MED / SURG - HESI : PN

A client diagnosed with bacterial meningitis is admitted to the unit and is prescribed neuro checks every 2 hours. Which manifestation would the practical nurse monitor for that would provide the first indication of altered neurological function? A) Change in level of consciousness B) Increasing muscular weakness C) Changes in pupil size bilaterally D) Progressive nuchal rigidity

A) Change in level of consciousness Rationale: A decrease or change in the level of consciousness is usually the first indication of neurological deterioration

A client diagnosed with emphysema that is oxygen-dependent lives alone at home and manages self-care with no difficulty. Which finding should prompt the home health practical nurse to consult the registered nurse case manager? A) A pulse oximetry reading of 91% on oxygen at 2 L/m. B) A weight loss of 5 pounds since the last monthly home visit. C) The client reports feeling as tired as at the last visit by the nurse. D) Upon entering the home, the PN noticed dirty dishes and clothing scattered around the home.

B) A weight loss of 5 pounds since the last monthly home visit. Rationale: A weight loss of 5 pounds in 1 month is a concern. Clients with COPD need additional calorie intake because they are using up a lot from the energy they are using to breath. The practical nurse needs to consult with the registered nurse case manager for a nutrition consult.

Which actions demonstrate to the practical nurse that the client understands the correct procedure administration of a metered dose inhaler (MDI)? (Select all that apply.) A) Sit or stand. B) Shake the inhaler. C) Attach the canister of medication to the mouthpiece. D) Breathe in through the mouth, filling the lungs. E) Use a spacer attachment and place the mouthpiece in the mouth. F) Close the lips around the mouthpiece. G) After inhaling the medication, hold the breath 10 seconds.

B) Shake the inhaler. C) Attach the canister of medication to the mouthpiece. E) Use a spacer attachment and place the mouthpiece in the mouth. F) Close the lips around the mouthpiece. G) After inhaling the medication, hold the breath 10 seconds. Rationale: The correct sequence of MDI administration includes: 1) shaking the inhaler. 2) attaching the canister to the mouthpiece. 3) attaching the spacer. 4) the client should then let their breath out through the mouth to empty the lungs and place the mouthpiece in the mouth. 5) closing the lips and mouth around the mouthpiece. 6) inhaling medication and holding the breath for 10 seconds.

A client with cirrhosis is being discharged home, with family members to provide the majority of the client's care. Which instructions are important to reinforce with the family regarding this client's care? (Select all that apply.) A) Maintain a low-fiber diet. B) Use a safety razor to shave the client. C) Avoid soap when bathing the client. D) Use a soft toothbrush and gentle oral care. E) Apply moisturizing lotion and turn the client frequently.

C) Avoid soap when bathing the client. D) Use a soft toothbrush and gentle oral care. E) Apply moisturizing lotion and turn the client frequently. Rationale: *A client with cirrhosis often has dry itchy skin. Soap can dry and irritate the skin further. *To prevent skin breakdown, the skin should be kept moist and the client turned frequently. *With cirrhosis, the liver is not able to produce some clotting factors, so bleeding prevention is a priority. *The family should be instructed to use electric razors, not a safety razor, and to use a soft toothbrush when providing gentle oral care.

A client diagnosed with diabetes has a prescription of 5 units of regular insulin and 15 units of NPH insulin. In which order should the practical nurse prepare to administer the insulin? List in order the nursing actions to be performed. Arrange the sequence options in the correct order by assigning each option a number. A) Inject 15 units of air into NPH insulin vial. B) Inject 5 units of air into regular insulin vial. C) Withdraw 5 units of regular insulin from vial. D) Perform hand hygiene according to facility policy. E) Inspect insulin vials for type and expiration dates. F) Withdraw 15 units of NPH insulin from vial.

D - 1. Perform hand hygiene according to facility policy. E - 2. Inspect insulin vials for type and expiration dates. A - 3. Inject 15 units of air into NPH insulin vial. B - 4. Inject 5 units of air into regular insulin vial. C - 5. Withdraw 5 units of regular insulin from vial. F - 6. Withdraw 15 units of NPH insulin from vial. Rationale: 1) The first nursing action is to perform hand hygiene. 2) The next action is to inspect vials for type and expiration dates and then add 15 units of air to NPH insulin vial. 3) Next add 5 units of air into regular insulin vial, then withdraw 5 units of regular insulin from vial, and withdraw 15 units of NPH insulin from vial. *Note that it is important to fill the syringe with regular insulin (shorter acting insulin) first to prevent contamination of the NPH insulin (intermediate-acting insulin).

A client is admitted to the hospital for a Crohn's disease flare up and severe dehydration. Which findings should the practical nurse report to the registered nurse and/or health care provider immediately? a. A rigid hard abdomen and elevated white blood cell count b. An appearance of mouth sores and joint pain c. Refusal to eat any of the meal and complaints of nausea d. Increase frequency of diarrhea and abdominal cramping

a. A rigid hard abdomen and elevated white blood cell count Rationale: A hard, rigid abdomen and elevated white blood cell (WBC) count are indicative of peritonitis, which is a medical emergency and should be reported to the RN and health care provider immediately.

Which foods should the practical nurse encourage a client to eat to increase their potassium intake? (Select all that apply.) a. Green beans b. Spaghetti with sauce c. Iced tea d. Milk e. Flounder f. Sweet potatoes g. Cantaloupe

a. Green beans d. Milk e. Flounder f. Sweet potatoes g. Cantaloupe Rationale: Flounder, sweet potatoes, milk, green beans, and cantaloupe are all potassium-rich foods.

A client mentions using garlic daily as an herb to lower cholesterol and triglyceride levels. Which nursing action is a priority? A) Monitor the client for signs of bleeding. B) Instruct the client that garlic tends to cause hypertension. C) This may relieve fever in the same way that acetaminophen does. D) Remind the patient to use tooth brushing and mouthwash to prevent garlic odor.

A) Monitor the client for signs of bleeding. Rationale: Garlic inhibits platelet aggregation in the same way that aspirin works, and the client should be monitored for bleeding. Garlic can lower the blood pressure, not raise it. It does not relieve fever. While the client will likely want to avoid garlic odor, it is not a priority.

The nurse is teaching concerned family members of a client who experienced a cardiac arrest prior to admission in the technique of cardiopulmonary resuscitation. The nurse recognizes the family members are performing the technique correctly if they use which depth of manual chest compression on the manikin? a. 0.5 inch (1.27 cm) to 1 inch (2.54 cm) b. 1.5 inch (3.8 cm) to 2 inches (5 cm) c. 2 inches (5 cm) to 2.4 inches (6 cm) d. 2.5 inches (6.4 cm) to 3 inches (7.6 cm)

c. 2 inches (5 cm) to 2.4 inches (6 cm) Rationale: According to the American Heart Association 2015 guidelines, the depth of compressions on an adult during CPR should be at least 2 inches (5 cm) to 2.4 inches (6 cm).

The practical nurse receives shift report on their assigned clients. Based on the change of shift report which situation has the highest priority? a. An IV that is infusing at 125 mL/hour currently has 200 mL left in the bag. b. A client's telemetry interpretation is sinus bradycardia with isolated premature ventricular contractions (PVCs). c. The 12-hour urinary output of a postoperative client which is 720 mL with an intake of 840 mL. d. No output in a hemovac from the abdominal incision of a client who is post-op day 1.

d. No output in a hemovac from the abdominal incision of a client who is post-op day 1. Rationale: The PN should first evaluate the client who has no hemovac output from the abdominal surgical site to determine if the hemovac needs to be compressed, drainage tube kinked, or if the drain is displaced from the wound.

A client asks the practical nurse what type of food is the best to eat reduce their chances of getting colon cancer. Which type of foods should the PN suggest to the client? (Select all that apply.) A) Red meats B) Fruits and vegetables C) Dairy products D) Whole grains E) Chicken and turkey F) Protein shakes

B) Fruits and vegetables D) Whole grains Rationale: According to the American Cancer Society, "studies suggest that fiber in the diet, especially from whole grains, may lower colorectal cancer risk."

A client has a serum potassium level of 3 mEq/L. Which findings should the practical nurse report to the charge nurse? (Select all that apply.) A) Muscle cramps B) Diarrhea C) Altered blood glucose level D) Increased energy E) Abnormal heart rhythms F) Increased anxiety

A) Muscle cramps E) Abnormal heart rhythms Rationale: A normal potassium level ranges from 3.5 to 5.0 mEq/L (mmol/L). Signs and symptoms of low potassium include: *muscle cramps *dysrhythmias.

The nurse is assisting with data collection for an older adult who is visiting the health care provider today. Which signs and symptoms should the nurse report to the health care provider as possible signs associated with colon cancer? (Select all that apply.) A) Rectal bleeding B) Weight gain C) Abdominal distention D) Sensation that bowels are not evacuating completely E) A diet high in vegetables such as cauliflower, cabbage, and kale

A) Rectal bleeding C) Abdominal distention D) Sensation that bowels are not evacuating completely Rationale: *Some signs and symptoms associated with colon cancer include: > rectal bleeding > abdominal distention > sensation the bowels are not evacuating completely. *A diet high in cauliflower, cabbage, and kale is associated with a reduced, not increased, risk of colon cancer. *A client who has colon cancer is more likely to have a weight loss rather than weight gain.

A client is walking in the hallway and begins experiencing an acute angina attack. Which is the first action for the nurse to take? a. Administer a nitroglycerine tablet sublingually. b. Notify the local emergency medical services. (EMS). c. Assist the client to walk back to the client's room. d. Ask the client if this attack occurred at the same time as yesterday's.

a. Administer a nitroglycerine tablet sublingually. Rationale: The first action is to administer nitroglycerine sublingually, in order to dilate the coronary arteries so that more oxygenated blood can be provided to the myocardium. It is not necessary to notify EMS unless the angina pain is unrelieved by three nitroglycerine tablets. The client should rest immediately, not walk back to the room. It is not a priority to determine whether or not the attack occurred at the same time as yesterday's.

A client diagnosed with a skull hematoma and fractured left (L) clavicle following a six foot fall from a ladder is admitted to the unit. Which sign should the practical nurse (PN) report immediately? a. Spontaneously opens eyes. b. Obeys commands in movement and grip. c. Answers questions, but is confused. d. Has abnormal flexion or extension of (L) arm.

c. Answers questions, but is confused. Rationale: Confusion following a head injury is usually the first sign of increased intracranial pressure.

Which abnormal laboratory finding should the practical nurse (PN) identify that indicates that a client with diabetes needs further evaluation for diabetic nephropathy? a. Hypokalemia b. Microalbuminuria c. Elevated serum lipids d. Ketonuria

b. Microalbuminuria Rationale: Microalbuminuria is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation.

A client is diagnosed with acute myocardial infarction (MI). Which diagnostic laboratory value should the practical nurse (PN) anticipate to be the first to elevate to establish a diagnosis of an acute myocardial infarction (MI)? A) Elevated troponin B) Elevated creatine kinase-MB (CK-MB) level C) Prolonged prothrombin time (PT) D) Elevated serum blood urea nitrogen (BUN) and creatinine

A) Elevated troponin Rationale: Tissue damage in the myocardium causes the release of cardiac enzymes into the blood system. According to the American College of Cardiology (ACS) and the European Society of cardiology (ESC), an elevation of the troponin will occur within 2 to 3 hours of an MI and is used to establish the diagnosis. It takes the CK-MB level 6 to 9 hours or longer to elevate.

A client has had a permanent pacemaker implanted. Which aspect should the nurse include when reinforcing instructions for care upon discharge? A) Stand 4 feet away from radar detectors in use. B) Stay away from homes and restaurants that use microwaves. C) Immediately report a pulse rate higher than the pacemaker rate setting. D) Request hand wand screenings when going through airport screening stations.

A) Stand 4 feet away from radar detectors in use. Rationale: *The client should be educated to stay 4 to 5 feet away from electromagnetic sources, such as radar detectors. *It is not necessary to avoid microwaves. *The client should be taught the pacemaker rate settings, and it is important to report a pulse lower than the settings, as that would indicate the pacemaker is not functioning. *Clients should inform airport security of the presence of a pacemaker; handheld wand screening should NOT be used over the pacemaker site.

A hospitalized client is receiving continuous nasogastric tube feedings at 90 mL/hour via a small-bore tube and an enteral infusion pump. Upon entering the client's room, which action should the practical nurse (PN) take first? A) Auscultate the client's breath sounds for a one minute. B) Ensure the client's head of bed is raised at least 30 degrees. C) Check placement of the nasogastric tube. D) Verify the prescribed feeding is hung.

B) Ensure the client's head of bed is raised at least 30 degrees. Rationale: The 30 degrees is the minimum degree elevation of the head of the bed for a client receiving continuous tube feedings to prevent aspiration.

The nurse has reinforced discharge instructions for a client has been diagnosed with deep vein thrombosis (DVT) in the right calf. The nurse realizes the client understands instructions regarding anticoagulant therapy if the client makes which statement? A) "While I am taking the anticoagulant, I should use a safety razor." B) "It is expected that my gums will bleed when I take the anticoagulants." C) "If I have a fever, I will need to take acetaminophen instead of aspirin." D) "While I take warfarin, I will need to get partial thromboplastin times tested weekly."

C) "If I have a fever, I will need to take acetaminophen instead of aspirin." Rationale: A client discharged following a DVT will be taking anticoagulant therapy. The client will need to take acetaminophen rather than aspirin because acetaminophen will not increase the risk of bleeding. Aspirin will increase the risk of bleeding if taken with anticoagulants. The client should use an electric razor, not a safety razor while taking anticoagulants. The client should report gum bleeding while taking anticoagulants. While taking warfarin, the client's blood testing will be prothrombin times, not partial thromboplastin times.

The practical nurse (PN) is assigned a client diagnosed with a hemothorax who had a chest tube inserted 36 hours ago; upon entering the room, the PN observes the client resting comfortably in the semi-Fowler position; respirations appear even and unlabored; the water in the suction chamber is bubbling; and there is serous drainage noted in the collection chamber. What is the best initial action for the PN to take? A) Measure and document in the drainage in the chamber. B) Clamp the chest tube while assessing for air leaks. C) "Milk" the tube to remove any excessive blood clot buildup. D) Decrease the bubbling in the suction chamber.

D) Decrease the bubbling in the suction chamber. Rationale: Follow the ABC's (airway, breathing, and circulation) to determine that the airway and breathing are stable, and the next step is to evaluate the extent of the bleeding. It is not necessary to change the amount of bubbling in the suction chamber. (?????)

The practical nurse (PN) is reviewing high-risk factors for type 2 diabetes with a client? The nurse realizes this discussion has been effective if the client selects which characteristics are risk factors for the development of diabetes? (Select all that apply.) a. Age 40 years or older b. Female gender c. African American d. Obesity e. Hispanic f. Asthma

a. Age 40 years or older c. African American d. Obesity e. Hispanic Rationale: Risk factors for developing type 2 diabetes include being 40 years or older, African American, Hispanic, and obese.

A client demonstrated pupillary constriction when a pen light was shined in their eyes. Which nursing action should the practical nurse perform? a. Report the finding to the health care provider. b. Record the finding on the assessment notes. c. Assess blood pressure to rule out hypertension. d. Record that the client has poor vision.

b. Record the finding on the assessment notes. Rationale: Pupillary constriction to light is a normal finding and should be documented in the assessment notes.

A client diagnosed with duodenal ulcers is admitted to the hospital. The client was administered ranitidine hydrochloride 150 mg PO at bedtime. Which finding would indicate a therapeutic response of the medication? a. Gastric secretions pH level below 3. b. Hemoccult testing is positive on two different occasions. c. No difficulty falling asleep reported. d. No complaints of abdominal pain or heartburn verbalized.

d. No complaints of abdominal pain or heartburn verbalized. Rationale: Lack of abdominal pain within 4 hours after meals indicates decreased duodenal irritation, a positive outcome in the treatment of duodenal ulcer.

The practical nurse has been assigned a client with a history of chronic obstructive pulmonary disease (COPD) who has been admitted to the hospital with a medical diagnosis of pneumonia. Which intervention poses the greatest risk of respiratory depression for a client with a history of COPD? a. Vancomycin 500 mg administered intravenously every 6 to 8 hours. b. Chest physiotherapy and nebulizers performed every 4 to 6 hours. c. Administration of acetaminophen 600 mg every 4 hours as needed for fever. d. Oxygen administration via nasal cannula 4 L/m.

d. Oxygen administration via nasal cannula 4 L/m. Rationale: Clients with COPD drive to breathe is a hypoxic state. Their body becomes use to the high CO2 levels and too much oxygen could cause the client to decrease their respiratory drive to breath. Oxygen administration in clients with COPD needs to be carefully monitored.

A client diagnosed with congestive heart failure has developed increasing pedal edema and pulmonary edema. What dietary modification is most important for the practical nurse (PN) to reinforce with this client? a. Avoid high carbohydrate foods. b. Decrease intake of fat-soluble vitamins. c. Decrease caloric intake. d. Restrict salt and fluid intake.

d. Restrict salt and fluid intake. Rationale: Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and pulmonary edema.

A client residing in a memory care nursing facility with a diagnosis of diabetes approaches the nurse crying, saying "I just do not feel good." What action should the practical nurse take first? A) Clarify the meaning of what is feeling good. B) Reassure the client that they are safe and okay. C) Give the client a glass of orange juice. D) Obtain a fingerstick blood glucose test.

D) Obtain a fingerstick blood glucose test. Rationale: An early sign of hypoglycemia increases confusion and/or irritability, sometimes described as "feeling bad." Based on the history of diabetes, the PN should first obtain objective data of a fingerstick blood glucose level to provide information to guide further nursing actions.

A client diagnosed with a brain tumor is receiving radiation beam treatments to the right frontal area. The practical nurse (PN) should observe this client for which problem during the early post-therapy days? a. Hemiplegia b. Headache c. Hearing loss d. Dysphagia

b. Headache Rationale: Radiotherapy is a local treatment, and most side effects are site-specific, such as inflammation of surrounding brain tissue, swelling, headache, and fatigue.

The nurse should recognize which symptom will be given the highest priority for monitoring for a client with Grave's Disease? a. Hypotension b. Tachycardia c. Hypothermia d. Depression

b. Tachycardia Rationale: A client experiencing symptoms of Grave's disease, or hyperthyroidism should have monitoring for tachycardia as the highest priority of care. Hypotension, hypothermia, and depression are associated with hypothyroidism.

The nurse has reinforced teaching regarding postoperative care for a client who has had a prostatectomy. Which statements indicate the need for further instructions? (Select all that apply.) A) "If I feel the need to void while the catheter is still in, I should try to void around the catheter." B) "I should drink about 12 glasses of water a day, once the indwelling catheter is removed." C) "I should only have intercourse twice weekly once I return home after surgery." D) "I should report bright red blood and large clots in my urine to my surgeon." E) "I can expect to have urine that is lightly tinged with blood when I get home."

A) "If I feel the need to void while the catheter is still in, I should try to void around the catheter." C) "I should only have intercourse twice weekly once I return home after surgery." Rationale: *After prostatectomy, the client should not try to void around the catheter. *It is common to feel pressure inside the bladder while the irrigating catheter is still in the bladder. *The client should not have intercourse immediately after surgery. *The client should drink 12 to 14 glasses of fluid once the catheter is removed. *Urine that is lightly blood tinged is common; bright red blood in the urine should be reported to the surgeon.

The nurse has reinforced instructions to a client with diabetes mellitus on how to self-monitor for symptoms of diabetic ketoacidosis (DKA). The nurse realizes the instructions have been effective if the client can list which symptoms? (Select all that apply.) A) Fruity breath odor B) Rapid, weak pulse C) Cold, clammy skin D) Extreme thirst E) Urinary frequency F) Protruding eyeballs

A) Fruity breath odor B) Rapid, weak pulse D) Extreme thirst E) Urinary frequency Rationale: *Diabetic ketoacidosis is caused by a profound deficiency of insulin. *Some common characteristics include: > a sweet, fruity breath odor > a rapid weak pulse > extreme thirst > urinary frequency > sunken-appearing eyeballs

The practical nurse (PN) received report on their assignment of clients. In which order should the PN assess these clients? Arrange the sequence options in the correct order by assigning each option a number. A) The client who has chronic renal disease is scheduled for hemodialysis today and three times weekly. B) The client with aphasia and right hemiplegia who is scheduled for gastrostomy tube (GT) placement today. C) The client who has had GI bleeding but had a negative guaiac test for the last three stools. D) The client who is recovering from a left total knee replacement and who ambulates with a walker.

B - 1. The client with aphasia and right hemiplegia who is scheduled for gastrostomy tube (GT) placement today. A - 2. The client who has chronic renal disease is scheduled for hemodialysis today and three times weekly. C - 3. The client who has had GI bleeding but had a negative guaiac test for the last three stools. D - 4. The client who is recovering from a left total knee replacement and who ambulates with a walker. Rationale: The client with aphasia should be seen first because this client has safety risks related to limited mobility and communication and requires assessment before the GT is placed. The client with chronic renal disease should be seen next to evaluate the impact of fluid balance and potassium on cardiac function between dialysis treatments. The client with GI bleeding is stable and should be seen third to evaluate resolution of bleeding. The ambulatory client is progressing toward independence and is the least likely to need immediate attention.

In order to provide culturally competent care to a group of clients, what action must the practical nurse do first? A) Treat each client the same, regardless of race or religion. B) Ensure that all Native American clients have access to a shaman. C) Understand one's own world views in addition to the client's. D) Include the family in the plan of care for older adult clients.

C) Understand one's own world views in addition to the client's. Rationale: *The nurse should understand their own values and views to prevent those beliefs being imparted to others, in addition to understanding the client's cultural views when providing cultural competent care. *Treating every client the same or assuming that all clients share the same values does not exhibit cultural competence or sensitivity.

A client who has undergone closed-appendectomy is prescribed to begin ambulation the next day. The next day when the practical nurse (PN) goes to assist the client with ambulation, the client yells he/she are watching the television and the/she do not feel like getting out of bed. Which response should the PN provide? A) "Your health care provider has prescribed ambulation on the first postoperative day." B) "You must ambulate to avoid serious complications that are much more painful." C) "I know how you feel—you're angry about having to do this, but it is required." D) "I'll be back in 30 minutes to help you get out of bed and walk around the room."

D) "I'll be back in 30 minutes to help you get out of bed and walk around the room." Rationale: Returning within 30 minutes provides a "cooling off" period, is firm, direct, and nonthreatening, and avoids arguing with the client.

A client with a history of emphysema is hospitalized for an exacerbation of the disease. The nurse expects to see which aspect emphasized in the plan of care? A) Oxygen administered at 6 L/m via nasal cannula. B) Fluids to be restricted to less than 1500 mL/day. C) Supine or low Fowler's position while resting in bed. D) Information on smoking cessation classes and support.

D) Information on smoking cessation classes and support. Rationale: The client should have information provided on smoking cessation classes and support while quitting. Oxygen is given at a low flow rate to prevent respiratory depression due to suppression of the stimulus to breathe. Fluids are encouraged to 3000 mL unless contraindicated. The client should be positioned sitting upright and bending slightly forward to promote breathing.

The nurse is reinforcing instructions regarding risk factor reduction for a client with angina. The nurse should focus instructions to reduce the risk of cardiovascular disease by which risk factors? (Select all that apply.) a. Blood pressure b. Age c. Blood sugar d. Gender e. Stressful lifestyle f. Family history

a. Blood pressure c. Blood sugar e. Stressful lifestyle Rationale: The nurse should focus instructions on risk factors that can be modified are blood pressure, blood sugar, and stressful lifestyle. The client cannot change age, gender, or family history.

A client is prescribed codeine USP 60 mg every 4 hours. The available medication is codeine USP 30 mg/tablet. How many tablets should the practical nurse administer? Fill in the blank. ________tablet(s)

2 tablets Rationale: Desired dose/available dose × mg/dose of available drug = mg to administer(60 mg/30 mg) × 1 tablet = 2 tabletsRatio and proportion:30 mg : 1 tab::60 mg : x tabs; 30 mg/1 tab = 60 mg/x tabs = 2 tablets

The nurse has been caring for a client on the medical unit who has a large abscess on his upper arm. The client develops septic shock and the rapid response team has arrived. Which priority action should the nurse do to assist the client while the rapid response team is preparing to transfer the client to intensive care? A) Monitor the client's vital signs every 15 minutes. B) Restrict intravenous fluid flow rate to less than 50 mL/hr. C) Locate the temporary pacemaker unit and bring it to the bedside. D) Assist the team in preparing vasodilating medications to add to the intravenous fluids.

A) Monitor the client's vital signs every 15 minutes. Rationale: *The nurse should monitor the client's vital signs every 5 to 15 minutes when the client is experiencing shock. *The intravenous fluid flow rate is very rapid, not restricted, with septic shock. *There is no data in the question suggesting a pacemaker is necessary; in shock, the heart rate is usually increased. *The team will most likely administer vasopressive, not vasodilating medications, because the client's blood pressure is likely very low.

A client diagnosed with rheumatoid arthritis is prescribed splints for night time use. Which statement by the client demonstrates to the practical nurse (PN) an accurate understanding of the use of the splints? A) Prevention of deformities B) Avoidance of joint trauma C) Relief of joint inflammation D) Improvement in joint strength

A) Prevention of deformities Rationale: Splints may be used at night by clients with rheumatoid arthritis to prevent deformities caused by muscle spasms and contractures.

A client has undergone craniotomy to remove a brain tumor. The client spent several days in the intensive care unit, and is now on the post-surgical unit. The nurse has urgently contact the surgeon to report signs of increasing intracranial pressure (ICP). Which was the most likely EARLY sign that the client was experiencing increased ICP? A) The client's blood pressure dropped from 128/70 to 124/68, preoperative BP 122/72 B) The client became more confused than he was upon transfer to the post-surgical unit. C) The client had a large amount of sanguineous drainage noted on the gauze dressings. D) The client's pulse rate had increased from 70 to 82 beats/min.

B) The client became more confused than he was upon transfer to the post-surgical unit. Rationale: *A change in the level of consciousness is most likely the earliest symptom of increased ICP. *Vital sign changes can also occur, with a widening pulse pressure and bradycardia. Neither of these are indicated by data in the options. *Sanguineous drainage does not indicate increased ICP.

The practical nurse (PN) is reviewing the health histories of assigned clients. Which factors have a potential for development of throat cancer? (Select all that apply.) a. Tobacco use b. Excessive intake of alcohol c. Intake of hot and spicy foods d. Human papillomavirus (HPV) e. Lack of exercise f. Lack of dietary fiber

a. Tobacco use b. Excessive intake of alcohol d. Human papillomavirus (HPV) Rationale: The most common risk factors for throat cancer are tobacco use, alcohol abuse, human papillomavirus (HPV), a diet lacking in fruits and vegetable, and gastroesophageal reflux disease (GERD). Foods seasoned with herbs and spices have shown to have some health benefits in decreasing the risk of developing cancer.

Which educational materials should the practical nurse select for reinforcement of teaching for secondary prevention? (Select all that apply.) a. Video that teaches client to do breast self-examinations. b. Pamphlets describing how to do testicular self-examinations. c. Chart that emphasizes childhood immunization schedule. d. Chart that emphasizes childhood immunization schedule. e. Postcard reminders for clients to get papanicolaou (Pap) smears and mammograms.

a. Video that teaches client to do breast self-examinations. b. Pamphlets describing how to do testicular self-examinations. e. Postcard reminders for clients to get papanicolaou (Pap) smears and mammograms. Rationale: Secondary prevention deals with early diagnosis to treat disease in the beginning of its development. Breast self-examinations, testicular self-examinations, mammograms, and Pap smears are considered secondary prevention methods.

A client is diagnosed with the hepatitis B virus (HBV) infection. The practical nurse (PN) who has been vaccinated with the hepatitis B series is assigned the client. What precautions should the PN implement when providing caring for this client? A) Restrict health care personnel who have not been vaccinated for hepatitis B from providing care to this client. B) Appropriate PPE should be worn if there is a possibility of bodily fluid exposure. C) No precautions are necessary when providing direct care to this client. D) Place a mask and gloves on the client when transporting them outside of their room.

B) Appropriate PPE should be worn if there is a possibility of bodily fluid exposure. Rationale: *Standard precautions should be implemented at all times regardless of a client's or health care personnel health status. *Hepatitis B is spread from contact of bodily fluids, mask and gloves are not necessary if there is no increased risk of exposure to bodily fluids. *Health care personnel who have not been vaccinated for hepatitis B can still provide care to the client; they need to ensure to follow standard precaution protocol.

A client sustained a burn injury greater than 25% of total body surface with majority of it lower extremities during a house fire. During the acute phase of care, which intervention is most important for the practical nurse to implement? a. Administer 0.5 mL of tetanus toxoid IM. b. Offer high-protein supplemental feedings. c. Perform active range-of-motion exercises. d. Application of compression stockings and ambulation.

a. Administer 0.5 mL of tetanus toxoid IM. Rationale: Prevention of infection from Clostridium tetani by administering tetanus toxoid has the highest priority for care of a client in the acute phase of burn care.

The practical nurse is reinforcing osteoporosis prevention education to a group of senior citizens. The nurse realizes teaching has been effective if the senior citizens select which life style choices will help decrease the risk of developing osteoporosis? (Select all that apply.) a. Alcohol in moderation and smoking cessation b. Avoidance of extreme temperatures and altitudes c. Regular weight-bearing exercises d. Implementation of a home safety plan to prevent falls e. Consumption of a diet rich in calcium and vitamin D

a. Alcohol in moderation and smoking cessation c. Regular weight-bearing exercises e. Consumption of a diet rich in calcium and vitamin D Rationale: Alcohol in moderation and smoking cessation, regular weight-bearing exercises at least 30 minutes a day, and consumption of a diet rich in calcium and vitamin D are life style choices that decrease the risk for developing osteoporosis.

A client diagnosed with chronic obstructive pulmonary disease complains to the practical nurse of extreme fatigue after coughing. Which self-care measures can help minimize the client's dyspnea? (Select all that apply.) a. Assume a sitting position with shoulders relaxed and knees flexed. b. Support forearms with a pillow and place both feet flat on the floor. c. Slightly drop the head, bend forward, and slowly exhale with pursed lips. d. Resume sitting up straight, using diaphragmatic breathing to inhale slowly and deeply. e. Repeat inhaling deeply and slowly with pursed lips while bending forward only once. f. Repeat exhaling and wait for the cough reflex to facilitate movement of the secretions. g. After coughing, inhale deeply from abdomen and cough three or four times while exhaling.

a. Assume a sitting position with shoulders relaxed and knees flexed. b. Support forearms with a pillow and place both feet flat on the floor. c. Slightly drop the head, bend forward, and slowly exhale with pursed lips. d. Resume sitting up straight, using diaphragmatic breathing to inhale slowly and deeply. Rationale: Effective coughing can help the client to cough secretions, therefore improving gas exchange and minimize fatigue. The client should assume the sitting position with shoulders relaxed and knees flexed. Their forearms should be supported with a pillow and both feet place flat on the floor. The client should slightly drop their head, bent forward, and slowly exhale through pursed lips using slow and deep diaphragmatic breathing to help facilitate effective coughing. The client should repeat the previous steps two or three times. The client should initiate the cough reflex, not wait for it. The client should also take a deep abdominal breath before initiating a cough.

A client who has had an AV (arteriovenous) fistula placement in the right forearm is transferred from the Post-anesthesia care unit (PACU) to the nursing unit. Which nursing measure is essential in promoting safe, effective care for the client? a. Avoid blood pressures or needlesticks in right arm. b. Place pressure dressing over AV insertion site. c. Do not elevate the right arm. d. Keep right arm immobilized in a splint.

a. Avoid blood pressures or needlesticks in right arm. Rationale: To prevent damage to the fistula from trauma or injury so that it can mature and be used as a future access site for hemodialysis, all blood pressures, blood draws, and IVs should be avoided to the affected (right) arm.

A 70-year-old client status post hip replacement is transferred to a rehabilitation facility. Which scale should the practical nurse (PN) identify as the best tool to predict the client's risk for developing skin breakdown? a. Braden Scale b. Morse Scale c. Aldrete Scale d. Wong-Baker Face Scale

a. Braden Scale Rationale: The Braden Scale is made up of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. A hospitalized adult with a score 16 or below or an older adult with a score of 18 or below is at an increased risk for skin breakdown.

A client with type 1 diabetes would like to participate in exercise classes offered by a community center. The nurse should reinforce which instruction? a. Carry a snack with you when you exercise. b. Try to time your activity to correlate with the insulin peak. c. Make sure to moisturize between your toes before you exercise. d. Be sure to wear well-fitting sandals whenever you run for exercise.

a. Carry a snack with you when you exercise. Rationale: The client should carry a snack when exercising to eat if the blood sugar drops with activity. The client should be aware not to exercise when the insulin is peaking because this could cause hypoglycemia. The client should not moisturize between the toes. This could lead to growth of bacteria and a difficult to treat foot infection. Sandals should not be worn for exercise; the client should wear well-fitting leather shoes to allow the shoes to stretch.

A client underwent a colon resection 48 hours ago. Which finding requires the most immediate intervention by the practical nurse (PN)? a. Fever of 102° F (38.9° C) and chills b. BP of 156/94 mm Hg and tachycardia c. Increase flatulence and diarrhea d. Dry mucous membranes and poor skin turgor

a. Fever of 102° F (38.9° C) and chills Rationale: A sudden increase in temperature is an indicator of peritonitis and chills, along with abdominal pain and tenderness. The PN should immediately notify the charge nurse, who should notify the health care provider.

A client diagnosed with prostate cancer is prescribed radioactive seed implantation (brachytherapy). What is the most important nursing action for the practical nurse (PN) to do? a. Follow radiation exposure precautions. b. Encourage regular meals. c. Collect all urine in sealed containers. d. Avoid touching the client.

a. Follow radiation exposure precautions. Rationale: Clients being treated for prostate cancer with brachytherapy (radioactive seeds implant) should be placed on radiation exposure precautions. The PN needs to follow the institution's protocols put in place regarding the amount of time and distance needed to prevent excessive exposure that would pose a hazard to others.

A client diagnosed with Guillain-Barré syndrome is hospitalized. Which finding is most important for the practical nurse to report to the primary health care provider? a. Ascending numbness from the feet to the knees. b. Decrease in cognitive status of the client. c. Blurred vision and sensation changes. d. Persistent unilateral headache.

b. Decrease in cognitive status of the client. Rationale: A decline in cognitive status in a client is indicative of symptoms of hypoxia that are the result of the respiratory muscles being affected and an indication that the client may require the assistance of mechanical ventilation.

The nurse is assisting with planning care for a client who is undergoing chemotherapy to treat breast cancer. Which elements should be included in the client's education on ways to prevent contracting pneumonia? (Select all that apply.) a. Maintain a healthy diet with protein, fruits, and vegetables. b. Ask your health care provider about receiving the flu and pneumonia vaccine. c. Try to find ways you are able to cut back on the number of cigarettes you smoke. d. Try to do your grocery shopping when your local grocery store is the least crowded. e. Stay awake most of the day time hours, so you can sleep uninterrupted during the night.

a. Maintain a healthy diet with protein, fruits, and vegetables. b. Ask your health care provider about receiving the flu and pneumonia vaccine. d. Try to do your grocery shopping when your local grocery store is the least crowded. Rationale: Adequate nutrition reduces the risk of contracting pneumonia. The client should receive all recommended flu and pneumonia vaccines. The client should go in public places when those places are the last crowded to avoid contact with large number of microorganisms. The client should stop smoking, not simply cut back. Adequate rest periods during the day can improve the client's ability to resist infection.

A client diagnosed with epilepsy is admitted to the unit. What intervention should the practical nurse (PN) implement if the client experiences a seizure? a. Observe the length and activity of the seizure. b. Insert an oral airway. c. Gently restrain the client to prevent harm. d. Call the code team.

a. Observe the length and activity of the seizure. Rationale: The PN should observe the client as they have their seizure. The length of time and movement by the client needs to be observed and then documented once the client is stable. The client should be placed on their side to help prevent aspiration.

An adult client is admitted to the emergency department with partial-thickness and full-thickness burns over 40% of the body surface area resulting from a car collision fire. After the health care provider and nurse have intubated the client, which intervention should the practical nurse (PN) do first? a. Remove all the client's clothing, shoes, and jewelry. b. Insert indwelling urinary foley. c. Initiate an intravenous catheter line. d. Obtain blood work and urine sample.

a. Remove all the client's clothing, shoes, and jewelry. Rationale: Interventions for moderate to severe burns of deep partial-thickness and full-thickness, once an airway and circulation is established, then the next thing is to remove all the victims clothing, shoes, and jewelry before the edema sets in and they become constricting, also it is possible to cause more severe burns by leaving clothing on.

A client is diagnosed with fluid volume deficit. Which findings would the practical nurse document consistent with fluid volume deficit? (Select all that apply.) a. Tachycardia b. Diaphoresis c. Cool skin d. Heart failure e. Decreased urine output f. Increased thirst

a. Tachycardia c. Cool skin e. Decreased urine output f. Increased thirst Rationale: Fluid volume deficit causes tachycardia because the body tries to compensate and pump blood efficiently. Cool skin is consistent with fluid volume deficit. Decreased urine output results from reduced fluid volume perfusing the kidneys. Thirst will be stimulated by the hypothalamus because of decreased fluid volume.

A client diagnosed with ulcerative colitis (UC) asks the practical nurse why a low-fiber diet has been prescribed. Which is the most appropriate response? a. To reduce the amount and frequency of stool b. To decrease fats and carbohydrates absorption c. To stop peristalsis and bowel movements d. To cleanse and evacuate stool from the large colon

a. To reduce the amount and frequency of stool Rationale: The purpose of a low-fiber diet is to reduce the amount and frequency of stooling to promote healing of the bowels by consuming foods that do not irritate the intestinal lining and prolong intestinal transit time to encourage optimal absorption of nutrients.

An older adult client diagnosed with dementia was admitted from a long-term facility to the hospital 2 days ago. The client's children express concern that their parent's confusion has gotten worse since being admitted. How should the practical nurse (PN) respond? a. "It is to be expected that older adult people will experience progressive confusion." b. "Confusion in an older person is expected with a relocation to new surroundings." c. "The dementia is progressing rapidly, but we will do everything we can to keep your parent safe." d. "The acute care staff is not as experienced as the long-term care staff at dealing with dementia."

b. "Confusion in an older person is expected with a relocation to new surroundings." Rationale: Relocation often results in confusion among older adult clients and is stressful for clients of all ages.

A practical nurse (PN) reinforced client teaching regarding the transmission of the HIV virus. Which statement by the client demonstrates an understanding of the reinforced teaching? a. "To be absolutely safe, I should wear two latex condoms during intercourse with an infected partner." b. "I may still contract HIV even though I am 62 years old." c. "Urinating immediately after having sexual relations will help reduce the risk of contracting HIV." d. "If I take AZT during my pregnancy, I will not give the virus to my unborn baby."

b. "I may still contract HIV even though I am 62 years old." Rationale: More than 10% of all AIDS cases in the United States are among those older than 50 years of age.

A client has had a gastrectomy to treat stomach cancer. The nurse has reinforced instructions on ways to prevent "dumping syndrome." Which client statement indicates the need for further instruction? a. "My meals need to be mostly protein." b. "I should walk around after each meal." c. "I should eat fewer carbohydrates." d. "I should eat smaller, more frequent meals."

b. "I should walk around after each meal." Rationale: The client should lie down after meals to avoid syncope. The client should eat more protein and less carbohydrates, and smaller more frequent meals.

A client had a bowel resection yesterday and has a nasogastric tube (NGT) attached to low intermittent suction. The client complains to the practical nurse of abdominal distention and nausea. What action should the PN take first? a. Irrigate the nasogastric tube with sterile normal saline. b. Assess the NGT drainage in the collection container. c. Advance the nasogastric tube 5 cm. d. Notify the health care provider.

b. Assess the NGT drainage in the collection container. Rationale: The immediate priority is to determine if the tube is functioning correctly, which the PN can do first by assessing the amount and characteristic of the drainage from the nasogastric tube. Based on the findings of the drainage will determine the PN next nursing intervention.

The receptionist at a very busy urgent care center, with a crowded waiting room, informs the nurse that a client who is pale and has been producing bloody sputum has arrived at the clinic. What should be the nurse's next action? a. Ask the client to wait in the waiting room until the health care provider is available. b. Escort the client to a private examination room within the urgent care center. c. At the waiting room window, ask the client how long these symptoms have been present. d. Remind the receptionist that clients can only be seen in the order of their arrival to the urgent care center.

b. Escort the client to a private examination room within the urgent care center. Rationale: Pallor and bloody sputum could be caused by a number of disorders. One of these disorders could be tuberculosis, and this client should not wait in the waiting room with others. It is a violation of client/patient privacy to ask the client questions in a crowded waiting room. Clients at an urgent care center are seen in the order of acuity.

The practical nurse (PN) is reinforcing colostomy care teaching to a client who is 3 days following placement of their colostomy. The client asked the PN why is it necessary to measure the colostomy's stoma each time when changing into a new appliance/wafer. What is the best response by the PN? a. Reassure the client that he will become accustomed to the stoma appearance in time. b. Inform the client that the stoma will become smaller when the initial swelling diminishes. c. Offer to contact a member of the local ostomy support group to help him with his concerns. d. Encourage the client to handle the stoma equipment to gain confidence with the procedure.

b. Inform the client that the stoma will become smaller when the initial swelling diminishes. Rationale: Postoperative swelling causes enlargement of the stoma. The PN needs to reinforce to the client that the stoma will become smaller when the swelling is diminished. This is necessary in order to prevent irritation to the surrounding skin from the colostomy's drainage (effluent). The purpose of the colostomy appliance is to provide a protective barrier surrounding the stomal skin, along with containing effluent from the colostomy.

A client is admitted from the emergency department with a diagnosis of left tibia fracture and the left leg has a splint in place. The client was medicated approximately 2 hours ago with a prescribed analgesic. The client is now complaining of excruciating leg pain and demanding "stronger pain medications." What initial action is most important for the practical nurse (PN) to take? a. Ask about any past history of drug abuse or addiction. b. Measure the pulse strength and capillary refill distal to the fracture. c. Apply an ice pack over the fracture area of the splint. d. Evaluate the fractured leg on two pillows.

b. Measure the pulse strength and capillary refill distal to the fracture. Rationale: The PN needs to measure the pulse strength and capillary refill distal to the fracture. Pain and diminished pulse volume are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast) or internal pressure after an injury resulting in inflammation and edema building up in the fascia space of the muscle which results in the pressure in this space building up and stopping the flow of blood to the tissues in the compartment. This is a medical emergency requiring a fasciotomy to relieve the pressure.

A client with a vaginal discharge and pruritus is diagnosed a yeast infection (Candidiasis) and is prescribed a 7-day course of an intravaginal tioconazole. What information should the practical nurse provide to the client about using this form of medication? a. Wait at least 30 minutes before douching after insertion of the medication. b. Remain recumbent for 5 to 15 minutes after insertion of the medication. c. Do not eat anything 1 hour before or 2 hours after medication administration. d. Sexual intercourse may be resumed after one dose of the medication.

b. Remain recumbent for 5 to 15 minutes after insertion of the medication. Rationale: The client should remain recumbent for 5 to 15 minutes after inserting the medication to facilitate absorption and to prevent loss of medication from the vagina.

A client with severe Parkinson disease diagnosed with anorexia, dysphagia, drooling, generalized weakness, and slurred speech is admitted to the unit. Which nursing action should the practical nurse implement first for this client? a. Provide the client with a word board. b. Set up a suction and Yankauer at client's bedside. c. Encourage passive and active range-of-motion exercises. d. Offer client nutritional milkshakes every 2 hours.

b. Set up a suction and Yankauer at client's bedside. Rationale: Dysphagia and drooling predispose this client to aspiration. A suction machine and Yankauer should be set up and near the client to be used to help prevent aspiration pneumonia. Aspiration is the primary concern in this situation.

The practical nurse is preparing a room for a client being admitted from the emergency department with a diagnosis of new onset of seizures. Which intervention should the nurse implement first? a. Ensure there is an IV pump and it is functioning properly. b. Set-up and check for functioning of a suction apparatus and oxygen delivery system at bedside. c. Placement of a padded tongue blade above the head of bed on wall. d. Presence of the call button and television remote at the head of bed.

b. Set-up and check for functioning of a suction apparatus and oxygen delivery system at bedside. Rationale: Maintaining the airway during a seizure is a priority for safety. The practical nurse needs to ensure there is a functioning suction apparatus to ensure airway clearance and an oxygen delivery system at bedside in the event of a seizure.

The nurse is caring for a 70-year-old female client who experienced a myocardial infarction. During review of the client's medical records, which signs and symptoms did the client most likely experience? (Select all that apply.) a. Hot dry skin b. Shortness of breath c. Fatigue d. Extreme hunger e. Sleep disturbances f. Melena

b. Shortness of breath c. Fatigue e. Sleep disturbances Rationale: A female client is more likely to experience dyspnea, fatigue, and sleep disturbances. Hot dry skin and extreme hunger are more likely associated with an elevated blood sugar. Melena is blood in the stools.

A client diagnosed with lymphoma is receiving chemotherapy. The client's hemoglobin is currently 6 g/dL. The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) to provide personal hygiene for this client. What instruction should the PN provide to the UAP? a. Report any signs of nausea or vomiting immediately. b. The client will be weak and unsteady and tire easily. c. Watch carefully for any signs of bleeding. d. The client's skin will be fragile and bruise easily.

b. The client will be weak and unsteady and tire easily. Rationale: A hemoglobin of 6 g/dL indicates anemia (normal for a female is 12 to 16 g/dL, for a male is 14 to 18 g/dL), which is a common adverse effect of chemotherapy. The UAP should be given instructions about how this will cause weakness and unsteadiness in the client and they will tire easily.

A plan of care for a 56-year-old client who has been diagnosed with osteopenia has been developed. The plan is focused on preventing further bone resorption and increasing bone mass. Which outcome statement should be included in the plan of care? a. The nurse practitioner will instruct the client on the use of alendronate. b. The client will decrease the number of cigarettes smoked by 50% within 2 weeks. c. The client will swim for 30 minutes three to four times per week for the next 2 months. d. The practical nurse will provide the client with a list of foods that are high in calcium.

b. The client will decrease the number of cigarettes smoked by 50% within 2 weeks. Rationale: A desired outcome statement should be client-centered with a measurable outcome, and the client decreasing the number of cigarettes smoked by 50% within 2 weeks is both client-centered and measurable. Cigarette smoking has a negative effect on bone resorption, so the client should be advised to stop smoking.

The nurse is assisting with planning care for an adult client with a diagnosis of pneumonia. Which aspects does the nurse expect to see emphasized in the plan of care? (Select all that apply.) a. Restrict fluids to less than 1500 mL/day. b. Use humidified oxygen as prescribed. c. Assist with deep breathing every 8 hours. d. Administer antibiotics promptly after the diagnosis is made. e. Notify the health care provider if the client begins using accessory muscles to breathe.

b. Use humidified oxygen as prescribed. d. Administer antibiotics promptly after the diagnosis is made. e. Notify the health care provider if the client begins using accessory muscles to breathe. Rationale: The client with pneumonia should use humidified oxygen in order to facilitate looser secretions to expectorate. Antibiotics should be administered promptly after the diagnosis is made. Using accessory muscles to breathe is a sign of respiratory distress and should be reported to the health care provider. Fluids should be encouraged up to 3000 mL/day unless contraindicated in order to liquefy secretions. The client should be assisted to deep breathe every 2 hours.

The Centers for Disease Control and Prevention (CDC) has issued guidelines for health care workers in relation to protection from HIV. The practical nurse (PN) who suspects they may be pregnant is assigned a client who is HIV+. What action should the PN implement? a. Make the suspected pregnancy known and request a different client assignment. b. Wear gloves when coming in contact with the blood or body fluids of a client. c. Limit contact and interaction with the client and have another nurse bathe the client. d. Put on all the PPE to include gown and mask when entering the client's room.

b. Wear gloves when coming in contact with the blood or body fluids of a client. Rationale: The CDC guidelines for standard precautions recommend that health care workers use gloves when coming in contact with blood or body fluids from any client because HIV is infectious before the client becomes aware of symptoms. Pregnancy of a nurse should not inhibit the nurse for taking care of a HIV+ client as long as standard precautions are observed.

A client diagnosed with status asthmaticus is admitted to the unit. Which breath sounds would the practical nurse anticipate to hear when auscultating the client's lungs? a. Fine crackles b. Wheezes c. Course crackles d. Stridor

b. Wheezes Rationale: Wheezes are continuous, high-pitched musical or squeaking-type sounds. They are reflective of the narrowing of the airways as a result of the inflammation from the asthma. Wheezes are generally heard with expiration, but can be heard with inspiration in severe cases of asthma.

The nurse is caring for a client who has an ileostomy and has reinforced instructions regarding ileostomy care. The nurse realizes the client needs additional instructions if the client makes which statement? a. "I should avoid high-fiber foods such as bran flakes." b. "I will need to empty the ostomy pouch when it is half full." c. "I will need to set a time every day when I can irrigate the ostomy." d. "I can use a simple squirt bottle to rinse out the pouch to remove odors."

c. "I will need to set a time every day when I can irrigate the ostomy." Rationale: The client will not be able to set a time to irrigate the ostomy because the ileostomy drains all the time. A client who has had an ostomy placed on the descending colon will most likely need to irrigate the ostomy at the same time each day. High-fiber foods will cause diarrhea. The client will need to empty the ostomy pouch when it is one-third to one-half full. Water and a simple squirt bottle can be used to remove effluence from the pouch and reduce odors.

A client diagnosed with a fracture of the left radius has a plaster cast applied. The nurse has reinforced instructions for drying the cast over the next 24 hours. Which statement by the client indicates the teaching was effective? a. "I will wrap the cast in plastic wrap for 24 hours." b. "I will support the cast on a firm surface during the night." c. "I will not cover it; instead I'll keep the cast surfaces exposed to circulating air." d. "I can use a blow dryer on medium setting until the plaster cast feels dry to the touch."

c. "I will not cover it; instead I'll keep the cast surfaces exposed to circulating air." Rationale: The nurse should instruct the client to keep the cast exposed to circulating air and avoid covering it with material that might keep it moist.

The practical nurse (PN) is assigned a client with a medical history of diabetes and gangrene who had a right below the knee amputation. At the time of rewrapping and inspecting the stump, the client refuses to look at their stump. The practical nurse (PN) tells the client that the incision is healing well, but the client refuses to talk about it. What is the best response to this client's silence? a. "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel." b. "Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery." c. "It is okay if you do not want to talk about your surgery. I will be available when you are ready." d. "I will ask another person who has had an amputation to come by and share their experiences with you."

c. "It is okay if you do not want to talk about your surgery. I will be available when you are ready." Rationale: Informing the client that it is okay they do not want to talk about their surgery and stating that the PN is available when they need them, displays sensitivity and understanding without judging the client.

A client has visited the health care provider and has been diagnosed with type 2 diabetes mellitus. Which symptom most likely prompted the client to seek medical attention? a. Severe thirst b. Increased urine output c. Fruity odor to the breath d. Frequent vaginal infections

d. Frequent vaginal infections Rationale: Symptoms of type 2 diabetes arise more slowly and are less dramatic. The client may learn then have type 2 diabetes when being treated for frequent infections, a change in vision and impotence. Extreme thirst, hunger, and a large urine output are more likely to be noticed with type 1 diabetes. Fruity odor to the breath is associated with diabetic ketoacidosis (DKA). Type 2 diabetes is less likely to cause DKA.

The nurse has reviewed the plan of care for a client with rheumatoid arthritis (RA) to a group of unlicensed assistive personnel (UAPs). Which comment by the UAP indicates the need for further teaching? a. "We should bathe the client when she feels most energetic." b. "We can turn on the television if she wants it when she is in pain." c. "We can use ice packs wrapped in washcloths to apply to painful joints." d. "When she is walking with us, we should remind her not to use jerky movements."

c. "We can use ice packs wrapped in washcloths to apply to painful joints." Rationale: A client with RA will benefit from warm moist heat, whirlpool baths, and warm showers. Ice would likely cause more discomfort. The client should be bathed when she feels most energetic. Distraction can somewhat reduce pain, and television can be used if the client prefers it. The UAPs can remind the client to walk with slow, smooth motions.

The practical nurse (PN) is taking vital signs on a client who has been treated for melanoma in the past. Which findings would cause the PN to consult the charge nurse? a. Increase of amount of freckles b. Dark liver spots c. An asymmetrical mole d. A mole that is purple in color

c. An asymmetrical mole Rationale: The practical nurse needs to consult the charge nurse about the asymmetrical mole. Melanoma is a skin cancer that is first identified by obvious change in the appearance of skin moles, which is one of the American Cancer Society's caution signs. The American Cancer Society uses the A, B, C, D method. A—asymmetry (a mole that is irregular in shape or two different looking halves); B—border; irregular, blurred, rough, or notched edges; C—changes in color or irregularity in the color of the appearance of the mole; D—diameter; moles larger than ¼ inch or 6 mm larger than a pencil.

A client scheduled for hip replacement surgery is prescribed a transfusion of a unit of packed red blood cells (RBCs). Which intervention is the best method to prevent a blood transfusion reaction? a. Verification of type and crossmatch of blood b. Transfusion of O negative blood c. An autologous transfusion d. Premedicating the client with diphenhydramine

c. An autologous transfusion Rationale: The best method for preventing transfusion reaction is an autologous transfusion (the client's own blood). A client's blood is generally collected 4 weeks before a scheduled surgery.

The nurse is assigned the care of a client whose spiritual beliefs are vastly different from the nurse's background. What action should the nurse take? a. Tell the client "I am uncomfortable with some of the religious items in your room." b. Tell the client "I will leave you alone most of the day so you can pray uninterrupted." c. Ask the client "Do you have any spiritual needs or concerns related to your health?" d. Tell the client "We only have regular food here, but your family can bring you food."

c. Ask the client "Do you have any spiritual needs or concerns related to your health?" Rationale: During time of illness, spiritual practices may be a source of comfort to the client. The nurse should ask clients if there are any spiritual needs or concerns related to their health that need to be addressed. It is inappropriate for the nurse to mention discomfort with religious items in the client's room. The nurse should not leave the client alone for most of the day, but should ask if there are particular times the client would like to pray or meditate. The nurse can then plan care around those times whenever possible. Referring to facility food as "regular food" insinuates that the client's foods are abnormal. In addition, depending on the client's prescribed diet, the family may or may not be able to bring in additional foods.

The health care provider informed a client diagnosed with stage 4 liver cancer that the cancer has spread to their spine. The client states to the practical nurse, "I have a cancer, but it is not malignant." What is the best initial nursing action? a. Encourage the client to attend a cancer education program. b. Perform a complete history and physical assessment. c. Ask the client to explain his understanding of the term malignancy. d. Offer the client emotional support to deal with the diagnosis.

c. Ask the client to explain his understanding of the term malignancy. Rationale: The best initial action is to assess the client's knowledge of the term malignancy when used to describe cancer. The client appears to have inaccurate knowledge. Stage 4 cancer means the cancer has spread (metastasized) from where it has started to another body part.

A client diagnosed with diabetic neuropathy has a nonhealing ulcer on the lateral aspect of their right (R) foot. Which question should the practical nurse (PN) ask to gather objective data for the development of a diabetic foot care teaching plan? a. Ask the client how they examine their feet. b. Ask which hypoglycemic medication they take. c. Ask to look at the pair of shoes they wear. d. Ask how long they have been diagnosed with diabetes mellitus.

c. Ask to look at the pair of shoes they wear. Rationale: Asking to look at the client's shoes will give the most objective data. The PN needs to inspect the client's shoes' inside for any area such as a seam that may be rubbing against the client foot causing trauma to their feet. Well-fitted shoes are very important to prevent the development of foot ulcers for the diabetic client.

A client diagnosed with viral influenza is prescribed vitamin C 1000 mg PO daily and acetaminophen 650 mg PO every 4 hours prn. The client complains to the practical nurse of abdominal cramping and increasing episodes of diarrhea. Which prescription change should the nurse anticipate? a. Change the acetaminophen to ibuprofen. b. Change the elixir to an injectable route. c. Decrease the dose of vitamin C. d. Begin treatment with an antibiotic.

c. Decrease the dose of vitamin C. Rationale: Diarrhea is an adverse effect of high doses of vitamin C, so the nurse should anticipate a reduction in the dose of vitamin C.

Which instruction to the unlicensed assistive personnel (UAP) is most appropriate to provide for a client who has peripheral vascular arterial disease (PVAD)? a. Apply a heating pad to the client's legs for warmth. b. Cut the client's toenails with a toe nail clipper every week. c. Make sure the client's knee high stockings are not constrictive. d. Keep the client's legs lower than the heart when resting in bed.

c. Make sure the client's knee high stockings are not constrictive. Rationale: With peripheral vascular disease, the nurse should make sure the client is not wearing any restrictive clothing. Heating pads are contraindicated with PVAD because a lack of blood supply is frequently associated with poor sensation. A heating pad could easily burn the client's skin. The toe nails should not be cut with a toe nail clipper; the client should see a foot care specialist. The client should not keep the legs in a dependent position.

Which interventions should the practical nurse implement to decrease the possibility of the client developing hypercalcemia? (Select all that apply.) a. Measure vital signs every 4 hours. b. Assist the client to turn, cough, and deep breathe every 2 hours. c. Remind the client to ambulate around the room at least three times daily. d. Irrigate the client's nasogastric (NG) tube every 2 hours. e. Increase fluid intake. f. Collaborate with the dietary nurse to increase foods high in calcium.

c. Remind the client to ambulate around the room at least three times daily. e. Increase fluid intake. Rationale: Hypercalcemia can result from immobility. Ambulation of the client helps to prevent calcium from leaking out of bones into the serum. Increasing fluid volume PO or IV helps to decrease calcium levels in the blood.

During a clinic visit, a client reports to the practical nurse (PN) that they felt a solid mass in their breast during self-examination, but it was not painful. What instruction should the PN reinforce with the client? a. Continue to monitor the mass until the next scheduled annual medical examination. b. Notify the health care provider if the mass becomes soft or painful or starts to drain. c. Schedule an appointment with the health care provider for evaluation. d. Breast masses are usually insignificant if they feel soft or are easily movable.

c. Schedule an appointment with the health care provider for evaluation. Rationale: A painless breast mass is an abnormal finding, and the PN should instruct the client to obtain prompt medical evaluation.

A client diagnosed with hypertension is prescribed a low-sodium diet. Which food choices selected from the hospital's menu demonstrates to the PN that the client understands their dietary restrictions? a. Tossed salad, low-sodium dressing, bacon and tomato sandwich b. New England clam chowder, no-salt crackers, fresh fruit salad c. Skim milk, turkey salad, roll, vanilla ice cream d. Macaroni and cheese, diet Coke, slice of cherry pie

c. Skim milk, turkey salad, roll, vanilla ice cream Rationale: The client's selection of skim milk, turkey salad, roll, and vanilla ice cream, although containing some sodium, are considered low-sodium foods.

The nurse is monitoring a client who has been receiving a unit of packed red blood cells for 10 minutes. The client suddenly develops a rapid heart rate, low back pain, and a decreased blood pressure. Which action should the nurse take first? a. Administer prescribed acetaminophen for pain. b. Notify the health care provider. c. Stop the blood transfusion. d. Prepare to administer prescribed diuretics.

c. Stop the blood transfusion. Rationale: The client is experiencing an acute hemolytic reaction, caused by blood incompatibility. The nurse must immediately stop the transfusion, before more incompatible blood enters the client's bloodstream. The health care provider will need to be notified, but the blood transfusion must be stopped first. Acetaminophen and diuretics are frequently given with blood transfusion reactions, but the first action is stopping the transfusion.

A client who had an abdominal hysterectomy 48 hours ago suddenly complains of chest pain and becomes short of breath, pale, and diaphoretic. The practical nurse (PN) immediately assesses the client's vital signs and obtains 100/80 mm Hg blood pressure, 110 beats/min heart rate, and 36 breaths/min respiratory rate. What nursing action should the PN to do next? a. Provide a paper bag for hyperventilation. b. Administer a prescribed prn analgesic. c. Lower the head of the bed and raise their feet. d. Apply oxygen at 2 L per nasal cannula.

d. Apply oxygen at 2 L per nasal cannula. Rationale: The PN should immediately provide oxygen while performing further assessment. Pulmonary embolism and pneumothorax are risks associated with major surgery.

An older adult client with a history of cardiac disease is admitted to the hospital. Since admission, the client has been confused and complaining about muscle cramps and has vomited twice. The client's vital signs are BP 130/70, P-47, and R-18. Which medication in the client's history should the practical nurse (PN) be most concerned? a. Warfarin b. Ibuprofen c. Nitroglycerine d. Digoxin

d. Digoxin Rationale: Older adult clients are particularly susceptible to the accumulation and toxicity of cardiac glycosides, such as digoxin. Toxicity can cause anorexia, nausea, vomiting, diarrhea, headache, muscle cramps, and fatigue.

The practical nurse (PN) is providing care to a client who is experiencing slight scrotal edema following indirect herniorrhaphy. Which postoperative prescription should the nurse question for this client? a. Ice packs applied to the scrotum. b. Elevate the scrotum on a soft pillow. c. Application of a scrotal support. d. Encourage deep breathing and coughing.

d. Encourage deep breathing and coughing. Rationale: A client should be discouraged from coughing following a hernia repair. The coughing will create too much intra-abdominal pressure putting increase pressure on the abdominal wall and could cause a dehiscence and/or evisceration of the surgical site. All other interventions are recommended for postop care of a hernia.

The nurse is caring for a client with glaucoma. The nurse expects which aspect to be included in the plan of care? a. Encourage the client to anticipate the return of vision once treatment has begun. b. Explain that the cloudy lens can be removed with surgery, usually as an outpatient. c. Encourage the client to place prescribed eye drops directly over the pupil of the eye. d. Explain to the client that eye drop use will be necessary for the rest of the client's life.

d. Explain to the client that eye drop use will be necessary for the rest of the client's life. Rationale: Glaucoma is increased intraocular pressure, which can eventually cause blindness if untreated. Eye drop instillation will be necessary for the rest of the client's life. Even with early treatment, vision loss cannot be reversed. A cloudy lens is associated with cataracts, not glaucoma. Eye drops should be placed in the conjunctival sac, not directly over the pupil.

The home health practical nurse is visiting with a client who has a history of second-degree heart block and pacemaker placement 6 months ago. Which symptom compliant by the client would be indicative of pacemaker failure? a. Facial flushing b. Nausea c. Pounding headache d. Feelings of dizziness

d. Feelings of dizziness Rationale: Feelings of dizziness may occur as the result of a decreased heart rate, leading to decreased cardiac output as a result of pacemaker failure.

A client status post-cholecystectomy 3 days is being prepared to be discharged home. Which client finding is the best indication to the practical nurse that postoperative nursing interventions have prevented respiratory complications? a. Uses an incentive spirometer (IS) frequently. b. Denies any cough or colored sputum. c. Breathes evenly and unlabored. d. Has a 95% pulse oximeter value on room air.

d. Has a 95% pulse oximeter value on room air. Rationale: Pulse oximetry of 95% on room air indicates adequate oxygenation.

A client diagnosed with osteoarthritis. Which intervention should the practical nurse implement to help relieve joint pain and stiffness? a. Encourage the client to perform weight-bearing exercises. b. Teach the client how to perform range-of-motion exercises. c. Explain the use of ice and massage for pain relief. d. Instruct the client to take an analgesic before walking daily.

d. Instruct the client to take an analgesic before walking daily. Rationale: Adequate pain management is important for the success of an exercise program. Keeping the joints active decreases pain, so taking an analgesic and walking daily is likely to help decrease joint pain and stiffness.

A client is hospitalized for an acute intestinal obstruction and has a nasogastric (NG) tube connected to low intermittent suction. Which task can be assigned to the unlicensed assistive personnel (UAP)? a. Providing sips of fluid around the clock b. Irrigating the nasogastric tube with normal saline c. Verifying the placement of the nasogastric tube in the stomach d. Measuring and emptying the contents of the nasogastric suction

d. Measuring and emptying the contents of the nasogastric suction Rationale: The nurse can assign the task of measuring and emptying the contents of the NG tube suction to the UAP. The client will not be allowed fluids because the NG tube would empty the fluid out as quickly as the patient drank the fluids. The nurse cannot assign any tasks which require judgment, such as irrigating the NG tube or verifying placement in the stomach.

A client diagnosed with ovarian cancer has just been informed that their cancer has metastasized to their liver. The client is quietly crying in their room. Which statement is appropriate for the practical nurse to say? a. I know many females who have survived ovarian cancer. b. Let's talk about the treatments of ovarian cancer. c. In my opinion, I would suggest getting a second opinion. d. Tell me about what you are feeling right now.

d. Tell me about what you are feeling right now. Rationale: The most appropriate response and therapeutic action is for the nurse to be an active listener and to encourage the client to explore their feelings.

The nurse is reinforcing hygiene instructions to unlicensed assistive personnel (UAP) who will be bathing a client who has been diagnosed with pneumonia. The nurse should instruct the UAP to plan to bathe the client at which time? a. The client with pneumonia should not be bathed. b. The client should be bathed according to facility schedule. c. The client should be bathed after noninfectious clients are bathed. d. The client should have activities such as bathing, alternated with rest periods.

d. The client should have activities such as bathing, alternated with rest periods. Rationale: The client should be allowed to rest before activities such as bathing take place. There is no contraindication for bathing a client with pneumonia. Facility schedules are not the primary reason to determine the timing of a client's bath. By using standard and other precautions, it would not matter whether the client with pneumonia is bathed before or after other noninfectious clients.

A client with chronic pancreatitis has been taking pancreatin with meals. How does the nurse assist with evaluating the effectiveness of the treatment? a. The client has no further gallstones. b. The powder is well mixed with applesauce. c. The client's blood sugar remains in normal range. d. The client's stools remain soft and medium brown in color.

d. The client's stools remain soft and medium brown in color. Rationale: The client taking pancreatin should have stools that are soft and medium brown in color. If the pancreatic enzyme replacement is not effective, the stools would be loose, frequent, and have a fatty consistency. Pancreatin will not prevent gallstones, nor stabilize the blood sugars. It is important that the pancreatin powder be mixed well with applesauce, but ensuring it is mixed well will not determine effectiveness of the medication.