: Multiple choice question Respiratory acidosis Respiratory alkalosis Respiratory compensation Respiratory decompensation

** Respiratory alkalosis** Hyperventilation causes excess amounts of carbon dioxide (CO 2) to be eliminated, causing respiratory alkalosis. Respiratory acidosis is caused by excess carbon dioxide (CO 2) retained in the lungs from conditions such as hypoventilation or chronic obstructive pulmonary disease (COPD). Respiratory compensation and decompensation are terms not associated with this situation.

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force? Multiple choice question Maintain the head of the bed at 35 degrees or less. With the help of another staff member, use a drawsheet when lifting the client in bed. Reposition the client at least every 2 hours and support the client with pillows. At least once every 8 hours, perform passive range-of-motion exercises of all extremities.

** With the help of another staff member, use a drawsheet when lifting the client in bed.** Shearing force is the pressure exerted on the skin when a debilitated client is pulled up in bed without a drawsheet, or when the client slides down in bed. With shearing, the skin adheres to the bed linens while the layers of subcutaneous tissue and bone slide in the direction of the body movements, causing a tearing of the skin. Using a drawsheet can reduce and minimize friction and shearing force. Maintaining the head of the bed at 35 degrees or less, repositioning the client at least every 2 hours and supporting with pillows, and, at least once every 8 hours, performing passive range-of-motion exercises of all extremities are all appropriate interventions to prevent further pressure injury and to promote circulation, but they are not as effective as using a drawsheet in prevention of shearing force.

At the conclusion of visiting hours, the parent of a 14-year-old adolescent scheduled for orthopedic surgery the next day hands the nurse a bottle of capsules and says, "These are for my child's allergy. Will you be sure my child takes one about 9 PM tonight?" What is the nurse's best response? Multiple choice question "I will give one capsule tonight before bedtime." "I will get a prescription so that the medicine can be taken." "Does your health care provider know about your child's allergy?" "Did you ask your health care provider if your child should have this tonight?"

**"I will get a prescription so that the medicine can be taken."** Legally, a nurse cannot administer medications without a prescription from a legally licensed individual. The nurse cannot give the medication without a current health care provider's prescription; this is a dependent function of the nurse. The nurse should not ask if the health care provider is aware of the problem; it is the nurse's responsibility to document the client's health history. It is the nurse's responsibility to review the health care provider's prescriptions and question them when appropriate

The nurse administers a pneumococcal vaccine to a 70-year-old client. The client asks "Will I have to get this every year like I do with the flu shot?" How should the nurse respond? Multiple choice question "You need to receive the pneumococcal vaccine every other year." "The pneumococcal vaccine should be received in early autumn every year." "You should get the flu and pneumococcal vaccines at your annual physical examination." "It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose."

**"It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose."** The Centers for Disease Control and Prevention recommend that adults be immunized with pneumococcal vaccine at age 65 or older with a single dose of the vaccine; if the pneumococcal vaccine was received before 65 years of age or if there is the highest risk of fatal pneumococcal infection, revaccination should occur five years after the initial vaccination. The pneumococcal vaccine should not be administered every two years. The pneumococcal vaccine should not be administered annually.

A health care provider prescribes 250 mg of a medication. The vial reads 500 mg/mL. How much medication (mL) should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place. mL

**0.5** The nurse should give ½ mL of the drug. The dosage is calculated as: 250 mg/X=500 mg/1 mL 500x=250 X=1/2 mL

Filgrastim (Neupogen) 5 mcg/kg/day by injection is prescribed for a client who weighs 132 lb. The vial label reads filgrastim 300 mcg/mL. How many milliliters should the nurse administer? Record the answer using a whole number. mL

**1** The health care provider prescribed 5 mcg/kg; therefore, 5 × 60 = 300 mcg. This desired amount is contained in 1 mL, as indicated on the vial label.

The intake and output of a client over an eight-hour period is: 0800: Intravenous (IV) infusing; 900 mL left in bag; 0830: 150 mL voided; From 0900-1500 time period: 200 mL gastric tube formula + 50 mL water; Repeated x 2.; 1300: 220 mL voided; 1515: 235 mL voided; 1600: IV has 550 mL left in bag. What is the difference between the client's intake and output? Record the answer using a whole number.

**495mL** Intake includes 350 mL of IV fluid, 600 mL of nasogastric intubation (NGT) feeding, and 150 mL of water via NGT, for a total intake of 1100 mL; output includes voidings of 150, 220, and 235 mL, for a total output of 605 mL. Subtract 605 mL from 1100 mL for a difference of 495 mL.

Ceftriaxone (Rocephin) 2.5 g intravenous piggyback (IVPB) every 8 hours is prescribed for a client with a severe infection. The pharmacy sends a vial labeled 5 g per 10 mL. What volume of ceftriaxone should the nurse add to the IVPB solution? Record your answer using a whole number. _______ mL

**5 mL** Use the "Desire over Have" formula of ratio and proportion to solve the problem. Desire 2.5g x mL ------------- = ----- Have 5 g 10 mL 5x = 25 x = 25 ÷ 5 x = 5 mL

The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status? Multiple choice question Except with rare blood disorders, hemoglobin seldom affects oxygenation status. There are many other factors that impact oxygenation status more than hemoglobin does. A low hemoglobin level causes reduced oxygen-carrying capacity. Hemoglobin reflects the body's clotting ability and may or may not impact oxygenation status.

**A low hemoglobin level causes reduced oxygen-carrying capacity.** Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low, the amount of oxygen-carrying capacity is also low. Higher levels of hemoglobin will increase oxygen-carrying capacity and thus increase the total amount of oxygen available in the blood. Hemoglobin does not affect clotting ability.

When caring for a client with a fractured hip, the nurse should place pillows around the injured leg to specifically maintain: Multiple choice question Abduction. Adduction. Traction. Elevation.

**Abduction.** abduction means to move the limb away from the median plane, or axis, of the body. In care of the client with a fractured hip, the legs and hip must be aligned in an abducted position to prevent internal rotation, reduce the risk of dislocation, and decrease pain. In a client with a fractured hip, adduction of the limb, traction, and elevation are not appropriate procedures. Adduction means to move the limbs toward the medial plane, or axis, of the body, and traction involves the process of applying a pulling force in opposite directions using weights.

On the third postoperative day following a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client? Multiple choice question Explain why there is a need to increase activity. Emphasize that with a prosthesis, there will be a return to the previous lifestyle. Appear cheerful and non-critical regardless of the client's response to attempts at intervention. Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving.

**Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving.** The withdrawal provides time for the client to assimilate what has occurred and integrate the change in body image. The client is not ready to hear explanations about why there is a need to increase activity until assimilation of the surgery has occurred. Emphasizing a return to the previous lifestyle does not acknowledge that the client must grieve; it also does not allow the client to express any feelings that life will never be the same again. In addition, it may be false reassurance. The client might feel that the nurse has no comprehension of the situation or understanding of feelings if the nurse appears cheerful and noncritical regardless of the client's response to attempts at intervention.

A nurse manager is evaluating the performance of the LPN/LVN who is supervising Unlicensed Assistive Personnel (UAP). What action indicates to the nurse manager that the LPN/LVN needs further instruction? Multiple choice question Requests that the UAP take vital signs on the clients assigned to their team. Asks the UAP to assess the client's response to a respiratory treatment Instructs the UAP to communicate to a client that the meal trays will be delayed. Collaborates with the UAP to determine the best time to ambulate a client.

**Asks the UAP to assess the client's response to a respiratory treatment** Assessing a client's response to care is beyond the scope of a nursing assistant's role. Evaluating a client's response to care is within the role of the licensed practical nurse. Informing a patient about a meal tray delay and taking routine vital signs is part of a UAP's scope of practice. The UAP is an essential part of the healthcare team, and all members of the team should collaborate to provide optimum patient care.

When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? Multiple choice question Skin breakdown Aspiration pneumonia Retention ileus Profuse diarrhea

**Aspiration pneumonia** Of the choices provided, the potential complication of highest risk for a client with an NG tube is aspiration pneumonia. Care should be taken to prevent dislodging of the tube or vomiting. Proper positioning of the client with an NG tube would include supine or side-lying semi-Fowler's or higher. Skin breakdown in a client with an NG tube may result from pressure of the tube against nasal structures. The tube should be periodically repositioned and taped to prevent this complication. A retention ileus is not related to an NG tube. A client who develops profuse diarrhea with an NG tube requires further investigation. It may be totally unrelated or a result of an enteral feeding incompatibility.

Which intervention is most important for the practical nurse (PN) to implement for a client who is experiencing urinary retention? A Placing client's hands in water. B Apply a skin protectant. C Encourage increased fluid intake. D Assess for bladder distention.

**Assess for bladder distention.** Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention therefore it is vital to assess for bladder distention.

A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? Multiple choice question Prejudice Stereotyping Assimilation Ethnocentrism

**Assimilation** Assimilation involves incorporating the behaviors of a dominant culture. Maintaining eye contact is characteristic of the American culture and not of Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike. Ethnocentrism is the perception that one's beliefs are better than those of others.

The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate? Multiple choice question Justice Veracity Autonomy Beneficence

**Autonomy** The client is exhibiting the freedom to make a personal decision, and this reflects the concept of autonomy. Justice refers to fairness. Veracity refers to truthfulness. Beneficence refers to implementing actions that benefit others.

A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and next: Multiple choice question Bending and then straightening their knees Bending at the waist and then straightening the back Placing one foot in front of the other and then leaning back Placing pressure against the client's axillae and then raising their arms

**Bending and then straightening their knees** The leg bones and muscles are used for weight bearing and are the strongest in the body. Using the knees for leverage while lifting the client shifts the stress of the transfer to the caregiver's legs. By using the strong muscles of the legs the back is protected from injury. Bending at the waist and then using the back for leverage is how many caregivers and people who must lift heavy objects sustain back injuries. The anatomical structure of the back is equipped only to bear the weight of the upper body. By leaning back, the client's weight is on the caregiver's arms, which are not equipped for heavy weight bearing. The caregiver's arms are not strong enough to lift the client. In the struggle to lift the client, the client and caregiver may be injured.

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by: Multiple choice question Promoting analgesia and circulation Numbing the nerves and dilating the blood vessels Promoting circulation and reducing muscle spasms Causing local vasoconstriction, preventing edema and muscle spasm

**Causing local vasoconstriction, preventing edema and muscle spasm** Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and therefore muscle spasm. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain. Cold does promote analgesia but not circulation. It may numb nerves but does not dilate blood vessels.

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? Multiple choice question Clear breath sounds Positive pedal pulses Normal potassium level Increased urine specific gravity

**Clear breath sounds ** Excess fluid can move into the lungs, causing crackles; clear breath sounds support that treatment was effective. While it may make palpation more difficult, excess fluid will not diminish pedal pulses. A normal potassium level can be maintained independently of fluid excess correction. As the client excretes excess fluid, the urine specific gravity will decrease, not increase.

A child is being treated with oral ampicillin (Omnipen) for otitis media. What should be included in the discharge instructions that the nurse provides to the parents of the client? Multiple choice question Complete the entire course of antibiotic therapy. Herbal fever remedies are highly discouraged. Administer the medication with meals. Stop the antibiotic therapy when the child no longer has a fever.

**Complete the entire course of antibiotic therapy.** Once antibiotic therapy is initiated, the antibiotics start to destroy specific bacterial infections that the health care provider is trying to treat. Antibiotic therapy takes a specific dose and number of days to completely eliminate the bacteria. If the caregivers start a dose and stop it before the course is complete, the remaining bacteria have a chance to grow again, become resistant to antibiotic treatment, and multiply. The nurse should not discourage use of herbal fever remedies; however the herbal treatment should be reviewed to see if it is contraindicated. Ampicillin should be taken 1-2 hours after meals. Antibiotic therapy should be completed as prescribed.

The practical nurse (PN) is instructing a client in the proper use of a metered-dose inhaler. Which instructions should the PN reinforce to the client to ensure the optimal benefits from the drug? A Inhale and then compress the inhaler. B Compress the inhaler while slowly breathing in through the mouth. C Compress the inhaler while inhaling quickly through the nose. D Exhale completely after compressing the inhaler and then inhale.

**Compress the inhaler while slowly breathing in through the mouth.** The medication should be inhaled through the mouth simultaneously with compression of the inhaler.

A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to utilize when discussing healthcare decisions with the client? Multiple choice question Contact an interpreter provided by the hospital. Contact the client's family member to translate for the client. Communicate with the client using Spanish phrases the nurse learned in a college course. Communicate with the client with the use of a hospital-approved Spanish dictionary.

**Contact an interpreter provided by the hospital.** Interpreters provided by the health care organization should be used to communicate with clients with limited English proficiency in order to ensure accuracy of communicated information. In hospital settings, it is not suitable for family members to translate health care information, but they can assist with ongoing interactions during the client's care. The other options do not ensure accurate interpretation of language.

After abdominal surgery a client reports pain. What action should the nurse take first? Multiple choice question Reposition the client. Obtain the client's vital signs. Administer the prescribed analgesic. Determine the characteristics of the pain.

**Determine the characteristics of the pain.** The exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery. Repositioning the client, obtaining the client's vital signs, and administering the prescribed analgesic should be done later; the first action is to determine the cause of the pain.

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? Multiple choice question Rapid, thready pulse Distended jugular veins Elevated hematocrit level Increased serum sodium level

**Distended jugular veins** Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its concentration is decreased.

The practical nurse (PN) is using the Glasgow Coma Scale to perform a neurological assessment. A comatose client winces and pulls away from a painful stimulus. What action should the PN take next? A Document that the client responded to a painful stimulus. B Observe the clientʼs response to verbal stimulation. C Place the client on seizure precautions for 24 hours. D Report decorticate posturing to the health care provider.

**Document that the client responded to a painful stimulus.** The client has demonstrated a purposeful response to pain, which should be documented as such.

To decrease abdominal distention following a client's surgery, what actions should the nurse take? Multiple selection question Encourage ambulation Give sips of ginger ale Auscultate bowel sounds Provide a straw for drinking Offer an opioid analgesic

**Encourage ambulation Auscultate bowel sound** Ambulation will stimulate peristalsis, increasing passage of flatus and decreasing distention. Monitoring bowel sounds is important because it provides information about peristalsis. Carbonated beverages, such as ginger ale, increase flatulence and should be avoided. Using a straw should be avoided because it causes swallowing of air, which increases flatulence. Opioids will slow peristalsis, contributing to increased distention.

While performing colostomy care, the practical nurse (PN) observes skin irritation around the stomal site. What action should the PN take when reapplying the colostomy bag? A Ensure that the hydrocolloidal stomal wafer covers the peristomal skin. B Apply petroleum jelly around the stomal site and under the wafer. C Do not irrigate the colostomy for 7 to 10 days until irritation is gone. D Wash the area around the stomal site with povidone-iodine and leave open to the air.

**Ensure that the hydrocolloidal stomal wafer covers the peristomal skin** Hydrocolloid stomal wafers should be measured precisely to ensure peristomal skin coverage and protection from irritation and breakdown. The stomal site should be cleansed gently with a moist, soft cloth and mild soap and another bag applied to prevent skin contact with fecal drainage.

A nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. On what aspect of care should the nurse focus? Multiple choice question Teaching how to make a room allergy-free. Referring to a support group for individuals with asthma. Arranging with the college to ensure a speedy return to classes. Evaluating whether the necessary lifestyle changes are understood.

**Evaluating whether the necessary lifestyle changes are understood.** Understanding the disorder and the details of care are essential for the client to be self-sufficient. Although teaching is important, a perceived understanding of the need for specific interventions must be expressed before there is a readiness for learning. Referring to a support group is premature; this may be done eventually. Although ensuring a speedy return to classes is important, involving the college should be the client's decision.

A client with a leg prosthesis and a history of syncopal episodes (fainting spells) is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for: Multiple choice question Falls Impaired cognition Imbalanced nutrition Impaired gas exchange

**Falls** The client is at risk for falls related to the leg prosthesis and history of syncope. There is no evidence or contributing factors in the patient scenario of the other nursing problems.

The practical nurse (PN) is caring for a dyspneic client whose oxygen saturation rate is currently 95%. What position is best for this client? A Supine with the legs slightly elevated. B Simʼs with a pillow under the upper leg. C Fowler's with both legs supported. D Any position that is comfortable.

**Fowler's with both legs supported.** In the Fowler position, the head is elevated 45 degrees, and the individual's knees are slightly flexed, which promotes maximum lung expansion and tracheal alignment. Even though the client's oxygen saturation rate is within normal limits (WNL), this client is having trouble breathing. Sitting up, so that the lungs can fully expand and the trachea is aligned, is usually helpful in promoting breathing.

The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms? Multiple choice question Soap Time Water Friction

**Friction** Friction is necessary for the removal of microorganisms. Although soap reduces surface tension, which helps remove debris, without friction it has minimal value. Although the length of time the hands are washed is important, without friction it has minimal value. Although water flushes some microorganisms from the skin, without friction it has minimal value.

A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? Multiple choice question Famotidine (Pepcid) Methyldopa (Aldomet) Ferrous sulfate (Feosol) Levothyroxine (Synthroid)

**Methyldopa (Aldomet) ** Methyldopa is associated with acquired hemolytic anemia and should be discontinued to prevent progression and complications. Famotidine will not cause these symptoms; it decreases gastric acid secretion, which will decrease the risk of gastrointestinal bleeding. Ferrous sulfate is an iron supplement to correct, not cause, symptoms of anemia. Levothyroxine is not associated with red blood cell destruction.

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? Multiple choice question Monitor for signs of electrolyte imbalance. Change the tube at least once every 48 hours. Connect the nasogastric tube to high continuous suction. Assess placement by injecting 10 mL of water into the tube.

**Monitor for signs of electrolyte imbalance.** Gastric secretions, which are electrolyte rich, are lost through the nasogastric tube; the imbalances that result can be life threatening. Changing the nasogastric tube every 48 hours is unnecessary and can damage the suture line. High continuous suction can cause trauma to the suture line. Injecting 10 mL of water into the nasogastric tube to test for placement is unsafe; if respiratory intubation has occurred aspiration will result.

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. The nurse recognizes that it is important to inform the client that he or she: Multiple choice question Is acting irresponsibly. Is violating the hospital policy. Must obtain a new healthcare provider for future medical needs. Must accept full responsibility for possible undesirable outcomes.

**Must accept full responsibility for possible undesirable outcomes. ** The client has the right to self-determination, which includes refusing medical treatment. However, if the client does so, he or she must accept full responsibility for any resulting illness and possible injury or undesirable outcomes. Health care professionals have a responsibility to inform the client and, if possible, have him or her sign an informed waiver or a leaving against medical advice document. Acting irresponsibly is a subjective assumption. The client may be violating the hospital policy; however, if the client is deemed competent, he or she has the right to refuse treatment. Leaving against medical advice does not mean that the current healthcare provider will refuse to provide care to the client in the future.

A nursing team leader identifies that a nurse is coming to work after drinking alcohol. What is the most appropriate way for the team leader to approach this ethical situation? Multiple choice question Counsel the nurse about the problem. Ignore the problem until it happens again. Notify the nurse manager about the problem. Resolve the problem by sending the nurse home.

**Notify the nurse manager about the problem.** The assessment phase of problem solving consists of collecting data. The next step involves exploring options to address the problem; this is best accomplished in collaboration with the nurse manager. Counseling the nurse about the problem is not the role of a nurse; the nurse who has been drinking needs professional counseling. Ignoring the problem until it happens again is unsafe; clients may be placed in jeopardy. Resolving the problem by sending the nurse home delays addressing the problem.

A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish normal bowel pattern? Multiple choice question Administer a mineral oil enema. Offer one cup of fluid every hour. Manually remove fecal impactions. Offer a cup of prune juice.

**Offer a cup of prune juice.** Prune juice does not require a health practitioner order and helps to promote bowel movement because it contains sorbitol, which increases water retention in feces. Administration of mineral enema requires an order from a health care provider. Encouraging the client's fluid intake by offering one cup of fluid every hour is helpful in preventing constipation but not as effective in resolving constipation as a prune juice. Removing impactions does not establish regular bowel patterns.

A client has a "prayer cloth" pinned to the hospital gown. The cloth is soiled from being touched frequently. What should the nurse do when changing the client's gown? Multiple choice question Make a new prayer cloth. Discard the soiled prayer cloth. Pin the prayer cloth to the clean gown. Wash the prayer cloth with a detergent.

**Pin the prayer cloth to the clean gown** The prayer cloth has religious significance for the client and should be preserved as is. Making a new prayer cloth disregards what the prayer cloth means to the client. The prayer cloth is the property of the client and should not be discarded. Washing the prayer cloth with a detergent disregards what the prayer cloth means to the client; this never should be done without the client's permission.

A client being treated for Influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution? Place a surgical mask on the client. Other than Standard Precautions, no additional precautions are needed. Minimize close physical contact. Cover the client's legs with a blanket.

**Place a surgical mask on the client.** Nurses should provide influenza clients with face masks to wear for source control and tissues to contain secretions when outside of their room. Special precautions such as face masks should be taken to decrease the risk of further outbreak. Minimizing close physical contact is not indicated. Covering the client with a blanket is for comfort and privacy, not because of a transmission precaution.

After changing a dressing that was used to cover a draining wound on a client with Vancomycin Resistant Enterococcus (VRE), the nurse should take which step to ensure proper disposal of soiled dressing? Multiple choice question Place the dressing in the bedside trash can. Place the dressing in a red bag/hazardous materials bag. Contact Environmental Services personnel to pick up the dressing. Transport the dressing to the laboratory to be placed in the incinerator.

**Place the dressing in a red bag/hazardous materials bag.** Contact precautions must be used for patients with known or suspected infections transmitted by direct contact or contact with items in the environment. The soiled dressing should not be placed in a single bag and left in the trash can. Infection control is every healthcare worker's responsibility, not just that of Environmental Services. The lab is not responsible for disposal of hazardous wastes that occur as a result of normal nursing activities.

A client has an order for a sublingual nitroglycerin tablet. The nurse should teach the client to use what technique when self-administering this medication? Multiple choice question Place the pill inside your cheek and let it dissolve. Place the pill under your tongue and let it dissolve Chew the pill thoroughly and then swallow it. Swallow the pill with a full glass of water.

**Place the pill under your tongue and let it dissolve** Sublingual medication is placed under the tongue and it is quickly absorbed through the mucous membranes into blood. Buccal route requires placing medication between the cheek and gums. Chewing and then swallowing may be done for oral administration of some large size pills but not with the sublingual route of administration. Taking the pill with water is required with the PO route of administration of medication but not with sublingual. In addition a full glass of water may be an excessive amount of fluid to swallow one pill.

A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? Multiple choice question Sodium Calcium Chloride Potassium

**Potassium** The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell's ability to function. Sodium is the most abundant cation of the extracellular compartment, not the intracellular compartment. Calcium is the most abundant electrolyte in the body; 99% is concentrated in the teeth and bones, and only 1% is available for bodily functions. Chloride is an extracellular, not intracellular, anion.

A client who had a chest tube removed 2 hours previously is now experiencing dyspnea and tachypnea. What action should the practical nurse (PN) take first? A Give oxygen at 2 liters per nasal cannula. B Raise the head of the bed. C Observe for tracheal deviation. D Reassure and stay with the client.

**Raise the head of the bed.** Raising the head of the bed facilitates respiratory functioning. The first action is that client should be placed in a semi-Fowler or Fowler position. Although tracheal deviation can occur with a tension pneumothorax, the client should be placed in an upright position in the bed before further assessment is obtained.

A nurse is caring for a client with hemiplegia who is frustrated. How can the nurse motivate the client toward independence? Multiple choice question Establish long-range goals for the client. Identify errors that the client can correct. Reinforce success in tasks accomplished. Demonstrate ways to promote self-reliance.

**Reinforce success in tasks accomplished.** Success is a basic motivation for learning. People receive satisfaction when a goal is reached. Progress toward long-range goals often is not apparent readily and may be discouraging. Constructive criticism is an important aspect of client teaching, but if it is not tempered with praise, it is discouraging. Demonstrating ways to promote self-reliance is an important part of teaching, but it probably will not motivate the client.

Nursing actions for the older adult should include health education and promotion of self-care. Which is most important when working with the older adult client? Multiple choice question Encouraging frequent naps Strengthening the concept of ageism Reinforcing the client's strengths and promoting reminiscing Teaching the client to increase calories and focusing on a high carbohydrate diet

**Reinforcing the client's strengths and promoting reminiscing** Reinforcing strengths promotes self-esteem; reminiscing is a therapeutic tool that provides a life review that assists adaptation and helps achieve the task of integrity associated with older adulthood. Frequent naps may interfere with adequate sleep at night. Reinforcing ageism may enhance devaluation of the older adult. A well-balanced diet that includes protein and fiber should be encouraged; increasing calories may cause obesity.

A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's outburst, what is the best indication that the nurse-client interaction has been therapeutic? Multiple choice question Increased physical activity Absence of further outbursts Relaxation of tensed muscles Denial of the need for further discussion

**Relaxation of tensed muscles** Relaxation of muscles and facial expression are examples of nonverbal behavior; nonverbal behavior is an excellent index of feelings because it is less likely to be consciously controlled. Increased activity may be an expression of anger or hostility. Clients may suppress verbal outbursts despite feelings and become withdrawn. Refusing to talk may be a sign that the client is just not ready to discuss feelings.

A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures to: Multiple choice question Restore the client's health Promote the client's recovery Relieve the client's discomfort Support the client's significant others

**Relieve the clients discomfort** Palliative measures are aimed at relieving discomfort without curing the problem. A cure or recovery is not part of palliative care; with a terminal disease the other goals are unrealistic. Although support of significant others is indicated, palliative care is related directly to relieving the client's discomfort.

A client using fentanyl (Duragesic) transdermal patches for pain management in late-stage cancer dies. What should the hospice nurse who is caring for this client do about the patch? Multiple choice question Tell the family to remove and dispose of the patch. Leave the patch in place for the mortician to remove. Have the family return the patch to the pharmacy for disposal. Remove and dispose of the patch in an appropriate receptacle.

**Remove and dispose of the patch in an appropriate receptacle ** The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.

The practical nurse (PN) is performing nasotracheal suctioning. After the client's trachea is suctioned for 15 seconds, large amounts of thick yellow secretions return. What action should the PN implement next? A Encourage the client to cough to help loosen secretions. B Advise the client to increase intake of oral fluids. C Rotate the suction catheter to obtain any remaining secretions. D Reoxygenate the client before attempting to suction again.

**Reoxygenate the client before attempting to suction again.** Suctioning should not be continued for longer than 10 to 15 seconds because the client's oxygenation is compromised during this time.

What physiological changes that occur with aging must be taken into consideration when the nurse provides care for the older adult? Multiple selection question Urinary urgency Loss of skin elasticity Increased body warmth Swallowing difficulties Elevated blood pressure

**Urinary urgency Loss of skin elasticity Swallowing difficulties Elevated blood pressure** Weakened muscles supporting the bladder in women and enlargement of the prostate gland in men commonly cause urinary urgency and frequency in older adults. Skin elasticity decreases in older adults because of a decline in subcutaneous fat and collagen fibers, as well as thinning of the epidermis. Swallowing difficulties result from a decrease in salivary gland secretions. With aging, an increase in systolic blood pressure and a slight increase in diastolic blood pressure occur. A decrease in subcutaneous fat results in a decreased body warmth.

A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? Multiple choice question Increase fluids. Increase fiber in the diet. Wash hands with soap and water. Wash hands with alcohol based hand sanitizer.

**Wash hands with soap and water.** Alcohol does not kill Clostridium difficile spores. Use of soap and water is more efficacious than alcohol-based hand rubs. Increased fluids and increased fiber does not decrease the risk of transmission of C. difficile.

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? Multiple choice question Skin turgor Intake and output results Client's report about fluid intake Blood lab results

**blood lab results** Blood lab results provide objective data about fluid and electrolyte status as well as about hemoglobin and hematocrit. Intake and output results provide data only about fluid balance but don't present comprehensive picture of the client's fluid and electrolyte status and therefore are not the best answer. Skin turgor is not a reliable indicator of hydration status for the elderly client because it is generally decreased with age. The client's report about fluid intake is a subjective data in general and not reliable because this client has dementia and therefore has memory problems.

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: Multiple choice question diminished. normal. full. bounding.

**full** The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. A 3+ rating indicates a full increased pulse. A zero rating indicates an absent pulse. A rating of a 1+ indicates a diminished pulse that is barely palpable. A 2+ rating is an expected/normal pulse, and a 4+ rating is a bounding pulse.

When assessing a client's blood pressure, the nurse notes that the blood pressure reading in the right arm is 10 mm Hg higher than the blood pressure reading in the left arm. The nurse understands that this finding: Multiple choice question is a normal occurrence. may indicate atherosclerosis. can be attributed to aortic disease. indicates lymphedema.

**is a normal occurrence.** When auscultating blood pressures, readings between the arms can vary as much as 10 mm Hg and are often higher in the right arm. Readings that differ by 15 mm Hg or more suggest atherosclerosis or disease of the aorta. Lymphedema is swelling in one or more extremities that is the result from impaired flow of the lymphatic system.

What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? Multiple selection question Diuresis Pain relief Antipyresis Bronchodilation Anticoagulation Reduced inflammation

** Pain relief, antipyresis, & reduced inflammation** Prostaglandins accumulate at the site of an injury, causing pain; NSAIDs inhibit COX-1 and COX-2 (both are isoforms of the enzyme cyclooxygenase), which inhibit the production of prostaglandins, thereby contributing to analgesia. NSAIDs inhibit COX-2, which is associated with fever, thereby causing antipyresis. NSAIDs inhibit COX-2, which is associated with inflammation, thereby reducing inflammation. NSAIDs do not cause diuresis; reversible renal ischemia and renal insufficiency in clients with heart failure, cirrhosis, or hypovolemia can be potential adverse effects of NSAIDs. NSAIDs do not cause bronchodilation. Anticoagulation is an adverse effect, not a desired outcome; NSAIDs can impair platelet function by inhibiting thromboxane, an aggregating agent, resulting in bleeding.

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock? Respirations of 10 Urine output of 30 ml/hour Lethargy Restlessness

**Restlessness** In the early stage shock, the client has increased epinephrine secretion. This, in turn, causes the client to become restless, anxious, nervous, and irritable. Decreased respiratory rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.

A nurse anticipates that a hospitalized client will be transferred to a nursing home. When should the nurse begin preparing the client for the transfer? Multiple choice question At the time of admission After a relative gives permission When the client talks about future plans As soon as the client's transfer has been approved

** at the time of admission** Preparation of clients for discharge to their own home or to a nursing home should begin on the day of admission. The client gives permission for transfer to a nursing home. Intervention includes talking to the family members, including them in plans, and helping them understand the importance of early preparation. The client may never talk about future plans. Waiting until the client's transfer has been approved will make the adjustment more difficult than if the client had adequate preparation time.

A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions? Multiple choice question "Inhale completely and exhale in short, rapid breaths." "Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale." "Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale." "Exhale halfway, then inhale a rapid, small breath; repeat several times."

**"Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale."** The correct procedure to maximize use of an incentive spirometer is to exhale completely, then take a slow, deep breath through the spirometer, and hold it as long as possible. This procedure will maximize inspiratory function by expanding the lungs. The client should practice using the incentive spirometer before surgery. Answer options 1 and 4 are completely inaccurate procedures for using an incentive spirometer. Option 3 is partially correct but does not state to use the incentive spirometer. When teaching clients, it is important to provide exact step-by-step instructions, thus not leaving out any critical points.

A client with tuberculosis is started on a chemotherapy protocol that includes rifampin (RIF). The nurse evaluates that the teaching about rifampin is effective when the client states: Multiple choice question "I need to drink a lot of fluid while I take this medication." "I can expect my urine to turn orange from this medication." "I should have my hearing tested while I take this medication." "I might get a skin rash because it is an expected side effect of this medication."

**"I can expect my urine to turn orange from this medication."** RIF causes body fluids, such as sweat, tears, and urine, to turn orange. It is not necessary to drink large amounts of fluid with this drug; it is not nephrotoxic. Damage to the eighth cranial nerve is not a side effect of rifampin; it is a side effect of streptomycin sulfate, sometimes used to treat tuberculosis. A skin rash is not a side effect of rifampin.

An adolescent that had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions? Multiple choice question "I can ride my bike in about a week." "I don't have to go to gym class for 3 months." "I can't perform any weightlifting for at least 3 weeks." "I can never participate in football again."

**"I can't perform any weightlifting for at least 3 weeks."** Weightlifting puts a strain on the incision and should be avoided for at least 3 weeks. Activities such as bike riding and physical education classes and football are contraindicated for approximately 3 weeks after uncomplicated surgery for an inguinal hernia. Refraining from these activities for this period of time prevents stress on the incision and promotes healing. However, the client should not participate in any of these activities until cleared by the surgeon.

A pharmacy technician arrives on the nursing unit to deliver opioids and, following hospital protocol, asks the nurse to receive the medications. The nurse is assisting a confused and unsteady client back to the client's room. How should the nurse respond to the technician? Multiple choice question "I can't receive them right now. Please wait a few minutes or come back." "Please leave the medications and sign-out sheet in a location where I can see them." "Please bring them to me and I will be sure to put them away in a couple of minutes." "I can't receive them right now. Please give them to the unlicensed assistive personnel (UAP)."

**"I can't receive them right now. Please wait a few minutes or come back."** The transfer of controlled substances from one authorized person to another must occur according to protocol. In this situation the controlled substance must be returned to the pharmacy and delivered at a later time. The controlled substances cannot be left unattended. The nurse cannot delay the securing of controlled substances; if time is not available when the medications are delivered, they must be returned to the pharmacy. The UAP does not have the authority to receive controlled substances.

A client is being treated for Influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction/clarification? Multiple choice question "I should practice respiratory hygiene/cough etiquette." "I should avoid contact with the elderly or children." "I should obtain a pneumococcal vaccination each year." "I should allow visitors for short periods of time only."

**"I should obtain a pneumococcal vaccination each year."** The client should be encouraged to receive an influenza vaccine each year. Pneumococcal vaccines will not prevent influenza. The nurse should stress the importance of practicing respiratory hygiene/cough etiquette. The client should avoid contact with vulnerable populations such as the elderly and children. Visitors for clients in isolation for influenza should be limited to persons who are necessary for the patient's emotional well-being and care. Visitors who have been in contact with the patient before and during hospitalization are a possible source of influenza for other patients, visitors, and staff.

A client is scheduled for a transurethral resection of the prostate (TURP). Which statement made by the client most indicates the need for further preoperative teaching? Multiple choice question "My urine will be red after surgery." "I will have a catheter after surgery." "My incision will probably be painful." "I will need to drink a lot after surgery."

**"My incision will probably be painful."** The TURP procedure is performed by insertion of a scope device into the urethra to reach the prostate from within the urinary tract. No incision is made to reach the prostate, therefore the client statement about an incision being painful after surgery warrants further evaluating and teaching by the nurse. The client is demonstrating correct knowledge about the TURP procedure by stating that after surgery his urine will be red, he will have a catheter, and he will need to increase fluid intake.

The practical nurse (PN) is preparing to administer a prescribed dose of digoxin 125 mcg PO. The medication available is 0.25 mg per tablet. How many tablets should the PN administer? (Fill in the blank. Type in numbers only and round to the nearest tenth.)

**0.5** 125 mcg × 1 mg/1000 mcg × 1 tablet/0.25 mg = 0.5 tablet

A client has an oral intake during the previous 8 hours of the following: 2 cups coffee, 240 mL milk, ¾ cup applesauce, 1 liter water, 6 ounces fruit juice, and 3 ounces pudding. How many milliliters will the practical nurse (PN) record as the total 8-hour oral intake? (Fill in the blank. Type in numbers only as your answer and round to the nearest whole number.)

**1900mL** Intake includes all liquid taken by mouth, any foods that turn to liquid at room temperature (e.g., gelatin, ice, ice cream), and intravenous fluids or tube feedings. Applesauce and pudding are not included as fluids because these items do not turn to liquid at room temperature. Fluids recorded in cups, liters, or ounces need to be converted to milliliters. Conversions needed to calculate the total intake include the following: 1 cup = 240 mL; 1 ounce = 30 mL; and 1 liter = 1000 mL. 480 mL + 240 mL + 1000 mL + 180 mL = 1900 mL

A client presents with a severe stiff neck, shuffling gate, and other extrapyramidal symptoms. Benztropine 2.5 mg by mouth is prescribed. The medication is available in 1-mg scored tablets. How many tablets should the nurse administer? Record the answer using one decimal place. tablets

**2.5** Solve the problem using the "Desire over Have" formula. Desire 2.5 mg x tablets ------------- = --------- Have 1 mg 1 tablets 1x = 1 × 2.5 x = 2.5 ÷ 1 x = 2.5 tablets

A client is to receive 125 mL of intravenous (IV) fluid every hour. The drop factor of the IV tubing is 10 gtt/mL. How many drops per minute should the nurse administer? Record your answer using a whole number. gtts/min.

**21** Multiply the amount to be infused (125) by the drop factor (10) and divide the result by the amount of time in minutes (60 minutes); the product, 20.8, must be rounded up to 21 gtt/min.

The physician orders intravenous fluids to be infused at 100 mL/hour. The intravenous tubing delivers 15 drops/milliliters. The nurse would infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour? Record your answer using a whole number. gtts/min.

**25** 100 cc/60 minutes x 15 drops/mL = 25 drops/mL

An intravenous (IV) solution of 1000 mL 5% dextrose in water is to be infused at 125 mL/hr to correct a client's fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an eight-hour period, at how many drops per minute should the nurse set the rate of flow? Record the answer using a whole number. gtts/min

**31** Use the following formula to solve the problem. Drops per minute = total volume in drops (total mL x drop factor)/Total time in minutes (hours x 60) Drops per minute = 1000 mL x 15/8 x 60 = 15,000/480 = 31.25 = 31 gtts/min

A nurse suspects that a client has poison ivy. Assessment findings reveal vesicles on the arms and legs. A vesicle can be described as: Multiple choice question A lesion filled with purulent drainage. An erosion into the dermis. A solid mass of fibrous tissue. A lesion filled with serous fluid.

**A lesion filled with serous fluid.** A vesicle is a small blisterlike elevation on the skin containing serous fluid. Vesicles are usually transparent. Common causes of vesicles include herpes, herpes zoster, and dermatitis associated with poison oak or ivy. A lesion filled with purulent drainage is known as a pustule; an erosion into the dermis is known as an excoriation or ulcer; and a solid mass of fibrous tissue is known as a papule.

The nurse is caring for an older adult client who is aphasic. The client's family reports to the nurse manager that the primary nurse failed to obtain a signed consent form before inserting an indwelling catheter to measure intake and output. What should the nurse manager consider before responding? Multiple choice question Procedures for a client's benefit do not require a signed consent. Clients who are aphasic are incapable of signing an informed consent. A separate signed informed consent for routine treatments is unnecessary. A specific intervention without a client's signed consent is an invasion of rights.

**A separate signed informed consent for routine treatments is unnecessary.** his is considered a routine procedure to meet basic physiological needs and is covered by a consent signed at the time of admission. The need for consent is not negated because the procedure is beneficial. This treatment does not require special consent.

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority? Multiple choice question Place the client in a left side-lying position. Apply oxygen via non-rebreather mask. Apply a petroleum gauze dressing over the site. Prepare to reinsert a new chest tube.

**Apply a petroleum gauze dressing over the site.** A petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax. The petroleum gauze dressing should be taped only on three sides to allow for excessive air to escape, preventing a tension pneumothorax. The physician should immediately be notified and the client assessed for signs of respiratory distress. Preparing to reinsert a new chest tube is not a priority of the nurse at this moment. Positioning the client on the left side will not make a difference in outcome. There is no indication that the client is experiencing respiratory distress.

Which action should the practical nurse (PN) implement to ensure that eye ointment is distributed evenly across the eye and lid margin? A Apply the ointment along the upper outer edge of the eyelid from the outer to the inner canthus. B Instill the ointment along the lower inner edge of the eyelid from the inner to the outer canthus. C Spread the ointment along the lower outer edge of the eyelid from the outer to the inner canthus. D Place the ointment along the upper and lower inner edges of the eyelids from the inner to the outer canthus.

**Apply the ointment along the upper outer edge of the eyelid from the outer to the inner canthus.** To instill eye ointment, the practical nurse (PN) would hold the ointment applicator above the lower lid margin and apply a thin stream of ointment along the inner edge of the lower eyelid on the conjunctiva from the inner canthus to the outer canthus.

A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin, decreased hair growth, and thickened toenails. The nurse understands that this may indicate: Multiple choice question Venous insufficiency Arterial Insufficiency Phlebitis Lymphedema

**Arterial Insufficiency** Clients suffering from arterial insufficiency present with pale colored extremities when elevated and dusky red colored extremities when lowered. Lower extremities may also be cool to touch, pulses may be absent or mild, and skin may be shiny, thin, with decreased hair growth, and thickened nails. Clients suffering from venous insufficiency often have normal colored extremities, normal temperature, normal pulses, marked edema, and brown pigmentation around ankles. Phlebitis is an inflammation of a vein that occurs most often after trauma to the vessel wall, infection, and immobilization. Lymphedema is swelling in one or more extremities that is a direct result from impaired flow of the lymphatic system.

The practical nurse (PN) is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later, the client reports that the insomnia continues despite following the same routine every night. What action should the PN take first? A Instruct the client to add a daily routine of regular exercise. B Determine if the client has been keeping a sleep diary. C Encourage the client to continue the routine until sleep is achieved. D Ask the client to describe the current routine practiced by the client.

**Ask the client to describe the current routine practiced by the client.** The PN should first evaluate whether the client has been adhering to the original instructions. A verbal report of the client's routine will provide more specific information.

Which nursing intervention is most appropriate for a client in skeletal traction? Multiple choice question Add and remove weights as the client desires. Assess the pin sites at least every shift and as needed. Ensure that the knots in the rope are tied to the pulley. Perform range of motion to joints proximal and distal to the fracture at least once a day.

**Assess the pin sites at least every shirt and as needed** Nursing care for a client in skeletal traction may include assessing pin sites every shift and as needed. The needed weight for a client in skeletal traction is prescribed by the physician, not as desired by the client. The nurse also should ensure that the knots are not tied to the pulley and move freely. The performance of range of motion is indicated for all joints except the ones proximal and distal to the fracture, since this area is immobilized by the skeletal traction to promote healing and prevent further injury and pain.

What should a nurse recommend to help a client best during the period immediately after a spouse's death? Multiple choice question Crisis counseling Family counseling Marital counseling Bereavement counseling

**Bereavement counseling** Bereavement counseling involves being a part of a group of people who also have sustained a loss; members provide support to each other. Individual counseling will not provide the support that a group provides; group counseling may last longer than crisis intervention. The information provided did not indicate other family members. Marital counseling involves both a husband and a wife.

An elderly client in a wheelchair wants to return to bed after eating breakfast. What assessment is most important for the practical nurse (PN) to consider before assisting this client? A Blood pressure of 86/54 mm Hg B 30% of diet eaten C Oriented to person only D Inelastic skin turgor

**Blood pressure of 86/54 mm Hg** Hypotension places the client at risk for falls because it can cause dizziness. To ensure client safety, it is most important for the PN to be aware of the client's low blood pressure before transfer.

A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? Multiple choice question Sodium Calcium Potassium Phosphorus

**Calcium** The muscle contraction-relaxation cycle requires an adequate serum calcium-phosphorus ratio; the reduction of the ionized serum calcium level associated with malabsorption syndrome causes tetany (spastic muscle spasms). Sodium is the major extracellular cation. Sodium's major route of excretion is the kidneys, under the control of aldosterone. Although it plays a part in neuromuscular transmission, potassium is not related to the development of tetany. Potassium is the major intracellular cation. Potassium is part of the sodium-potassium pump and helps to balance the response of nerves to stimulation. Potassium is not related to the development of tetany. Although phosphorus is closely related to calcium because they exist in a specific ratio, phosphorus is not related to the development of tetany.

A nurse addresses the needs of a client who is hyperventilating to prevent what complication? Multiple choice question Cardiac arrest Carbonic acid deficit Reduction in serum pH Excess oxygen saturation

**Carbonic acid deficit** Hyperventilation causes excessive loss of carbon dioxide, leading to carbonic acid deficit and respiratory alkalosis. Cardiac arrest is unlikely; the client may experience dysrhythmias but will lose consciousness and begin breathing regularly. Hyperventilation causes alkalosis; the pH is increased. Excess oxygen saturation cannot occur; the usual oxygen saturation of hemoglobin is 95% to 98%.

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? Multiple choice question Sunken eyes Dry, flaky skin Change in mental status Decreased bowel sounds

**Change in mental status** Older adults are sensitive to changes in fluid and electrolyte levels, especially sodium, potassium, and chloride. These changes will manifest as a change in mental status and confusion. It is difficult to assess dehydration in older adults based on sunken eyes, dry skin and decreased bowel sounds, because these can be prominent as general normal findings in the elderly client.

A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? Multiple choice question Once a day, clean the tubing with a mild soap and water, starting at the drainage bag and moving toward the insertion site. After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. Clean the insertion site daily using a solution of one part vinegar to two parts water. Change the drainage bag at least once a week as needed.

**Change the drainage bag at least once a week as needed.** Once a day, the client should wash the first inches of the catheter starting at the insertion site and moving outward. The foreskin should be pushed forward as soon as the foreskin has been cleaned and dried. The drainage bag, not the insertion site, should be cleaned with the vinegar and water solution. It is recommended to change the bag at least once a week.

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? Multiple choice question Clear breath sounds Positive pedal pulses Normal potassium level Increased urine specific gravity

**Clear breath sounds** Excess fluid can move into the lungs, causing crackles; clear breath sounds support that treatment was effective. While it may make palpation more difficult, excess fluid will not diminish pedal pulses. A normal potassium level can be maintained independently of fluid excess correction. As the client excretes excess fluid, the urine specific gravity will decrease, not increase.

The nurse is caring for a client with a closed soft tissue injury. The nurse describes the injury as a/an: Abrasion Contusion Laceration Avulsion

**Contusion** Closed wounds are considered contusions and hematomas because the skin is not broken. Abrasions, lacerations, and avulsions are considered open because there is a break in the skin integrity.

What is a nurse's responsibility when administering prescribed opioid analgesics? Multiple selection question Count the client's respirations. Document the intensity of the client's pain. Withhold the medication if the client reports pruritus. Verify the number of doses in the locked cabinet before administering the prescribed dose. Discard the medication in the client's toilet before leaving the room if the medication is refused.

**Count the client's respirations. Document the intensity of the client's pain. Verify the number of doses in the locked cabinet before administering the prescribed dose.** Opioid analgesics can cause respiratory depression; the nurse must monitor respirations. The intensity of pain must be documented before and after administering an analgesic to evaluate its effectiveness. Because of the potential for abuse, the nurse is legally required to verify an accurate count of doses before taking a dose from the locked source and at the change of the shift. Pruritus is a common side effect that can be managed with antihistamines. It is not an allergic response, so it does not preclude administration. The nurse should not discard an opioid in a client's room. Any waste of an opioid must be witnessed by another nurse.

Which instruction should the practical nurse (PN) provide to a client whose vision is being tested with a Snellen chart? A Stand on a line drawn 10 feet from the chart. B Read each sentence slowly and carefully. C Cover one eye while reading the chart with the other. D Begin by identifying the first line that is hard to read.

**Cover one eye while reading the chart with the other.** Each eye should be tested separately because visual acuity can vary from one eye to the other. The client should be instructed to begin at or near the top of the chart with the line that can be easily read, moving down until a line is reached that cannot be read.

A nurse is evaluating the appropriateness of a family member's initial response to grief. What is the most important factor for the nurse to consider? Multiple choice question Personality traits Educational level Cultural background Past experiences with death

**Cultural Background** In the initial stage of grief the degree of anguish experienced is influenced by cultural background. Although personality traits factor into the grief process, they are not as important as culture. Educational level is not related directly to a grief response. While past experience is important, it is not as significant as culture.

A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam (Ativan); I get so annoyed when people drink too much." What does this nurse's comment reflect? Demonstration of a personal bias. Problem solving based on assessment. Determination of client acuity to set priorities. Consideration of the complexity of client care.

**Demonstration of a personal bias** When nurses make judgmental remarks and client needs are not placed first, the standards of care are violated and quality of care is compromised. Assessments should be objective, not subjective and biased. There is no information about the client's acuity to come to this conclusion. The statement does not reflect information about complexity of care.

According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions? Multiple choice question Anger Denial Bargaining Depression

**Denial** Denial includes feelings that the health care provider has made a mistake, so the client seeks additional opinions. Anger follows denial; behavior will be hostile and critical. Bargaining occurs after anger; the client verbally or secretly may promise something in return for wellness or a prolonged life. Depression occurs after bargaining; the client feels sadness and despair and may be withdrawn.

A client with Type I Diabetes complains of hunger, thirst, tiredness, and frequent urination. Based on these findings, the nurse should take what action? Multiple choice question Notify the physician immediately about the client's symptoms. Determine the client's blood glucose level. Administer the client's prescribed insulin. Give the client a peanut butter and graham cracker snack.

**Determine the client's blood glucose level.** Polyphagia, polydipsia, lethargy, and polyuria indicate hyperglycemia. The nurse must determine the glucose level before notifying the physician, as these are common symptoms of hyperglycemia. The nurse must then look at medication orders after obtaining the glucose reading. The client may have a sliding scale short-acting insulin order in addition to his prescribed insulin. Administering the prescribed insulin will not affect the blood glucose level immediately. Administering a peanut butter and graham cracker snack would increase the glucose level.

When performing sterile wound care in the acute care setting, the practical nurse (PN) obtains a bottle of normal saline from the bedside table that is labeled opened and is dated 48 hours before the current date. What is the best action for the PN to take? A Use the normal saline solution once more and then discard. B Obtain a new sterile syringe to draw up the labeled saline solution. C Use the saline solution, then relabel the bottle with the current date. D Discard the saline solution and obtain a new and unopened bottle.

**Discard the saline solution and obtain a new and unopened bottle.** Solutions labeled within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded.

A visitor in the waiting room of the emergency department has a syncopal episode and collapses on the floor. The event is witnessed by a nurse, who provides initial care. The nurse assessed the client, maintained safety of the environment, and gave a report to the emergency department nurse, who will provide ongoing care. What should the nurse who witnessed the event do next? Multiple choice question Contact the family Document the incident Report the incident to the nurse manager Escort the client to the radiology department

**Document the incident** Documenting the event on an incident report form provides a legal record and is critical in providing appropriate care and follow-up. Calling the family is the responsibility of the health care provider and nurse providing ongoing care. Reporting the incident to the nurse manager should be done, but it is not as critical as documenting the incident. Escorting the client to radiology is not the responsibility of the witnessing nurse. Once care is transferred to the emergency department nurse, it is the emergency department nurse's responsibility to arrange for or to escort the client to radiology.

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? Multiple choice question Don an N95 respirator mask before entering the room. Put on a permeable gown each time before entering the room. Implement contact precautions and post appropriate signage. After finishing with patient care, remove the gown first and then remove the gloves.

**Don an N95 respirator mask before entering the room.** A N95 respirator mask is unique to airborne precautions. It is unique for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be non-permeable to be protective. Airborne precautions are required, not contact precautions. When finished with care, gloves should be removed first because they are the most contaminated.

A nurse is reviewing a client's plan of care. What is the determining factor in the revision of the plan? Multiple choice question Time available for care Validity of the problem Method for providing care Effectiveness of the interventions

**Effectiveness of the interventions** When the implementation of a plan of care does not produce the desired outcome effectively, the plan should be changed. Time is not relevant in the revision of a plan of care. Client response to care is the determining factor, not the validity of the health problem. Various methods may have the same outcome; their effectiveness is most important.

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? Multiple choice question Increase fluid intake. Restrict fluids. Encourage early mobility. Elevate the knee gatch of the bed.

**Encourage early mobility.** In the immediate postoperative period, mobility is encouraged because veins require the assistance of the surrounding muscle beds to help pump blood toward the heart. This reduces venous stasis and the risk of thrombophlebitis. Increased fluid intake, if not contraindicated, will prevent dehydration and venous stasis. Therefore, restriction of fluids may promote venous stasis and increase risk. Elevating the knee gatch of the bed will impede venous blood flow and also increase the risk for thrombophlebitis.

When being interviewed for a position as a licensed practical nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? Multiple choice question Negligence Malpractice Breach of duty False imprisonment

**False imprisonment** False imprisonment is a wrong committed by one person against another in a willful, intentional way without just cause or excuse. Negligence is an unintentional tort. Malpractice, which is professional negligence, is classified as an unintentional tort. Breach of duty is an unintentional tort.

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? Multiple choice question Postural drainage Cupping the chest Nasotracheal suctioning Frequent changes of position

**Frequent changes of position** Frequent changes of position minimize pooling of respiratory secretions and maximize chest expansion, which aids in the removal of secretions; this helps maintain the airway and is an independent nursing function. Postural drainage and cupping the chest are part of pulmonary therapy that requires a health care provider's prescription. Nasotracheal suctioning will remove secretions once they accumulate in the upper airway, not prevent their accumulation.

A nurse is caring for a client who is being treated with continuous ambulatory peritoneal dialysis (CAPD) for chronic glomerulonephritis. What dietary need should the nurse discuss with the client? Multiple choice question Low-calorie foods High-quality protein Increased fluid intake Foods rich in potassium

**High-quality protein** Although proteins may be restricted, those eaten should be high-quality proteins that are used to replace proteins lost during dialysis. A high-caloric intake should be encouraged. Increased fluid intake is inappropriate; fluids usually are restricted moderately because of impaired renal function. Foods rich in potassium are inappropriate; high-potassium foods are restricted because of impaired renal function.

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L and a potassium level of 3.6 mEq/L. Based on the lab results and symptoms, what is the client experiencing? Multiple choice question Hypernatremia Hyponatremia Hyperkalemia Hypokalemia

**Hyponatremia** The normal range for serum sodium is 135 to 145 mEq/L, and for serum potassium it is 3.5 to 5 mEq/L. Vomiting and use of diuretics, such as furosemide (Lasix), deplete the body of sodium. Without intervention, symptoms of hyponatremia may progress to include neurological symptoms such as confusion, lethargy, seizures, and coma. Hypernatremia results when serum sodium is greater than 145 mEq/L; hyperkalemia results when serum potassium is greater than 5.0 mEq/L; hypokalemia results when serum potassium is less than 3.5 mEq/L

A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong? Multiple choice question Isotonic Isomeric Hypotonic Hypertonic

**Hypotonic** Hypotonic solutions are less concentrated (contain less than 0.85 g of sodium chloride in each 100 mL) than body fluids. Isotonic solutions are those that cause no change in the cellular volume or pressure, because their concentration is equivalent to that of body fluid. This relates to two compounds that possess the same molecular formula but that differ in their properties or in the position of atoms in the molecules (isomers). Hypertonic solutions contain more than 0.85 g of solute in each 100 mL.

The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions? Multiple choice question "I should carry objects about 18 inches from my body." "I should sleep on my stomach with a firm mattress." "I should carry objects close to my body." "I should pull rather than push when moving heavy objects."

**I should carry objects close to my body** By carrying objects close to the center of the body, the client can lessen back strain. Sleeping on the stomach, pulling objects, and carrying objects too far away from the body add pressure and strain to the back muscles.

A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, the nurse should instruct the client to: Multiple choice question Increase oral fluid intake to 2 to 3 L per day. Maintain bed rest after discharge. Limit fluid intake to 1 L/day. Void at least every hour.

**Increase oral fluid intake to 2 to 3 L per day.** Increasing oral fluid intake to 2 to 3 L per day, if not contraindicated, will dilute urine and promote urine flow, thus preventing stasis and complications such as renal calculi. Bed rest and limited fluid intake may lead to urinary stasis and increase risk for the formation of renal calculi. Voiding at least every hour has no effect on urinary stasis and renal calculi.

The nurse is caring for a client with acute renal failure. The most serious complication for this client is: Multiple choice question Anemia Infection Weight loss Platelet dysfunction

**Infection** Infection is responsible for one third of the traumatic or surgically induced deaths of clients with acute renal failure, as well as for medically induced acute renal failure. Resistance is reduced in clients with kidneys that fail because of decreased phagocytosis, which makes them susceptible to microorganisms. Anemia occurs often with acute renal failure, but it is not the most serious complication and should be treated in relation to the client's adaptations; erythropoietin and iron supplements usually are prescribed. Weight loss is not life threatening. Platelet dysfunction occurs because of decreased cell surface adhesiveness, but it is not as serious as an infection.

A nurse identifies that an older adult has not achieved the desired outcome from a prescribed proprietary medication. When assessing the situation, the client shares that the medication is too expensive and the prescription was never filled. What is an appropriate nursing response? Multiple choice question Ask the pharmacist to provide a generic form of the medication. Encourage the client to acquire the medication over the internet. Inform the health care provider of the inability to afford the medication. Suggest that the client purchase insurance that covers prescription medications.

**Inform the health care provider of the inability to afford the medication.** The health care provider needs to be aware of the reason for the client's lack of response to the medication so that an alternate treatment plan or financial assistance can be arranged (e.g., go to The National Council on the Aging web site [BenefitsCheckUpRx] to establish whether the client is eligible for assistance from any community, state, or federal programs or from the drug company). A health care provider may prefer the proprietary form of the medication. To ask the pharmacist to provide a generic form of the medication is unsafe. To recommend that the client obtain a generic form of the medication is not within the legal role of the nurse, unless the health care provider documents that this is acceptable. Medications purchased over the internet may be illegally imported, counterfeit, expired, or contaminated and therefore should be avoided. Although some prescription insurance plans may help to reduce the cost of some medications, the client may not be able to afford the insurance.

As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults' most frequent cause of falls? Multiple choice question Moving the client's bedside table closer to the bed. Encouraging the client to take an available sedative. Instructing the client to call the nurse before going to the bathroom. Assisting the client to telephone home to say goodnight to the spouse.

**Instructing the client to call the nurse before going to the bathroom** Statistics indicate that the most frequent cause of falls by hospitalized clients is getting up or attempting to get up to the bathroom unassisted. Although moving the bedside table closer to the bed is helpful in reducing falls because it moves the bedside table closer to the client's center of gravity, it is not the primary intervention to prevent falls. Sedatives contribute to the risk for falls by altering the client's sensorial abilities. Although talking to the spouse may calm the client and contribute to sleep, it does not reduce the incidence of falls.

A client receiving steroid therapy states, "I have difficulty controlling my temper, which is so unlike me, and I don't know why this is happening." What is the nurse's best response? Multiple choice question Tell the client it is nothing to worry about. Talk with the client further to identify the specific cause of the problem. Instruct the client to attempt to avoid situations that cause irritation. Interview the client to determine whether other mood swings are being experienced

**Interview the client to determine whether other mood swings are being experienced** Steroids increase the excitability of the central nervous system, which can cause labile emotions, manifested as euphoria and excitability or depression. Telling the client it is nothing to worry about denies the value of the client's statement and offers false reassurance. The client has already stated the problem and does not know why this is happening. Instructing the client to attempt to avoid situations that cause irritation is difficult for the client to do because the mood swings may occur without an overt cause.

A nurse applies an ice pack to a client's leg for 20 minutes. The cold application will cause what physiological effect? Multiple choice question Local anesthesia Peripheral vasodilation Depression of vital signs Decreased viscosity of blood

**Local anesthesia** Cold reduces the sensitivity of pain receptors in the skin. In addition, local blood vessels constrict, limiting the amount of edema and its related pressure and discomfort. Local blood vessels constrict. Local cold applications do not depress vital signs. Local cold applications do not affect blood viscosity directly.

A client reports vomiting and diarrhea for three days. What clinical finding most accurately will indicate that the client has a fluid deficit? Multiple choice question Presence of dry skin Loss of body weight Decrease in blood pressure Altered general appearance

**Loss of body weight** Dehydration is measured most readily and accurately by serial assessments of body weight; 1 L of fluid weighs 2.2 lb. Although dry skin may be associated with dehydration, it also is associated with aging and some disorders (e.g., hypothyroidism). Although hypovolemia eventually will result in a decrease in blood pressure, it is not an accurate, reliable measure because there are many other causes of hypotension. Altered appearance is too general and not an objective determination of fluid volume deficit.

Following an open reduction of a fractured femur, a client is placed in skeletal traction. Based on the nursing diagnosis of "Potential impairment of skin integrity related to immobility," which nursing intervention should the practical nurse (PN) implement? A Release the traction, turn the client, and give back care. B Turn the client while someone lifts the traction weights and give back care. C Lubricate the hands, slide them under the client, and give back care. D Give back care after the client is released from traction.

**Lubricate the hands, slide them under the client, and give back care.** Back care provides the best method for solving immobility problems, such as skin breakdown, when the client is in traction.

A nurse is preparing to administer an oil-retention enema and understands that it works primarily by: Multiple choice question Stimulating the urge to defecate. Lubricating the sigmoid colon and rectum. Dissolving the feces. Softening the feces.

**Lubricating the sigmoid colon and rectum.** The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil-retention enema does not dissolve feces .

A client reports smoke coming from a utility room on the nursing unit. What is the initial action the nurse should take? Multiple choice question Pull the fire alarm on the unit. Remove anyone that is in immediate danger. Obtain a fire extinguisher and report to the fire area. Close all windows and fire doors and await further instructions.

**Remove anyone that is in immediate danger.** The nurse is following the standard fire safety procedure RACE: "R" represents removing any clients from immediate danger. In RACE, "A" represents alarming or activating the fire alarm, "C" represents containing the fire source by closing all windows and fire doors, and "E" represents extinguishing the fire and/or evacuating.

A health care provider prescribes transdermal fentanyl (Duragesic) 25 mcg/hr every 72 hours. During the first 24 hours after starting the fentanyl, what is the most important nursing intervention? Multiple choice question Change the dose until pain is tolerable. Manage pain with oral pain medication. Assess the client for anticholinergic side effects. Instruct the client to take the medication with food.

**Manage pain with oral pain medication.** It takes 24 hours to reach the peak effect of transdermal fentanyl (Duragesic). Oral pain medication may be necessary to support client comfort until the fentanyl reaches its peak effect. The nurse needs to administer the dose of transdermal fentanyl exactly as prescribed by the health care provider. This is associated with tricyclic antidepressants, not transdermal fentanyl. A transdermal medication is administered through the skin via a patch applied to the skin, not via the gastrointestinal tract.

A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make? Multiple choice question Eating beef and veal is prohibited. Consumption of fish with scales is forbidden. Meat and milk at the same meal are forbidden. Consuming alcohol, coffee, and tea are prohibited.

**Meat and milk at the same meal are forbidden** Jewish dietary laws prohibit any combination of milk and meat at the same meal. The Hindu, not Jewish, religion prohibits the ingestion of beef and veal; many Hindus believe that the cow is sacred. Fish that have scales and fins are considered clean, and therefore allowed in the diet. Seventh Day Adventists, Baptists, Mormons, and Muslims prohibit some or all of these beverages.

The spouse of a client with terminal cancer provided the practical nurse (PN) with a copy of the client's living will. What action should the PN take? A Place a certified copy of the living will in the client's chart. B Notify the health care provider of the client's wishes. C Alert the nursing staff of the client's "do not resuscitate" (DNR) status. D Facilitate a family meeting with the palliative care team.

**Notify the health care provider of the client's wishes.** The health care provider needs to be informed of the clientʼs wishes and a prescription written to specify how the staff should respond to medical emergencies. A copy should be placed on the chart, but it does not need to be a certified copy. A living will does not necessarily indicate DNR status. The client and the clientʼs family should be informed about palliative care, but a meeting with the team should be facilitated only at their request.

The nurse is providing post-procedure care for a client that had a liver biopsy. To prevent hemorrhage, it is the nurse's highest priority to place the client in what position? Multiple choice question Prone High-Fowler's On the right side Trendelenburg

**On the right side** Placing a client on the right side after a liver biopsy compresses the liver against the abdominal wall, thus holding pressure on the biopsy site and allowing clot formation. There is no indication that the other three positions are beneficial or appropriate for the client.

A health care provider prescribes famotidine (Pepcid) and magnesium hydroxide/aluminum hydroxide (Maalox) for a client with a peptic ulcer. The nurse should teach the client to take the Maalox at what time? Multiple choice question Only at bedtime, when famotidine is not taken. Only if famotidine is ineffective. At the same time as famotidine, with a full glass or water. One hour before or two hours after famotidine.

**One hour before or two hours after famotidine.** Antacids interfere with complete absorption of famotidine; therefore, antacids should be administered at least one hour before or two hours after famotidine. Magnesium hydroxide/aluminum hydroxide usually is taken one hour after meals and at bedtime. Famotidine usually is prescribed once a day at bedtime. The client has received a prescription for both medications; the client should not be instructed to omit one of the medications without checking with the health care provider first.

A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action? Multiple choice question Orient the client to the unit environment. Have a copy of hospital regulations available. Explain that that there is no reason to be concerned. Reassure the client that the staff is available if the client has questions.

**Orient the client to the unit environment.** Orienting the client to the hospital unit provides knowledge that may reduce the strangeness of the environment. Having a copy of hospital regulations available is part of orienting the client to the unit. This alone is not enough when orienting a client to the hospital. Explaining that that there is no reason to be concerned may be false reassurance, because no one can guarantee that there is no reason to be concerned. Reassuring the client that the staff is available to answer questions implies that staff members are available only if the client has specific questions.

A nurse assesses for hypocalcemia in a postoperative client. One of the initial signs that might be present is: Multiple choice question Headache. Pallor. Paresthesias. Blurred vision.

**Paresthesias.** Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia.

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse identifies an ocular problem common to persons at this client's developmental level, which is: Multiple choice question Tropia Myopia Hyperopia Presbyopia

**Presbyopia** Presbyopia is the decreased accommodative ability of the lens that occurs with aging. Tropia (eye turn) generally occurs at birth. Myopia (nearsightedness) can occur during any developmental level or be congenital. Hyperopia (farsightedness) can occur during any developmental level or be congenital.

What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment? Multiple choice question Age and sex Physical and physiological status Intelligence and economic status Previous experience and cultural values

**Previous experience and cultural values** Interpretation of pain sensations is highly individual and is based on past experiences, which include cultural values. Age and sex affect pain perception only indirectly because they generally account for past experience to some degree. Overall physical condition may affect the ability to cope with stress; however, unless the nervous system is involved, it will not greatly affect perception. Intelligence is a factor in understanding pain so it can be tolerated better, but it does not affect the perception of intensity; economic status has no effect on pain perception.

A client who sustained a large open wound as a result of an accident is receiving daily sterile dressing changes. To maintain sterility when changing the dressing, the nurse should: Multiple choice question Put the unopened sterile glove package carefully on the sterile field Remove the sterile drape from its package by lifting it by the corners Don sterile gloves before opening the package containing the field drape Pour irrigation liquid from a height of at least three inches above the sterile container

**Remove the sterile drape from its package by lifting it by the corners** The outer one inch of the sterile field is considered contaminated and can be touched without wearing sterile gloves. The outside of an unopened sterile glove package is not sterile. The field will become contaminated if the unopened package is placed on the sterile field. The outer package, which contains a sterile field drape, is not sterile; if it is touched with sterile gloves, the sterile gloves will become contaminated. Liquids should be poured from a height of 4 to 6 inches; this ensures that the solution bottle does not contaminate the sterile container.

A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. What is the most therapeutic nursing intervention? Multiple choice question Sitting quietly with the client. Telling the client that crying is not helpful. Suggesting that the client play a board game. Recommending how the client can change this situation.

**Sitting quietly with the client** Sitting quietly with the client conveys the message that the nurse cares and accepts the client's feelings; this helps to establish trust. Telling the client that crying is not helpful negates feelings and the client's right to cry when upset. Distraction (suggesting that the client play a board game) closes the door on further communication of feelings. After a trusting relationship has been established, the nurse can help the client explore the problem in more depth.

A nurse is providing preoperative teaching for a client who is scheduled for a transurethral resection of the prostate. What should the nurse include in the client's postoperative teaching plan? Multiple choice question The urine will be bright red for 24 to 48 hours Spasms of the bladder occur during the first 24 to 48 hours To decrease bladder contractions, the Valsalva maneuver and Kegel exercises will be encouraged To maintain proper fluid balance, oral fluids are restricted during continuous urinary bladder irrigations

**Spasms of the bladder occur during the first 24 to 48 hours ** Spasms result from irritation of the bladder during surgery; they decrease in intensity and frequency as healing occurs. Urine that is bright red for 24 to 48 hours is too long; this indicates hemorrhage. Drainage should be dark red and after the first few hours gradually turn pink. The Valsalva maneuver should be avoided because it may initiate prostatic bleeding, not bladder contractions. The presence of continuous bladder irrigation (CBI) is unrelated to the amount of oral fluids that should be consumed; once the continuous bladder irrigation is discontinued, oral fluids should be encouraged.

A nurse is caring for a client with pulmonary tuberculosis who is to receive several antitubercular medications. Which of the first-line antitubercular medications is associated with damage to the eighth cranial nerve? Multiple choice question Isoniazid (INH) Rifampin (Rifadin) Streptomycin Ethambutol (Myambutol)

**Streptomycin** Streptomycin is ototoxic and can cause damage to the eighth cranial nerve, resulting in deafness. Assessment for ringing or roaring in the ears, vertigo, and hearing acuity should be made before, during, and after treatment. Isoniazid does not affect the ear; however, blurred vision and optic neuritis, as well as peripheral neuropathy, may occur. Rifampin does not affect hearing; however, visual disturbances may occur. Ethambutol does not affect hearing; however, visual disturbances may occur.

A client has a paracentesis, and the health care provider removes 1500 mL of fluid. To monitor for a serious postprocedure complication, the nurse should assess for: Multiple choice question Dry mouth Tachycardia Hypertensive crisis Increased abdominal distention

**Tachycardia** Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemia and compensatory tachycardia. Dry mouth may occur with dehydration, but it is not as vital or immediate as signs of shock. Dry mouth is a subjective symptom that cannot be measured objectively. The fluid shift can cause hypovolemia with resulting hypotension, not hypertension. A paracentesis decreases the degree of abdominal distention.

A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? Multiple selection question Take the aspirin with meals or a snack. Make an appointment with a dentist if bleeding gums develop. Do not chew enteric-coated tablets. Switch to Tylenol (acetaminophen) if tinnitus occurs. Report persistent abdominal pain.

**Take the aspirin with meals or a snack Do not chew enteric-coated tablets Report persistent abdominal pain.** Acetylsalicylic acid (aspirin) is irritating to the stomach lining and can cause ulceration; the presence of food, fluid, or antacids decreases this response. Bleeding gums should be reported to the practitioner, not the dentist. Enteric-coated tablets must not be crushed or chewed. Acetaminophen does not contain the anti-inflammatory properties present in aspirin; tinnitus should be reported to the practitioner. Aspirin therapy may lead to GI bleeding, which may be manifested by abdominal pain; if present, the prescriber must be notified immediately.

A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? Limits had to be set to control the child's crying. The child had a right to remain in the room with the other children. The child had to be removed because the other children needed to be considered. Segregation of the child for more than half an hour was too long a period of time.

**The child had a right to remain in the room with the other children.** Legally, a person cannot be locked in a room (isolated) unless there is a threat of danger either to the self or to others. Limit setting in this situation is not warranted. This is a reaction to separation from the parent, which is common at this age. Crying, although irritating, will not harm the other children. A child should never be isolated.

A client with a history of ulcerative colitis is admitted to the hospital because of severe rectal bleeding. The client engages in angry outbursts and places excessive demands on the staff. One day an unlicensed assistive personnel (UAP) tells the nurse, "I've had it. I am not putting up with that behavior. I'm not going in there again." What is the best response by the nurse? Multiple choice question "You need to try to be patient. The client is going through a lot right now." "I'll talk with the client. Maybe I can figure out the best way for us to handle this." "Just ignore it and get on with your work. I'll assign someone else to take a turn." "The client's frightened and taking it out on the staff. Let's think of approaches we can take."

**The client's frightened and taking it out on the staff. Let's think of approaches we can take."** he correct response interprets the client's behavior without belittling the UAP's feelings; it encourages the UAP to get involved with plans for future care. Telling the UAP to be patient recognizes the client's feelings, but it does not address the UAP's feelings or help the UAP cope with the client's behavior. The nurse should not assume the UAP has nothing to contribute and that only the nurse can deal with the problem. Saying "Just ignore it" does not help the UAP understand the client's behavior, nor does it demonstrate an understanding of the client's feelings.

A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the charge nurse or surgeon? Multiple choice question Incisional pain Absent bowel sounds Urine output of 20 mL/hour Serosanguineous drainage on the dressing

**Urine output of 20 mL/hour** A urinary output of 50 mL/hr or greater is necessary to prevent stasis and consequent infections after this type of surgery. The nurse should notify the surgeon of the assessment findings, as this may indicate a urinary tract obstruction. Incisional pain, absent bowel sounds, and serosanguineous drainage are acceptable assessment findings for this client after this procedure and require continued monitoring but do not necessarily require reporting to the surgeon.

A lithotripsy to break up renal calculi is unsuccessful, and a nephrolithotomy is performed. Which postoperative clinical indicator should the nurse report to the health care provider? Multiple choice question Passage of pink-tinged urine Pink drainage on the dressing Intake of 1750 mL in 24 hours Urine output of 20 to 30 mL/hr

**Urine output of 20 to 30 mL/hr** utput should be at least 30 mL/hr or more; a decreased output may indicate obstruction or impaired kidney function. Blood, tinting the urine pink, is expected. Drainage may be pink; bright red drainage should be reported. The intake of 1750 mL in 24 hours is adequate; however, a higher intake usually is preferred (e.g., 2000 to 3000 mL).

A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" What is the nurse's most appropriate response? Multiple choice question "This is a decision you alone can make." "Do not tell your partner unless asked." "You are having difficulty deciding what to say." "Tell your partner that you don't know how you became sick."

**You are having difficulty deciding what to say** The correct response promotes an exploration of the client's dilemma; it encourages further communication. Although the decision is for the client to make, this response is not supportive and abandons the client. It is inappropriate for the nurse to give advice.

While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response? Multiple choice question "I don't mind it." "You seem upset." "This is part of my job." "Nurses get used to this."

**You seem upset.** The nurse should identify clues to a client's anxiety and encourage verbalization of feelings. Saying it is part of the job focuses on the task rather than on the client's feelings. Saying "I don't mind it" or "Nurses get used to this" negate the client's feelings and present a negative connotation.

A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication will be prescribed because of its major role in wound healing? Multiple choice question Vitamin A (Aquasol A) Cyanocobalamin (Cobex) Phytonadione (Mephyton) Ascorbic acid (Ascorbicap)

**ascorbic acid** Vitamin C (ascorbic acid) plays a major role in wound healing. It is necessary for the maintenance and formation of collagen, the major protein of most connective tissues. Vitamin A is important for the healing process; however, vitamin C is the priority because it cements the ground substance of supportive tissue. Cyanocobalamin is a vitamin B12 preparation needed for red blood cell synthesis and a healthy nervous system. Phytonadione is vitamin K, which plays a major role in blood coagulation.

While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. This condition is known as: Multiple choice question Osteoarthritis Osteoporosis Muscle atrophy Contracture

**contracture** Immobilized clients are at high risk for the development of contractures. Contractures are characterized by permanent shortening of the muscle covering a joint. Osteoarthritis is a disease process of the weight-bearing joints due to wear and tear. Osteoporosis is a metabolic disease process in which the bones lose calcium. Muscle atrophy is a wasting and/or decrease in the strength and size of muscles due to a lack of physical activity or a neurological or musculoskeletal disorder.

A health care provider prescribes an antibiotic intravenous piggyback (IVPB) twice a day for a client with an infection. The health care provider prescribes peak and trough levels 48 and 72 hours after initiation of the therapy. The client asks the nurse why there is a need for so many blood tests. The nurse's best response is, "These tests will: Multiple choice question determine adequate dosage levels of the drug." detect if you are having an allergic reaction to the drug." permit blood culture specimens to be obtained when the drug is at its lowest level." allow comparison of your fever to when the blood level of the antibiotic is at its highest."

**determine adequate dosage levels of the drug."** Drug dosage and frequency are adjusted according to peak and trough levels to enhance efficacy by maintaining therapeutic levels. Peak and trough levels reveal nothing about allergic reactions. Blood cultures are obtained when the client spikes a temperature; they are not related to peak and trough levels of an antibiotic. A sustained decrease in fever is the desired outcome, not reduction just at peak serum levels of the medication.

To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what type of dietary plan does the nurse expect? Multiple choice question Low in fat High in iron High in fluids Low in residue

**high in fluids** A common side effect of vincristine is a paralytic ileus, which results in constipation. Preventative measures include high fiber foods and fluids that exceed minimum requirements. These will keep the stool bulky and soft, thereby promoting evacuation. Low fat, high in iron, and low in residue dietary plans will not provide the roughage and fluids needed to minimize the constipation associated with vincristine.

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. The nurse recognizes that it is important to inform the client that he or she: Multiple choice question Is acting irresponsibly. Is violating the hospital policy. Must obtain a new healthcare provider for future medical needs. Must accept full responsibility for possible undesirable outcomes.

**must accept full responsibility for possible undesirable outcomes** The client has the right to self-determination, which includes refusing medical treatment. However, if the client does so, he or she must accept full responsibility for any resulting illness and possible injury or undesirable outcomes. Health care professionals have a responsibility to inform the client and, if possible, have him or her sign an informed waiver or a leaving against medical advice document. Acting irresponsibly is a subjective assumption. The client may be violating the hospital policy; however, if the client is deemed competent, he or she has the right to refuse treatment. Leaving against medical advice does not mean that the current healthcare provider will refuse to provide care to the client in the future.