LVN NCLEX 4 pic
Reye The parents of a child diagnosed with leukemia have stated that they'll give aspirin to their child for pain relief. Which statement by the nurse about aspirin would be most accurate? "It's contraindicated because it decreases platelet production." "It's contraindicated because it promotes bleeding tendencies." "It's not a strong enough analgesic." "It decreases the effects of methotrexate."
"It's contraindicated because it promotes bleeding tendencies." Explanation: Aspirin would be contraindicated be cause it promotes bleeding. Aspirin use has also been associated with Reye syndrome in children. For home use, acetaminophen is recommended for mild to moderate pain. Aspirin enhances the effects of methotrexate and has no effect on platelet production. Non opioid analgesia has been effective for mild to moderate pain in children with leukemia.
A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which homecare instruction should the nurse reinforce? "Make sure to get sunlight exposure daily." "Do not limit your activity between flare-ups." "Monitor your temperature for signs of infection." "Stop the steroid when your symptoms subside."
"Monitor your temperature for signs of infection." Explanation: Fever can signal an exacerbation of SLE and should be reported to the primary care provider. Sunlight and other sources of ultraviolet light can precipitate severe skin reactions and exacerbate the disease. Fatigue can cause a flare-up of SLE; the client should be encouraged to pace activities and plan rest periods. Corticosteroids must be gradually tapered because they can suppress adrenal gland function. Abruptly stopping corticosteroids can cause adrenal insufficiency, a potentially life-threatening situation.
A pregnant client comes to the clinic after missing several scheduled prenatal appointments. During the initial assessment, the client states, "I haven't been coming to some of my appointments because I go to a homeopathic specialist who takes great care of me." Which response by the nurse is best? "That's fine; you can see whichever health care professional you prefer." "You should mention the homeopathic specialist to your health care provider so he can help devise the best care plan for you." "You really need to come to each scheduled appointment here; missing appointments could be harmful." "Don't you want to continue to be cared for by your clinic health care provider?"
"You should mention the homeopathic specialist to your health care provider so he can help devise the best care plan for you."
A client's blood glucose level is 45 mg/dL. Which signs and symptoms should the nurse be alert for in this client? Decreased level of consciousness (LOC), anxiety, confusion, headache, and cool, moist skin Kussmaul respirations, dry skin, hypotension, and bradycardia Polyuria, polydipsia, hypotension, and hypernatremia Polyuria, polydipsia, polyphagia, and weight loss
Decreased level of consciousness (LOC), anxiety, confusion, headache, and cool, moist skin Explanation: Signs and symptoms of hypoglycemia # glucose level below 70 mg/dL include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, decreased LOC, and seizures. Kussmaul respirations, dry skin, hypotension, and bradycardia are signs and symptoms of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms of diabetes mellitus.
hemophilia A client with hemophilia is admitted to the medical-surgical unit. When providing care for this client, which factor is most important? Performing effective client teaching Delegating tasks effectively Ensuring client safety Maintaining continuity of care
Delegating tasks effectively
A client tells the nurse that she doesn't want to sign the hepatitis B vaccination consent form because she heard that, "vaccinations can cause autism." What's the most appropriate nursing interaction? Telling the client that such information hasn't been substantiated Supporting the client's decision because all vaccines have associated risks Encouraging the client to discuss the issue with the pediatrician at the infant's 2-week check-up Discussing the purpose of the vaccine and providing the client with written information
Discussing the purpose of the vaccine and providing the client with written information Explanation: There are many misconceptions about vaccine safety and complications. The nurse should provide information about why the vaccine is given, the benefits and risks, and common adverse reactions. Health care providers are required to use a handout that provides all federally required information about the vaccine because informed consent requires that there has been a full disclosure of available information. If the client still refuses after full disclosure, the nurse needs to support and document the decision. It's a nursing responsibility to complete client teaching first and then refer the client with additional questions and concerns to the physician.
A nurse on the psychiatric unit realizes that she typically fails to administer medications according to schedule. What's the best way for the nurse to improve her medication administration practice? Change medication administration times to meet the client care schedules. Evaluate her current practice and devise an improvement plan. Review the medication administration principles she learned in nursing school. Ask a nurse colleague to keep track of the amount of time it takes her to administer the medications.
Evaluate her current practice and devise an improvement plan.
While a nurse on the orthopedic floor is administering medications to her group of clients, the physical therapy department calls to inform her that two of her clients are late for their scheduled session. What should the nurse do? Continue administering medications and have the clients attend physical therapy when she finishes. First, administer scheduled medications to the clients who require physical therapy, and then have them attend therapy. Immediately stop administering medications and arrange for the clients to be taken to therapy. Cancel the client's therapy session for the day and continue administering medication.
First, administer scheduled medications to the clients who require physical therapy, and then have them attend therapy. Explanation: Clients recovering on the orthopedic unit commonly require physical therapy as part of their treatment plan. The nurse caring for such clients should recognize the importance of therapy and administer their medications first and then have them attend therapy. The nurse shouldn't compromise the physical therapy department schedule by administering medications to all of her other clients before sending these clients to therapy. The nurse shouldn't delay medication administration for these clients by sending them to therapy without first receiving their medications. The nurse shouldn't cancel the physical therapy session, which is a prescribed part of their treatment plan. Canceling the session might delay recovery.
A client is scheduled for an appendectomy. The nurse is reinforcing education to the client about incision splinting and leg exercises. When is the best time for the nurse to provide this education? upon the client's admission to the recovery room when the client returns from the recovery room during the intraoperative period before the surgical procedure
before the surgical procedure Explanation: Education is most effective when provided before any surgery. Upon admission to the recovery room, the client is usually very drowsy, making this an ineffective time for teaching. When the client returns from the recovery room, the client might still be drowsy. During the intraoperative period, anesthesia alters the client's mental status, rendering education ineffective.
hemophilia A child with hemophilia is hospitalized with bleeding into the knee. Which action should the nurse take first? prepare to administer a whole blood transfusion prepare to administer a plasma transfusion perform active range-of-motion (ROM) exercise on the affected part elevate the affected part
elevate the affected part Explanation: Bleeding into the joints is the most common type of bleeding episode in the more severe hemophilia forms. Elevating the affected part and applying pressure and cold are indicated. The nurse should anticipate transfusing the missing clotting factor—not whole blood or plasma, which won't stop the bleeding promptly and may pose a risk of fluid overload. Active ROM exercises are contraindicated because they may cause more bleeding, injury, and pain.
A nurse walks into a client's room and sees the trash smoldering. What should the nurse do first? remove the client from the room activate the fire alarm extinguish the fire contain the fire by closing the door
remove the client from the room explanation Fire # RACE remove; alarm; contain; extinguish
The employer of a client on a psychiatric unit calls the nursing station inquiring about the client's progress. The nurse is unsure whether the client has given consent for information to be shared with callers on the phone. Which response by the nurse would be best? "I'm not permitted to discuss the client's progress." "I'll give you the name and telephone number of the client's health care provider." "I'll have the client call you." "I can't confirm whether your employee is a client here."
"I can't confirm whether your employee is a client here." "I can't confirm whether your employee is a client here." Explanation: The nurse's release of information to the client's employer without the client's consent is a breach of confidentiality. The stigma associated with psychiatric illness may affect the client's employment; therefore, it is better to maintain confidentiality and refrain from disclosing any information about the client, including whether the employee is a client in the hospital.
The nurse-manager asks a newly hired LPN if the facility's rules of ethical conduct are understood. Which statement by the LPN indicates the need for further education? "I make sure that I do everything in my client's best interest." "I maintain client confidentiality at all times." "I'll support the Patient Care Partnership." "I don't discuss advance directives unless the client initiates the conversation."
"I don't discuss advance directives unless the client initiates the conversation." Explanation: The law mandates that health care agencies ask all clients if they have an advance directive. Therefore, the nurse must address this question regardless of whether the client initiates a conversation about it. Nurses need to always act in the best interest of their clients, maintain confidentiality, and support the Patient Care Partnership.
The daughter of a client diagnosed with Alzheimer's disease tells a nurse, "My mother is incompetent. You'll need to contact me or my sister if any decision must be made about my mother's care." Which response by the nurse is best? "Thank you for informing me of your wishes." "I'll tell the health care team that you and your sister will make all of your mother's health care decisions." "I'll need a physician's order that permits you and your sister to make care decisions." "I must respect your mother's rights until she is legally deemed incompetent."
"I must respect your mother's rights until she is legally deemed incompetent." Explanation: Even though the client has a psychiatric diagnosis, the nurse is still legally responsible to respect the client's wishes until she is legally deemed incompetent. Accepting the daughter's wishes and telling the health care team to abide by them violate the client's rights. The client's rights must be upheld regardless of the physician's order.
When reinforcing education with parents of an infant newly diagnosed with diabetes insipidus, which statement by the parent indicates an appropriate understanding of this condition? "When my infant stabilizes, I won't have to worry about giving hormone medication." "I don't have to measure the amount of fluid intake that I give my infant." "I realize that treatment for diabetes insipidus is lifelong." "My infant will outgrow this condition."
"I realize that treatment for diabetes insipidus is lifelong." Explanation: Diabetes insipidus requires lifelong treatment. The amount of fluid intake is important and must be measured with the infant's output to monitor the medication regimen. The infant won't outgrow this condition.
After receiving education about the treatment plan for acute lymphocytic leukemia (ALL) for a preschooler, the caregiver asks the nurse, "I saw a movie where a baby born to the parents was able to be a donor for stem cell transplant for the sibling with leukemia. Is that something we could do?" What is the nurse's best response? "If this is something you are considering, I recommend you speak to the health care provider about a consult to a genetic counselor." "As is often the case when medical treatments are represented in movies, this is not something that is really done in practice." "The time it will take for you to have another baby coupled with the possibility that that child will not be a match makes this impractical." "I saw that movie too. I thought it was unfair for the younger sibling to have to undergo all those invasive medical procedures."
"If this is something you are considering, I recommend you speak to the health care provider about a consult to a genetic counselor." Explanation: The nurse recommends the caregivers speak with a genetic expert related to their question. "Savior siblings" are children conceived via in-vitro fertilization, and the embryos are chosen based on being a match as a donor for the existing child. A typical application for savior siblings is the use of cord blood for stem cell transplant. Therefore, this is a procedure done in medical practice (although it has ethical concerns), and using this process ensures the new child will be a match. The nurse does not respond by offering a personal opinion related to a movie plot. In the case of cord blood donation, the new sibling does not "undergo medical procedures."
A client requested a do-not-resuscitate (DNR) order upon admission to the hospital and later tells the nurse, "I want to have everything possible done to help me get better." Which response by the nurse would be most appropriate? "It's too late to change your mind now." "We'll have to ask your health care provider if the DNR can be changed." "You should talk with your family before making this decision." "It isn't a problem to rescind your DNR order.
"It isn't a problem to rescind your DNR order. Explanation: A client is allowed to rescind a DNR order at any time. The client can make a decision about a DNR order without input from the health care provider or family members. A nurse should not question a client's motives in rescinding the DNR order; that could make the client feel defensive and shut down communication with the nurse.
The nurse has received the shift report on a group of preschool-aged clients. In which order, from first to last, should the nurse assess the clients? All options must be used. Explanation: The nurse prioritizes the client who has experienced hematemesis. Although significant hemorrhage after tonsillectomy is rare, the nurse needs to ensure this client is stable and does not have evidence of hemodynamic instability. The client requiring analgesia should be assessed next so that pain can be promptly treated. For the two clients with scheduled medications due, the client requiring insulin takes priority as aspart insulin's timing in relation to meals needs to be more precise # ideally 10 minutes prior to starting the meal compared to a scheduled short-acting beta-agonist for asthma, which is often scheduled every 6 hours. The client awaiting discharge can be prioritized last. This ensures the more time-sensitive care for the other clients has been completed and the nurse is less likely to be interrupted during the discharge teaching.
1st a client who is 10 hours post-tonsillectomy who has just experienced hematemesis 2nd a client with a casted fractured femur whose caregivers are requesting analgesia 3th a client with type 1 diabetes who is due for insulin aspart prior to breakfast 4th a client with asthma who is due for a scheduled short-acting beta-agonist nebulizer 5th a client who has discharge orders written and whose caregivers are requesting instructions
The nurse on a medical surgical unit receives the end-of-shift report from the outgoing nurse. Which client should the nurse see first? diabetic client with fasting blood glucose of 138 mg/dL (7.66mmol/L) hemodialysis client with a creatinine level of 3.2 mg/dL (282.88 umol/L) 3-day postoperative client with a temperature of 102.5 degrees Fahrenheit (39.2 C) 1-day postoperative client with a temperature of 100 degrees Fahrenheit (37.8 C)
3-day postoperative client with a temperature of 102.5 degrees Fahrenheit (39.2 C) Explanation: third day postoperative client with fever needs to be seen first as this may be a sign of infection. The client with a blood sugar level of 138 is abnormal but not critical. A dialysis client with a 3.2 creatinine level is expected with kidney disease. A temperature of 100 degrees Fahrenheit 1 day postoperatively is reactionary pyrexia and is expected.
The nurse is working on an ethics committee that is reviewing client-nurse interactions. Which nursing action indicates negligence? A nurse forgot to remove the tourniquet after phlebotomy, resulting in tissue injury. A nurse failed to complete a fall risk assessment on a client until right before discharge. A nurse crushed medication ordered for oral administration and gave it through the PEG tube. A nurse administered a generic drug instead of a brand-name drug per the pharmacist's orders.
A nurse forgot to remove the tourniquet after phlebotomy, resulting in tissue injury. Explanation: Negligence is the unintentional failure of a nurse to perform or not perform an act or behave in a way a reasonable nurse would not. Additionally, for a nursing action to be considered negligent, there must be client injury. A reasonable nurse would have removed the tourniquet after obtaining blood, therefore, the unintentional act harmed the client and constitutes negligence. Although the nurse failed to complete a fall risk assessment within an appropriate time frame, there was no client injury; therefore, it is not considered a negligent action. Crushing medication and giving it is intentional and may be within the facility's policy and therefore not negligence. Administering a generic drug instead of a brand-name drug per the pharmacist's orders constitutes no error.
A nurse is assigned to care for four clients. Which client should a nurse assess first? A postoperative client who just returned from surgery and is vomiting A client with gastroenteritis and fever A client with recurrent diarrhea A client with a history of gastric bleeding
A postoperative client who just returned from surgery and is vomiting Explanation: Because of the decreased level of consciousness associated with recovery from surgery, vomiting after surgery may cause aspiration. Therefore, the nurse should see this client first. The clients with gastroenteritis or recurrent fever and diarrhea will need attention next. A history of gastric bleeding does not imply a current problem, so this client's assessment is less important than that of the other clients.
A nurse is reinforcing education with a client about three medications that the client will receive after discharge. While performing the discharge education, the nurse notices that the client suddenly becomes withdrawn and appears anxious. What action should the nurse take? Notify the primary health care provider, and request a change in the prescriptions. Acknowledge the client's behavior, and seek clarification. Request that the primary health care provider prescribe generic alternatives. Explore with the client whether the client can purchase the medications over an extended period.
Acknowledge the client's behavior, and seek clarification. Explanation: The nurse should clarify the client's behavior to determine the appropriate cause of the action. The nurse should not request to have the prescriptions changed or that generic alternatives be prescribed. Treatment should not be delayed while the nurse explores the possibility of purchasing medications over an extended period.
The nurse is caring for a preschooler brought to the emergency department with an asthma attack. In which order, from first to last, should the nurse perform the health care provider's prescriptions? All options must be used. Explanation: The nurse's priority is maintaining airway and breathing for the preschooler with an asthma attack. The nurse places the child sitting upright and administers oxygen first. The nurse then administers the short-acting beta-agonist (albuterol/salbutamol) to promote bronchodilation. Once the nebulizer treatment has been started, the nurse can then gain intravenous (IV) access. Once IV access is established, the corticosteroid should be administered first as this is the first-line treatment to reduce inflammation associated with asthma attacks. Once the corticosteroid is administered, the magnesium sulfate may be given to help further relax the smooth muscle of bronchioles and promote bronchodilation.
Administer oxygen to maintain an oxygen saturation level of 95%. Administer albuterol (salbutamol) 3 mg via nebulizer every 20 minutes. Establish peripheral intravenous access. Administer methylprednisolone 30 mg intravenously once. Administer magnesium sulfate 80 mg intravenously once.
A 2-year-old child recently diagnosed with hemophilia A is discharged home. What information should the nurse include in a teaching plan about home care?
Apply pressure and ice for bleeding while elevating and resting the extremity.
A nurse enters a postpartum client's room to collect data and observes the perineal pad is completely saturated with lochia rubra. Which action by the nurse is the priority? Vigorously massage the fundus. Immediately call the health care provider. Have the charge nurse review the finding. Ask the client when she last changed her perineal pad.
Ask the client when she last changed her perineal pad. Explanation: If the morning assessment is done relatively early, it's possible that the client hasn't yet been to the bathroom, in which case her perineal pad may have been in place all night. Secondly, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus isn't recommended for heavy bleeding or hemorrhage. It would be inappropriate at this time to call the health care provider. More information is needed to determine the status of the situation. If the nurse is uncertain, she should ask a more experienced nurse to check the client but only after a complete assessment of the client's status. Remediation: Postpartum hemorrhage management Perineal care, postpartum
The nurse noted on the progress note of a 17-year-old client scheduled for surgery that the surgeon has explained the procedure, including benefits and adverse effects. However, the consent was signed by the surgeon and not the client. What should the nurse do? Ask the parents to sign the consent. Ask the client to sign the consent. No consent is required because the client is still a minor. Ask the manager to sign the consent.
Ask the parents to sign the consent. Explanation: Age 17 is not a legal age of adulthood in the United States. The parents should sign the consent. The client is underage and should not be required to sign a consent except if the child is emancipated or in case of emergencies. The manager cannot sign the consent. If there is no legal guardian or parent, a court-appointed guardian signs the form. Add a Note
A client who underwent surgery 1 day ago is concerned about worsening incisional pain and isn't scheduled to receive pain medication for 2 hours. Which action by the nurse is most appropriate? Encourage diversional activities to divert the client's attention away from the pain. Assess the incision and then notify the charge nurse of the client's worsening pain. Assist the client with ambulation to reduce pressure on the incision. Administer another dose of pain medication and notify the physician.
Assess the incision and then notify the charge nurse of the client's worsening pain. Explanation: Although diversion is an acceptable approach to help control pain, because the client underwent surgery 1 day ago, a complication could be occurring at the surgical site. Therefore, the nurse should assess the incisional site and then notify the charge nurse. A client with incisional pain isn't likely to benefit from ambulation. The nurse can't give additional pain medications without a physician's order.
A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which action is most appropriate for the nurse to take? Clearing the client's airway Making the client comfortable Starting cardiopulmonary resuscitation Stopping the feeding and removing the NG tube
Clearing the client's airway Explanation: A living will states that no life-saving measures are to be used in terminal conditions. There is no indication that the client is terminally ill. Furthermore, a living will doesn't apply to nonterminal events such as choking on enteral feedings. The nurse should clear the client's airway. Making the client comfortable ignores the reversible, life-threatening event. Cardiopulmonary resuscitation isn't indicated, and removing the NG tube would exacerbate the situation
When prioritizing a client's plan of care based on Maslow's hierarchy of needs, the nurse's first priority would be: allowing the family to see a newly admitted client. referring the client to a support group. administering pain medication. placing wrist restraints on the client.
administering pain medication. In Maslow's hierarchy of needs, pain relief is on the first tier. Safety (as in wrist restraints) is on the second tier. Love and belonging (as in family or a support group) are on the third tier.
An emancipated adolescent is pregnant and plans to raise her child. She has no income or health insurance. Which recommendation should the nurse make to help the client with her health care expenses? Completing a Medicaid application Applying for Medicare Asking her parents for financial aid Providing her with the name of a lawyer to obtain child support from the baby's father
Completing a Medicaid application xplanation: The nurse can best help the client's situation by recommending that she complete an application for Medicaid. Medicaid is the largest source of funding for medical and health-related services for people with limited income. Medicare is a national health insurance program for people age 65 and older, some people younger than age 65 with disabilities, and people with end-stage renal disease who require dialysis or transplantation. Asking the client's parents for financial aid and providing the client with the name of a lawyer to seek child support aren't appropriate actions for the nurse to take.
A client in labor, who attended natural birth classes, is asking for something to relieve the pain. What is the most appropriate action for the nurse to take? Remind the client that medications for pain are not good for the baby. Contact the health care provider, supporting the client until an analgesic is prescribed. Put on the television to distract the client from the pain. Do nothing because the client will not remember that she requested pain medication.
Contact the health care provider, supporting the client until an analgesic is prescribed. Explanation: The nurse should act as a client advocate and contact the health care provider to ask for a prescription for pain medication. Reminding the client that pain medication may be harmful to the baby and using the television as a distraction are inappropriate. Every client has a right to pain relief; doing nothing violates that right.
A client is being discharged from the hospital after a total hip replacement. The physician has ordered home health services for the client. What's the most appropriate action for the nurse to take? Contact the home health agency and provide a report of the client's condition and needs. Instruct the client to call the home health agency when he arrives home. Notify the social worker of the discharge plans. Notify the pharmacy of the client's medications.
Contact the home health agency and provide a report of the client's condition and needs. Explanation: The nurse should provide a report to the home health agency to facilitate continuity of care. The nurse can provide the home health agency with information regarding the specific needs of the client. It isn't necessary for the client to contact the home health agency because hospital personnel should handle this task. Although it's important for the social worker and pharmacy to be included in discharge planning, the nurse's most important consideration is to ensure that the home health agency is aware of the client's specific needs.
A 3½-year-old Vietnamese child with a fever, decreased urine output, wheezing, and coughing is brought to the emergency department. On data collection, the nurse discovers red, round, weltlike lesions on the child's upper back and chest. The nurse would interpret these lesions to be caused by which of the following? Shingles Impetigo Allergic reaction Cultural practice
Cultural practice Explanation: Many Vietnamese perform coining, a cultural practice in which a coin is repeatedly rubbed lengthwise on the oiled skin to rid the body of a disease. Coining can produce weltlike lesions on the child's back or chest, and children subjected to the practice are often thought to have been abused. Interviewing the family and assessing its cultural background helps distinguish between abuse and cultural practice. Shingles, a form of herpes zoster, is a communicable disease usually affecting immuno compromised individuals and older adults. The disease produces small crusty pustules on the lower back and trunk. Impetigo presents as honey-colored, crusted lesions. The description of the lesions doesn't fit those produced by an allergic reaction.
Two nurses are working the night shift on a medical unit. The first nurse obtains vital signs on assigned clients. One hour later, the second nurse finds the first nurse asleep in the lounge. What should the second nurse do in this situation? Cover by gathering data from the first nurse's clients hourly. Nothing; the first nurse's clients did not call for assistance. Discuss the situation with the first nurse, including the safety implications of sleeping on the job. Ask the nurse on the day shift to report the situation to the nurse manager.
Discuss the situation with the first nurse, including the safety implications of sleeping on the job. Explanation: The second nurse is responsible for immediately discussing this behavior and its safety implications with the first nurse. The other options do not demonstrate behavior representative of advocating for safe and competent care.
A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder-retraining program? Establish a predetermined fluid intake pattern for the client. Encourage the client to increase the time between voiding. Restrict fluid intake to reduce the need to void. Evaluate present elimination patterns.
Evaluate present elimination patterns. Explanation: The guidelines for initiating bladder retraining in a client frustrated by urinary incontinence include evaluating the client's intake patterns, voiding patterns, and reasons for each unintentional voiding. Lowering the client's fluid intake would not reduce or prevent incontinence. The client should actually be encouraged to drink 1.5 qt to 2 qt (1.4 to 1.9 L) of water per day. A voiding schedule should be established after evaluation.
A voluntary client in a facility decides to leave the unit before treatment is complete. To detain the client, the nurse refuses to return the client's personal effects. This is an example of which of the following? False imprisonment Limit setting Slander Violation of confidentiality
False imprisonment Explanation: Confining a voluntary client against his or her will may be considered false imprisonment. Slander is oral defamation of character. The nurse hasn't given out any information about the client, so confidentiality hasn't been violated.
The nurse is administering medications to a client when the client indicates that the name of the medication does not sound familiar. What should the nurse do? Encourage the client to take the medication because the doctor ordered it. Crush the medication and give it without the client knowing. Inform the client that he or she probably knows the medication by a different name. Hold the medication and verify that the client should receive the medication.
Hold the medication and verify that the client should receive the medication. Explanation: The nurse should listen to the client's concern and verify that the client can indeed receive the medication. The nurse should not encourage the client to take the medication without verifying the client's concern. Crushing and disguising the medication is equal to lying and tricking the client. This is not acceptable. Informing the client that he or she probably knows the medication by a different name does not address the concern of the client. The nurse should verify and then notify the client if the medication is known by a different name.
A nurse is caring for a client who sustained a gunshot wound to the leg during a jewelry store robbery. The client is in police custody and receiving treatment in the emergency department. A member of the media asks the nurse about the client's condition. How should the nurse respond? Ask security to escort the media to the client care area to interview the client. Notify the nursing supervisor so she can obtain a formal statement from the physician about the client's condition for the media. Contact the physician to receive an update on the client's condition and then inform the media. Meet with the media in the lobby and inform them of the client's condition.
Notify the nursing supervisor so she can obtain a formal statement from the physician about the client's condition for the media. Explanation: The nurse should contact the nursing supervisor, who can contact the physician for a formal statement and then inform the media. It is a violation of the client's privacy to escort media to the client care area. The staff nurse shouldn't speak to the media herself.
When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should take which of the following actions? Prepare for epidural anesthesia Prepare for catheterization Start IV infusion of 0.9% normal saline Notify the obstetrician
Notify the obstetrician Explanation: The symptoms indicate transitional phase. The nurse should notify the obstetrician for delivery of the baby. Catheterization is not indicated. There is no indication in the question for fluid replacement. It is too late at 9cm dilatation to administer epidural anesthesia.
A client is prescribed digoxin 0.125 mg by mouth stat. The pharmacy dispenses digoxin 0.25 mg. The nurse promptly administers the medication and then realizes the incorrect dose has been administered. How should the nurse proceed? Obtain vital signs, and immediately notify the primary health care provider and charge nurse of the error. Obtain a copy of the primary health care provider's prescription, and inform the pharmacy of the dispensing error. Immediately inform the pharmacist of his dispensing error, and document the incident. Inform the pharmacist and the nursing supervisor of the error, and document the incident.
Obtain vital signs, and immediately notify the primary health care provider and charge nurse of the error. Explanation: The nurse should obtain the client's vital signs and immediately notify the primary health care provider and charge nurse of the error. An incident report should then be completed to document the error. The nurse administering the drug is legally responsible for ensuring that the nurse calculates and administers the correct dose. The pharmacist should be notified of the incident after the incident report is completed.
While preparing a client for a postpartum tubal ligation, a nurse overhears the client tell her husband that they can always have reversal surgery if they decide they want more children in the future. Which intervention by the nurse would be best? Inform the couple that successful reversal is unlikely. Report the conversation to the health care provider. Complete the perioperative checklist. Review the client's understanding of the procedure in private.
Review the client's understanding of the procedure in private. Explanation: Informed consent requires that the client has full disclosure and understanding of information before the surgical procedure. The nurse needs to ensure that the client and her husband understand that surgical sterilization, tubal ligation, is considered a permanent end to fertility because reversal surgery is not always successful. The nurse should review the client's understanding of the procedure with the client in private to maintain her confidentiality. After the conversation, the nurse should evaluate whether the supervising nurse and health care provider should be notified based on the client's level of understanding. It is inappropriate to assume that a signed consent form indicates informed consent.
A client with type 2 diabetes comes to the clinic with a diabetic foot ulcer on his left heel that hasn't responded to treatment. Which action should a nurse take after assessing the ulcer? Clean the ulcer with povidone-iodine solution, and wrap it with clean gauze. Tell the patient that this is to be expected. Suggest a consult with a wound care specialist. Complete the client's vital signs, document any increase in temperature, and set up an appointment for the next week.
Suggest a consult with a wound care specialist. Explanation: Because the wound is not responding to the current treatment plan, a consult with the wound care specialist should be suggested. Cleaning and redressing the wound and telling the patient that the lack of a response to treatment is expected don't address the problem with healing. Completing vitals signs and documenting any changes in body temperature are appropriate; however, a client needs more care before he is sent home with an appointment to return in 1 week. Remediation: Diabetes mellitus (type 2), long-term care
A registered nurse (RN) is supervising a licensed practical nurse (LPN). The LPN is caring for a client diagnosed with a terminal illness. Which statement by the LPN should the RN correct? "Some clients write a living will indicating their end-of-life preferences." "The law says you have to write a new living will each time you go to the hospital." "You could designate another person to make end-of-life decisions when you can't make them yourself." "Some people choose to tell their health care provider they don't want to have cardiopulmonary resuscitation."
The law says you have to write a new living will each time you go to the hospital." since ONE living will is sufficient for all hospitalizations unless the client wishes to make changes. The "No Code" or "Do Not Resuscitate" status is discussed with the health care provider, who then enters this in the client's chart. A living will explains a person's end-of-life preferences. A durable power of attorney for health care can be written to designate who will make health care decisions for the client in the event the client can't make decisions for himself.
The labor and delivery unit has 10 clients in varying stages of labor. Staffing for the upcoming shift consists of four registered nurses (RNs) and one licensed practical nurse (LPN). Which client care assignment is best? Each nurse should care for two clients. The stable clients in the early stages of labor should be assigned to the LPN. The LPN should be allowed to go home because the unit is overstaffed. Each RN should care for one client and assist the LPN with the care of the remaining six clients.
The stable clients in the early stages of labor should be assigned to the LPN.
A client is admitted to an inpatient psychiatric unit. After data collection and admission procedures are completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in a specific corner of the dayroom." The nurse is communicating these planned nursing interventions for which main rationale? To establish a trusting relationship To provide a structured environment for the client To instill hope in the client To provide time for completing nursing responsibilities
To establish a trusting relationship Explanation: Availability, reliability, and consistency are critical factors in establishing trust with a client. Being specific about the time and place of meetings helps establish trust, which is initially the main objective. Although important, structuring the environment and instilling hope aren't the primary tasks at this time. Arranging a regular meeting with the client allows the nurse to plan the workload but isn't the major reason for such scheduling.
A nurse has been providing care to the same group of clients for 4 consecutive days. On day 5, she sees that her assignment has changed, and she is concerned about the continuity of care for these clients. What should the nurse do? Change the assignment. Voice her concerns about continuity of care with the charge nurse. Provide care for her newly assigned clients. Visit her former clients on her scheduled breaks.
Voice her concerns about continuity of care with the charge nurse. Explanation: The nurse should voice her concerns about the need for continuity of care with the charge nurse. The nurse shouldn't independently change her assignment without the charge nurse's permission to do so. Just providing care for the newly assigned clients and visiting the former clients on breaks don't address the need for continuity of care.
The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated? Sterile objects are held above the waist of the technician. Sterile packages are opened with the first edge away from the technician. The outer inch of the sterile towel hangs over the side of the table. Wetness in the sterile cloth on top of the nonsterile table has been noted.
Wetness in the sterile cloth on top of the nonsterile table has been noted. Explanation: Moisture outside the sterile package contaminates the sterile field because fluid can be wicked into the sterile field. Bacteria tend to settle, so there is less contamination above waist level and away from the technician. The outer inch of the drape is considered contaminated but does not indicate that the sterile field itself has been contaminated
A nurse working in the triage area of an emergency department sees that several pediatric clients arrive simultaneously. Which child is treated first? a crying 4-year-old child with a laceration on his or her scalp a 3-year-old child with a barking cough and flushed appearance a 3-year-old child with Down syndrome who's pale and asleep in his or her mother's arms a 2-month-old infant with stridorous breath sounds, sitting up in his or her mother's arms and drooling
a 2-month-old infant with stridorous breath sounds, sitting up in his or her mother's arms and drooling Explanation: The 2-month-old infant with the airway emergency should be treated first because of the risk of epiglottitis. The 3-year-old with the barking cough and fever should be suspected of having croup and should be seen promptly, as should the child with the laceration. The nurse would need to gather more information about the child with Down syndrome to determine the priority of care.
The home health nurse is reviewing clients for hospice care. Which client would qualify for hospice care? a client with late-stage acquired immunodeficiency syndrome (AIDS) a client with left-sided paralysis resulting from a stroke a client who's undergoing treatment for heroin addiction a client who had a myocardial infarction 2 weeks previously
a client with late-stage acquired immunodeficiency syndrome (AIDS) Explanation: Hospices provide supportive, palliative care to terminally ill clients, such as those with late-stage AIDS, as well as their families. Hospice services wouldn't be appropriate for a client with left-sided paralysis resulting from a stroke, a client who's undergoing treatment for heroin addiction, or one who recently had a myocardial infarction because these health problems aren't necessarily terminal.
A licensed practical nurse (LPN) receives a report on several assigned clients at the beginning of the evening shift. The nurse would plan to collect data on which client first? a client scheduled for a cardiac catheterization in the morning who is visiting with family a client with a central line infusion at 60 mL/hour with 400 mL remaining in the IV bag a client with a chest tube inserted for a pneumothorax who is resting comfortably an older adult client with bacterial pneumonia experiencing periods of confusion
an older adult client with bacterial pneumonia experiencing periods of confusion Explanation: The older adult client's diagnosis of pneumonia and periods of confusion puts the client at risk for decreased oxygenation and injury. Therefore, the nurse should evaluate this client first. The other clients are more stable and can be seen once the nurse has collected data on the client with
A client with hemophilia has a very swollen knee after falling from bicycleriding. Which of the following is the first nursing action? a)initiate an IV site to begin administration of cryoprecipitate b) type and cross-match for possible transfusion c) monitor the client's vital signs for the first 5 minutes d) apply ice pack and compression dressings to the knee
apply ice pack and compression dressings to the knee EXPLANATION rest, ice, compression, and elevation (RICE)are the immediate treatments to reduce the swelling and bleeding into the joint. These are the priority actions for bleeding into the joint of a client with hemophilia
A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation shown, which laboratory result is the priority for the nurse to report to the health care provider? rheumatoid factor negative blood culture positive for Satphyococcus aureus alkaline phosphatase 60 unit/L ESR erythrocyte sedimentation rate 10mm/hr
blood culture Explanation: Osteomyelitis is a bacterial infection of the bone and soft tissue that occurs by extension of soft tissue infection, direct bone contamination following surgery, or spreading from other infection sites in the body. A positive blood culture should be reported immediately to the health care provider so that specific antibiotic therapy can begin or be adjusted based on the positive culture. A negative rheumatoid factor would be expected in a possible diagnosis of osteomyelitis. An alkaline phosphatase level of 60 IU/L is within the normal range, and an ESR of 10 mm/hour is also within the normal range.
A licensed practical nurse (LPN) is participating as a part of a team of staff members presenting a program about legal issues associated with nursing. As part of the program, the LPN will be giving examples of battery. Which examples would the LPN most likely include? SATA giving an injection after a client has stated refusal pushing a client onto a bedside commode forcibly removing a client's clothing writing in the medical record that a client is racist not allowing a client to leave against medical advice
giving an injection after a client has stated refusal pushing a client onto a bedside commode forcibly removing a client's clothing Explanation: Battery refers to an assault that is carried out and typically includes some willfulness, force, anger or negligent touching of another person's body. Examples include giving an injection even after a client has refused it, pushing the client into a chair, or forcibly removing a client's clothing. Writing in the medical record that a client is racist is an example of libel. Not allowing a client to leave against medical advice is an example of false imprisonment.
A nurse is carrying out the plan of care developed for a client diagnosed with dissociative identity disorder (DID). Which intervention would be the priority for this client? giving antipsychotic medications as prescribed maintaining consistency when interacting with the client confronting the client about the use of alter personalities preventing client interaction with others when one of the alter personalities is in control
maintaining consistency when interacting with the client Explanation: Using consistency to establish trust and support is important when interacting with a client with DID. Many of these clients have had few healthy relationships. Medication hasn't proven effective in the treatment of DID. Confronting the client about the alter personalities would be ineffective because the client has little, if any, knowledge of the presence of these other personalities. Isolating the client wouldn't be therapeutic.
A nurse is working with the multidisciplinary team providing care to a pregnant client with hyperemesis gravidarum who will need close monitoring at home. The nurse as part of the team would expect to assist in beginning discharge planning at which time? on the day of discharge when the client expresses readiness to learn when the client's vomiting has stopped on admission to the facility
on the day of discharge xplanation: Discharge planning should begin when a client is first admitted to the hospital. Initially, discharge planning requires collecting information about the client's home environment, support systems, functional abilities, and finances. This information is used to determine what support services will be needed. Notifying support services on the day of discharge will not be sufficient to ensure meeting the client's needs in a timely fashion. Waiting until the day of discharge to begin planning is also likely to cause the client to become overwhelmed and anxious. Factors such as when the client stops vomiting or expressing a readiness to learn should not influence when the nurse begins discharge planning.
Reye A child with Reye syndrome is exhibiting signs of increased intracranial pressure (ICP). Which nursing intervention would be most appropriate for this child? position the child with the head elevated and the neck in a neutral position maintain the child in the prone position cluster together interventions that may be perceived as noxious position the child in the supine position, with head turned to the side
position the child with the head elevated and the neck in a neutral position Explanation: Positioning the child with Reye syndrome with the head elevated and the neck in neutral position helps decrease ICP. The prone and supine positions cause increased ICP. Interventions that may be perceived as noxious should be spaced over time because if clustered together they may have a cumulative effect in increasing ICP. Turning the head to the side may impede venous return from the head and increase ICP.
Which nursing intervention should the nurse give highest priority to when caring for an unconscious client? maintaining the patency of an indwelling urinary catheter positioning the client with the head of bed at a 15 to 30 degree angle inserting a nasogastric (NG) tube for gastric decompression administering stool softeners as needed to maintain bowel elimination
positioning the client with the head of bed at a 15 to 30 degree angle Explanation: Positioning the client with the head of the bed at a 15 to 30 degree helps to maintain a patent airway, promotes drainage of secretions, and helps to reduce intracranial pressure. An indwelling urinary catheter and NG tube can be inserted for this client's care but are not priority over airway patency. Stool softeners are administered to facilitate bowel elimination but are not a priority.
A nurse is reviewing the interdisciplinary plan of care for a client experiencing hallucinations. Which intervention would the nurse most likely identify as being included in the plan? confining the client to the room until the client feels better providing a competing stimulus that distracts from the hallucinations discouraging attempts to understand what precipitates the hallucinations supporting perceptual distortions until the client gives them up on own accord
providing a competing stimulus that distracts from the hallucinations Explanation: Providing a competing stimulus acknowledges the presence of the hallucinations and teaches the client ways to decrease their frequency. The other nursing actions support and maintain hallucination occurrence or deny its existence.
A client with dissociative disorder is hospitalized. The client has threatened to commit suicide. When gathering data from the client, which set of circumstances would the nurse identify as indicating the highest risk of suicide? suicide plan, handy means of carrying out plan, and history of previous attempt preoccupation with morbid thoughts and limited support system suicidal ideation, active suicide planning, and family history of suicide threats of suicide, recent job loss, and intact support system
suicide plan, handy means of carrying out plan, and history of previous attempt Explanation: A lethal plan with a handy means of carrying it out along with a previous attempt poses the highest risk and requires immediate intervention. Although all the remaining risk factors can lead to suicide, they are not considered as high a risk as a formulated, lethal plan and the means at hand. However, a client exhibiting any of these risk factors should be taken seriously and considered at risk for suicide.
A nurse working in the emergency department (ED) is caring for several clients. The nurse determines that obtaining informed consent for treatment would be unnecessary for which client? the client who is diagnosed with a mental illness the client who refuses to give informed consent the client who is bleeding profusely from a car crash the client who asks the nurse to give substituted consent
the client who is bleeding profusely from a car crash Explanation: The law does not require informed consent in an emergency situation such as the client who is bleeding profusely, when the client is unable to give consent and no next of kin is present. A mentally competent client may refuse or revoke consent at any time. The client may also refuse treatment. Even though a client who has been declared mentally incompetent cannot give informed consent, mental illness does not by itself indicate that the client is incompetent to give informed consent. Although the nurse may act as a client advocate, the nurse can never give substituted consent.
A nurse is repositioning a client in bed. What should the nurse do to maintain proper body mechanics? straighten the knees and back use a wide stance for support lift the client to the proper position stand several feet from the client
use a wide stance for support Explanation: When repositioning a client in bed, the nurse should stand with the feet apart (one foot in front of the other) to establish a wide base of support and good body alignment. To reduce the energy needed to move the client's weight against gravity, the nurse should slide, roll, push, or pull, rather than lift the client. The nurse should flex the knees and use arm and leg muscles instead of the back. To minimize stress, the nurse should stand as close to the client as possible. Remediation: Helping to Transfer Someone Safely
The parents of a 2-year-old scheduled for surgical repair of an inguinal hernia are fearful and their fears are affecting their child. A play therapist is consulted to help with the child's care. The nurse should explain to the parents that the play therapist will: allow the parents to discuss their fears and how they're affecting their child. explain that a support group is available for the parents. use puppets to gain insight into how the child feels about his hospitalization and fears. offer financial resources for the family to alleviate anxiety.
use puppets to gain insight into how the child feels about his hospitalization and fears. Explanation: The play therapist gains insight into how a child feels by enabling him to express his feelings through the use of such items as puppets, books, dolls, and drawings. The therapist may talk to the parents about how they're upsetting the child, but that isn't her main role. Social services are designed to help families with financial concerns. Support groups aren't available for parents whose children are undergoing minor surgical procedures such as hernia repair. Remediation: Relaxation and stress management techniques
