Medical-surgical practice exam

An adult male who is covered with "road rash" after falling off his bicycle arrives at the clinic. He holds his hand to his chest and tells the practical nurse (PN) that he hurts when he breathes. The PN hears an audible "slurping" sound each time the client takes a breath. Which intervention should the PN implement first? Document findings and evaluate response to treatment. Request a prescription for an analgesic. Insert an IV saline lock and rinse superficial wounds. Apply oxygen and inspect the chest wall.

Apply oxygen and inspect the chest wall. Rationale Falls from a moving bicycle can cause a foreign body or fractured rib to penetrate the chest wall and create a "sucking" chest wound. The most important action is to apply oxygen (D) and inspect the chest wall surface for a wound that may require immediate action. (A) should be implemented once the client's care is provided or delegated to another caregiver. (B and C) should be obtained after providing supplemental oxygen.

A client with major burns is receiving cimetidine (Tagamet). Which finding should the practical nurse (PN) obtain to best evaluate the effectiveness of the medication? Soft, non-tender abdomen. Change in stool frequency. Hyperactive bowel sounds. Absence of blood in the stool.

Absence of blood in the stool. Rationale In burns, Curling's ulcer, a type of gastroduodenal stress ulcer, is caused by a generalized stress response resulting in decreased production of mucus and increased gastric acid secretion, which can cause epigastric pain, gastric ulceration, and bleeding. Cimetidine (Tagamet), a histamine blocker, reduces gastric acid secretion and is used for prevention of Curling's ulcers associated with severe trauma, such as major burns. Absence of blood in the stool (D) or the occurrence of black, tarry stool indicates the medication is effective. Although abdominal findings (A), change in stool frequency (B) or bowel sounds (C) provides information about the effectiveness of therapy, the best evaluation of the prevention of GI distress and ulceration is the absence of blood in the stool.

A client is admitted with a C4 spinal cord injury (SCI) after falling from a roof at a construction site. After returning to the unit for a CT scan to confirm the vertebral fracture, which assessment by the practical nurse has the highest priority? Assess lower extremities for movement and strength. Check the respiratory effort and pulse oximeter reading. Obtain a baseline Glasgow Coma Scale (GCS) score. Monitor for acute onset of hypotension and bradycardia.

Check the respiratory effort and pulse oximeter reading. Rationale A SCI at C3 or above impairs phrenic nerve innervation that results in paralysis of the diaphragm. Swelling from the acute injury at C4 can extend above this area and impair respirations. Assessing for effective respirations (B) takes priority over expected compromise of (A, C, and D) related to a cervical SCI.

A male client is having an intraocular pressure (IOP) measurement using a tonometer for the first time. The client is fearful that the test hurts and may damage his vision. Which explanation should the practical nurse provide? Eyedrops will be prescribed for abnormal IOP readings. A topical anesthetic will be used on the eye surface. The test is quick and does not cause injury or blindness. Reassure the client that the procedure does not hurt.

A topical anesthetic will be used on the eye surface. Rationale Pain sensation is eliminated by the use of a topical ophthalmic anesthetic (B) placed in the conjunctival sac prior to the placement of a tonometer when measuring IOP for glaucoma, which is a common cause of blindness if early treatment is not implemented. (A, C, and D) do not provide the client with specific measures taken to prevent discomfort during the procedure.

A practical nurse (PN) is coordinating the care of four clients on an oncology unit. Which neutrophil count should the PN identify as a risk for a life-threatening infection in one of the clients? 500/mm3. 1000/mm3. 2000/mm3. 3000/mm3.

500/mm3. Rationale A neutrophil count of 500/mm3 (neutropenia) (A) places a client at risk for a life-threatening infection. (B, C, and D) are within normal values.

The practical nurse (PN) is assisting the occupational health nurse with employee health screening. Which technique should the PN use to determine a client's visual acuity? Check the pupil response to light. Have the client read the Snellen eye chart. Observe both eyes for nystagmus. Tell the client to watch the PN's finger move.

Have the client read the Snellen eye chart. Rationale The Snellen eye chart (B), which has lines of black letters with the largest sized letter at the top, is used to determine visual acuity. (A) assesses pupil reactivity and accommodation which evaluates the function of cranial nerves III, IV, and VI, not visual acuity (cranial nerve II). Nystagmus (C) is an involuntary back and forth movement of the eyes that may indicate a pathology in the labyrinth, cerebellum, or brain stem, not visual acuity. Following the PN's finger assesses extraocular eye muscle movement, which is controlled by cranial nerves III, IV, and VI (D).

Which instruction should the practical nurse (PN) reinforce with a female client about skin care after her first radiotherapy treatment? Cleanse the area with bar soap and water. Moisten the skin with lotions after treatment. Avoid using ice packs on the exposed area. Protect the skin from exposure to air.

Avoid using ice packs on the exposed area. Rationale The client should keep the irradiated area of skin dry and clean. Irritants, such as ice packs (C), should also be avoided. (A, B, and C) are not indicated.

A male client receives the negative results for his recent fecal occult blood test and calls the clinic to cancel his colonoscopy scheduled for the next day. Which information should the practical nurse provide? The colonoscopy should be canceled if he is asymptomatic. A negative result for occult blood does not rule out lesions in the colon. A followup colonoscopy should be scheduled after one month. Two negative fecal occult results are needed to verify no bleeding is occurring.

A negative result for occult blood does not rule out lesions in the colon. Rationale To determine the presence of colon cancer, a colonoscopy of the entire colon should be visualized and a tissue sample taken for biopsy, if warranted. A negative fecal occult blood result does not rule out the possibility of a lesion in the colon (B). (A, C, and D) are not correct.

The practical nurse (PN) is reviewing the side effects associated with chlopromazine (Thorazine) rectal suppository for a client with nausea and vomiting. Which information should the PN review with the client? Limit fresh fruit and dietary roughage intake. Report any signs of urinary frequency. Minimize exposure to sunlight during therapy. Eat a balance diet to minimize weight loss.

Minimize exposure to sunlight during therapy. Rationale The most common adverse effects of chlorpromazine (Thorazine) are sedation, orthostatic hypotension, and anticholinergic effects, such as dry mouth, blurred vision, urinary retention, photophobia, constipation, tachycardia and photosensitivity. Clients should be advised to minimize unprotected exposure to sunlight (C). The use of a rectal suppository may stimulate peristalsis, but Thorazine is more likely to slow GI motility, causing constipation, so (A) is not indicated. Information about other anticholinergic side effects, such as dry mouth, blurred vision, urinary hesitation, not (B), and tachycardia, should be discussed. Weight gain, not (D), is a common side effect.

A client who received graphs for a full-thickness burn of the right arm is admitted to the rehabilitation unit. Which action is important for the practical nurse to reinforce with the client to prevent long-term complications? Exercise the affected arm everyday. Drink 2 liters of fluid per day. Encourage visitors to wash hands. Request analgesics as needed.

Exercise the affected arm everyday. Rationale Exercise (A) is an important component in the rehabilitation stage following a severe burn to prevent contracture formation, which impairs normal function of the muscle and joints of the arm. Although fluids (B) are important in the initial stage after a severe burn, it is not a key need in rehabilitation in preventing long-term complications. (C) is important in the prevention of infection. (D) may be indicated during convalescence, but exercise is vital to ensure range of motion and prevention of long-term effects of contractures.

A male client with peptic ulcer disease complains of feeling weak and dizzy. The practical nurse (PN) observes that the client is diaphoretic, has a firm abdomen, thready pulse at 104 beats/minute, and blood pressure of 90/50. Which action should the PN implement? Place the client in a left side-lying position. Obtain vital signs every 2 hours. Increase the client's oral fluid intake. Notify the healthcare provider.

Notify the healthcare provider. Rationale Peptic ulcer perforation can cause hemorrhage. The client is manifesting signs of hypovolemic shock, a life-threatening emergency that requires intervention, so the healthcare provider should be notified immediately (D). (A, B, and C) delay obtaining life-saving prescriptions.

Which assessment is most important for the practical nurse (PN) to implement for a client who returns from surgery for an arthroscopic repair of the right knee? Evaluation of pain symptoms. Auscultation of bowel sounds. Palpation of both pedal pulses. Observation of body temperature.

Palpation of both pedal pulses. Rationale Although complications are uncommon after arthroscopic procedures, monitoring for neurovascular compromise is most important. Neurovascular assessments, such as presence of pedal pulses (C), evaluate circulatory integrity of tissues that are distal to the surgical site. Although evaluating the client's pain level (A), bowel function (B), and temperature (D) are components of postoperative care, compromised circulation or nerve innervation due to the surgery require immediate action to prevent permanent damage to tissues.

Which findings should the practical nurse identify in a client with anemia due to a vitamin B 12 deficiency? Select all that apply Gradual weight gain. Smooth, beefy-red oral cavity. Macrocytic red blood cells (RBC). Paresthesia of hands and feet. Leukopenia.

Smooth, beefy-red oral cavity. Paresthesia of hands and feet. Rationale Correct choices are (B and D). Vitamin B 12 deficiency anemia is due to a dietary deficiency or failure to absorb vitamin B12 from the intestinal tract as a result of partial gastrectomy or pernicious anemia. Manifestations of pernicious anemia include glossitis (a smooth, beefy-red tongue) (B), fatigue, paresthesia (D), pallor and jaundice, and weight loss, not (A). The results of a complete blood count (CBC) that show macrocytic anemia (C), leukopenia (E) and thrombocytopenia are indicative of bone marrow failure, not vitamin B12 deficiency.

A client is scheduled for a transurethral resection of the prostate (TURP). What statement by the client reveals to the practical nurse that the client needs additional information? "I need to drink a lot after surgery." "My urine should be red after surgery." "My incision will probably be painful." "I should have a catheter after surgery."

"My incision will probably be painful." Rationale Transurethral resection of the prostate (TURP) is performed by inserting a rectoscope through the urethra. No incision is made, so the client's statement about an incision (C) indicates the need for more information about the procedure. Liberal oral fluids are often encouraged (A) after surgery to prevent infection. Postoperatively, urine is blood-tinged (B) due to resection and traumatized urinary membranes. A client with TURP should have an indwelling catheter (D) for drainage and bladder irrigation to prevent occlusion of the catheter with blood clots.

A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the practical nurse to report to the healthcare provider? Pain radiating to the right shoulder. Clay-colored stool. Hard, rigid abdomen. Vomiting bile-stained emesis.

Hard, rigid abdomen. Rationale As bile accumulates due to obstruction of the common bile duct, the gallbladder distends and can perforate, which is manifested by a distended, hard, rigid abdomen (C) that should be reported immediately to the healthcare provider. Radiating pain (A) and clay-colored stool (B) are manifestations associated with obstructive jaundice due to cholelithiasis. (D) indicates the obstruction of the common bile duct is reduced.

The practical nurse (PN) is completing focused assessments for four clients. Which client finding should be the PN's first priority? A client with bronchitis who is short of breath and can only speak in phrases. A client with emphysema who has a pulse oximeter 90% and 101.1 F temperature. A client with asthma who is coughing and has distant auscultated breath sounds. A client with pneumonia who is wheezing and expectorating green sputum.

A client with asthma who is coughing and has distant auscultated breath sounds. Rationale The priority finding is compromised air flow manifested by diminished or absent breath sounds (C) which is indicative of atelectasis of an affected lobe due to mucus obstruction. (A and B) are expected findings for clients with chronic obstructive pulmonary disease (COPD) and are not as emergent as the client with obstructed air flow and poor oxygenation. (D) requires treatment, but the priority is (C).

The practical nurse (PN) determines that a client's nasogastric tube (NGT), which is attached to low intermittent suction, has a decreased amount of drainage in the collection unit. Gastric secretions have pooled in the tubing and do not move with the onset of intermittent suction. Which action should the PN implement? Clamp the NGT and adjust the suction in the wall outlet. Remove the NGT and prepare to reinsert a new tube. Assess the placement of the NGT. Irrigate NGT with 50 ml of normal saline.

Assess the placement of the NGT. Rationale The NGT should be assessed for proper functioning if gastric secretions become stagnant in the tube. Determining placement of the tube (C) is the first action. (A, B, and D) are actions that may need to be implemented based on the evaluation of the NGT.

A client who experienced a thrombolic stroke has received recombinant tissue plasminogen activator (TPA)( Alteplase) two hours ago in the emergency center. Which priority precaution should the practical nurse implement for this client on admission to the medical unit? Disuse syndrome. Risk for infection. Fall precautions. Bleeding precautions.

Bleeding precautions. Rationale TPA increases the client's risk for bleeding, so (D) should be implemented for thrombolytic and anticoagulant therapy. (A, B, and C) should be included in the plan of care for this client, but the risk for bleeding is the most immediate risk related to the client's recent thrombolytic therapy.

The wife of a client with a large brain tumor asks the practical nurse (PN) to explain why the tumor should be surgically removed. What is the best response for the PN to provide? Benign brain tumors are readily treatable and have a favorable prognosis. Brain tumors increase cerebral mass, resulting in increased intracranial pressure. Most brain tumors cause death by metastasizing to vital organs, such as the liver or lungs. Malignant brain tumors are usually not treatable surgically and are managed with chemotherapy.

Brain tumors increase cerebral mass, resulting in increased intracranial pressure. Rationale Local effects of cranial tumors are caused by tumor compression that decreases cerebral blood flow and increases intracranial pressure (B), causing seizures, visual disturbances, unstable gait, and cranial nerve dysfunction. Although (A) is a positive response, benign tumors can compromise cerebral tissue integrity and cause sequela. Intracranial brain tumor metastasis to other organs (C) is limited because there are no lymphatic channels within the brain. (D) is inaccurate.

The practical nurse (PN) is performing a focused assessment for a postoperative client who returns to the unit after receiving general anesthesia. Which finding should the PN identify as an indicator that the client is free of respiratory complication? Client is able to use the incentive spirometer. Coughs effectively to produce yellow mucus. Respirations are 22 breaths/minute. Breath sounds are clear bilaterally.

Breath sounds are clear bilaterally. Rationale Clear lung sounds (D) indicate that the client is free of respiratory complication. (A) is indicative of the client's ability to use the equipment, not a physiological response. Expectorant mucus should be clear, not (B). (C) is not significantly abnormal, but may indicate the client is experiencing unrelieved pain.

Which action should the practical nurse (PN) implement to reduce the risk of infection for a client who is receiving total parenteral nutrition (TPN)? Administer antibiotics secondary to the TPN fluid. Replace the peripheral cannula every 48 hours. Change the transparent dressing every 72 hours. Use a semipermeable dressing on the insertion site.

Change the transparent dressing every 72 hours. Rationale To prevent infection, TPN sterile dressing changes should be implemented every 3 to 7 days using a transparent dressing (C), which allows inspection of the site for signs of redness, swelling, foul odor, or purulent drainage. (A and B) are incorrect procedures for TPN. (D) does not address the concept of infection control.

The practical nurse (PN) auscultates the abdomen of a client who had a barium swallow 24 hours ago and determines the client has decreased bowel sounds. The client reports having no bowel movements for 2 days. Which nursing intervention should the PN implement? Collect a stool specimen for analysis. Limit intake of products with caffeine. Increase fluid intake to 3,000 ml daily. Check digitally for a bowel impaction.

Check digitally for a bowel impaction. Rationale Findings such as decreased or absent bowel sounds and reports of constipation after barium swallow are indicative of a barium impaction, which can be confirmed by a digital check (D). Although stool analysis confirms the presence of barium, the client is unable to have a bowel movement (A). (B and C) may reduce the risk of constipation, but do not address the consequences of retained barium.

The practical nurse is caring for a client who is admitted with signs of possible acute brain attack (stroke) three hours ago. The client's blood pressure is 170/96, regular radial pulse 76 beats/minute, respirations are nonlabored at 11 breaths/minute, and a SpO2 of 99%. What action is most important for the PN to implement? Call healthcare provider for antihypertensive. Assess the client for Brudzinski's sign. Continue to monitor client's blood pressure. Monitor client's IV fluid intake and urine output.

Continue to monitor client's blood pressure. Rationale The goals for management of a client with a suspected stroke is continuous monitor of blood pressure (C) and neurological deterioration to determine eligibility for reperfusion therapy. Antihypertensives are indicated if the systolic is 180- 230 or diastolic is 105-140, so (A) is not indicated at this time. (B) is most likely associated with meningeal irritation related to meningitis. Although (D) is a basic component of client care, the priority is monitoring the client's blood pressure.

A client with Parkinson's disease asks the practical nurse (PN) to explain how this disease causes his muscles to malfunction. Which underlying pathophysiology should the PN use as a basis for the explanation? Synaptic levels of norepinephrine decrease in the neuromuscular junction. Cerebellar levels of acetylcholine rise and inhibit voluntary movement. Degeneration of the basal ganglia leads to a decrease in dopamine levels. Neuronal signals from the cerebral cortex increase acetylcholine.

Degeneration of the basal ganglia leads to a decrease in dopamine levels. Rationale Parkinson's disease is caused by a degeneration of the basal ganglia (C) and a decrease in dopamine (C), a neurochemical transmitter that affects coordinated and fine voluntary skeletal muscle movements. (A, B, and D) are inaccurate.

The practical nurse (PN) is reviewing laboratory results for a client admitted with possible meningitis and identifies that the c erebrospinal fluid (CSF) findings are positive for bacteria. Which action is most important for the PN implement? Direct others to use safety precautions. Implement droplet precautions. Ensure the room is quiet and dark. Report the client's positive Kernig's sign.

Implement droplet precautions. Rationale Respiratory isolation (A) should be implemented for a minimum 24 hours of effective antibiotic therapy. (A, C, and D) should be implemented but do not address the priority of implement infection control measures.

Which finding prompts the practical nurse (PN) to check the nasogastric tube (NGT) placement? The client has vomited. The pH of aspirated fluid is 6.5. The fluid has a grassy green appearance. The abdomen is distended.

The client has vomited. Rationale A NGT can become displaced with vomiting (A) and NGT placement should be verified. The pH of fluid aspirated from the stomach should be 5 or lower, but does not impact placement (B). Fluid aspirated from the stomach can have a grassy green, brown, or clear, mucoid-flecked appearance (C). (D) is not an uncommon finding for a client with a NGT.

Which client should the practical nurse question a PRN prescription for sumatriptan (Imitrex) for migraine headaches? 30-year-old with bronchial asthma. 40-year-old with diabetes mellitus. 50-year-old with Prinzmetal's angina. 60-year-old with chronic kidney disease.

50-year-old with Prinzmetal's angina. Rationale Imitrex reduces pain and other associated symptoms of migraine headache by binding to serotonin receptors and triggering generalized vasoconstriction, which can cause coronary vasospasm in clients with Prinzmetal's or variant angina (C). (A, B, and D) are inaccurate.

The practical nurse (PN) is reviewing the admission laboratory results for a client with cirrhosis of the liver. Which finding should the practical nurse (PN) report to the healthcare provider? Hemoglobin of 12 grams/dl. Serum potassium of 4 mEq/L. Elevated serum ammonia. Urobilinogen.

Elevated serum ammonia. Rationale Serum ammonia levels (C) are elevated in conditions that result in hepatocellular injury, such as cirrhosis of the liver. (A and B) are normal. (D) is an expected finding in a client with cirrhosis and jaundice.

The practical nurse (PN) is reinforcing information to a older male client with a history of coronary artery disease about his prescribed daily medication regimen. Which medication is most likely to reduce the client's risk factors? A potassium sparing diuretic. A high daily Vitamin C dose. A low protein binding antibiotic. A low-dose aspirin given daily.

A low-dose aspirin given daily. Rationale Low-dose aspirin reduces the risk of platelet aggregation, thereby minimizing clot formation that can result in coronary vessel occlusion (D). (A, B, and C) do not reduce the risk of coronary occlusion or thrombolic stroke.

An older client with presbyopia receives a prescription for corrective lenses. Which information should the practical nurse provide that explains the expected results of the corrective lenses? Helps to sharpen distance vision. Improves both near and distance vision. Corrects vision for reading and close work. Assists with bilateral accommodation.

Corrects vision for reading and close work. Rationale Due to aging of the lenses and loss of elasticity, presbyopic changes reduce the lenses' ability to accommodate, which makes close vision blurry. Corrective lenses improve visual acuity for reading and in close work (C). (A, B, and D) are inaccurate.

What information should the practical nurse reinforce while reviewing discharge instructions with a client who has a joint dislocation? Calcium supplements should be taken daily. Prescribed exercises should be performed daily. Cortisone medication side effects should be reviewed. Future surgery for removal of fixation devices may be required.

Prescribed exercises should be performed daily. Rationale Muscle strengthening exercises are prescribed for dislocations as the most effective method of preventing additional dislocation (B). (A, C, and D) do not address the concepts of mobility and coordination of care.

What equipment should the practical nurse (PN) ensure is the room for a client after a thyroidectomy? Tracheostomy tray. Padded tongue blades. Closed chest drainage system. Sterile gauze.

Tracheostomy tray. Rationale A complication in the immediate postoperative period after a thyroidectomy is airway obstruction, so a tracheostomy tray (A), oxygen, and suction equipment should be available in the client's room. (B, C, and D) are not necessary at the bedside after a thyroidectomy.

A male client who is unconscious after blunt trauma to the head during a baseball game is admitted for observation for possible epidural hematoma. The client is awake and oriented at each hourly check and becomes more difficult to arouse. Which additional finding should the practical nurse report? Hyperactive gag reflex. Nuchal rigidity. Vomiting. Bounding peripheral pulses.

Vomiting Rationale A client with an epidural hematoma, an arterial intracranial bleed, typically manifests unconsciousness at the scene of the injury followed with lucid intervals of orientation, decreasing levels of consciousness, and other symptoms, such as vomiting (C) or focal findings, which should be reported. (A, B, and D) are not indicative of increasing intracranial pressure.

A male client returns to the surgical nursing unit after having a thyroidectomy. Which action is most important for the practical nurse to implement? Check the back of the neck for bleeding. Determine whether the client can speak. Assess the client's respiratory status. Ask the client if he has pain.

Assess the client's respiratory status. Rationale Postoperative complications after a thyroidectomy include laryngeal edema. The priority assessment is monitoring the client's respiratory status (C), including airway obstruction and oxygen saturation. Assessment for bleeding (A), ability to speak (B), and pain (D) are important actions upon return from surgery, but respiratory assessment takes priority.

A client's results for this morning's platelet count is 30,000/mm 3 . What action should the practical nurse (PN) implement first? Notify the healthcare provider. Institute bleeding precautions. Observe intravenous access sites. Take vital signs as soon as possible.

Institute bleeding precautions. Rationale Bleeding precautions (B) should be implemented first since the low platelet count places the client at risk for bleeding. (A, C, and D) are implemented after (B).

Which actions should the practical nurse implement for a client whose fractured tibia is causing swelling of the lower leg? Massage and ice pack. Heating pad and massage. Ice application and elevation. Narcotic analgesia and moist heat.

Ice application and elevation. Rationale Standard measures for swelling of a traumatic injury is rest, ice, compression, and elevation (RICE) (C). (A, B, and D) are inaccurate.

The practical nurse (PN) is caring for a client who is receiving radiotherapy for cancer of the larynx. Which information should the PN provide the client to reduce the undesirable effects of radiation? Use sugarless gum and candy to increase salivary secretions. Decrease caloric intake during the course of radiation to prevent nausea. Rinse mouth with commercial mouthwashes to decrease oral inflammation. Apply oil-based lotions to moisturize dry skin areas that are irradiated.

Use sugarless gum and candy to increase salivary secretions. Rationale Dry mouth (xerostomia) is often a side effect of external beam radiation to the head and neck. Increasing fluid intake, chewing sugarless gum or sugarless candy (A), or using non-alcoholic mouth rinses or artificial saliva may provide relief. (B, C, and D) are contraindicated for a client receiving external beam radiation.

Before implementing oral feedings for a client who has had a stroke, which action should the practical nurse (PN) implement? Cut all food into very small pieces. Verify that the client is able to swallow. Explain the location of all the food on the tray. Position the client in the dorsal recumbent position.

Verify that the client is able to swallow. Rationale Neurologic damage increases the risk of swallowing disorders. The client's ability to swallow should be evaluated before offering anything by mouth (B). (A and C) can be implemented during feeding. (D) places the client at risk for aspiration.

A male client with increased intracranial pressure (ICP) due to a skull fracture is in the supine position with his legs elevated. What should the practical nurse (PN) do first? Obtain the client's vital signs. Raise the head 30 degrees and lower the feet. Complete a Glasgow Coma Scale. Check the IV infusion rate and urinary output.

Raise the head 30 degrees and lower the feet. Rationale Elevating the legs above the head increases venous pressure which increases ICP. The first action is to lower the client's feet and raise his head 30 degrees to minimize brain swelling and cerebral anoxia. (A, C, and D) can be implemented after (B).

The practical nurse (PN) is reviewing discharge instructions with a client after out-patient surgery. Which client response indicates to the PN the need for teaching reinforcement? The bandage should be changed daily. A normal diet can be started tomorrow. Family assistance should be available. Pain medication should be taken every day.

Pain medication should be taken every day. Rationale Pain should be less with each subsequent postoperative day, so the client may not need to take pain medication every day (D), which indicates an opportunity to reinforce teaching. (A, B, and C) indicate client understanding.

What is the priority data that the practical nurse (PN) should obtain for a client with a cervical spinal cord injury (SCI)? Mental status and pupil reaction. Heart rate and rhythm. Muscle strength and reflexes. Respiratory pattern and airway.

Respiratory pattern and airway. Rationale The priority data to obtain for a client with a cervical SCI are respiratory status and airway patency (D). Clients with cervical spine injuries are at risk for respiratory compromise due to impairment of diaphragm movement. (A, B, and C) are not the priority.

The practical nurse (PN) should place a client in which position for a thoracentesis? In a modified Sims' position with arms extended above the head. Sitting upright in a tripod position leaning on an overbed table. In a supine position with the head of the bed elevated 45 degrees. Lying prone in a Trendelenburg position with both arms extended.

Sitting upright in a tripod position leaning on an overbed table. Rationale A client undergoing thoracentesis is positioned in a tripod position that allows the client to sit upright with the arms on an overbed table (B). (A, C, and D) are incorrect positions.

Which information should the practical nurse (PN) reinforce with a client with a tracheostomy who is learning self-feeding? Follow each spoon of food with water. Dilute foods to a thin liquid consistency. Tilt the chin forward toward the chest when swallowing. Inflate the tracheostomy tube cuff tightly before eating.

Tilt the chin forward toward the chest when swallowing. Rationale Tilting the chin toward the chest facilitates swallowing and closes the glottis to prevent aspiration by directing food into the esophagus. The other instructions do not reduce the risk of aspiration. Over-inflation of the cuff causes pressure and necrosis on the tracheal wall.

After a stroke, a male client with left hemiplegia ignores his left leg and arm. He is unable to use his right arm to assist with moving his left arm or leg. Which descriptor should the practical nurse (PN) document to describe this behavior? Mood changes. Sensory deficits. Unilateral neglect. Behavioral changes.

Unilateral neglect. Rationale A client's failure to recognize or respond to stimuli on the affected side of the body after a stroke is an example of unilateral neglect (C), which should be documented and the example included in a narrative note. (A, B, and D) are inaccurate.

A client is receiving a unit of packed red blood cells (RBC's). Which finding should the practical nurse (PN) report to the healthcare provider? Reports IV infusion feels "cold". Skin color pale and cool to touch. Heart rate 98 beats/minute. Urticaria on the neck and chest.

Urticaria on the neck and chest. Rationale Urticaria signals an allergic reaction and must be reported to the healthcare provider (D). Blood products are refrigerated prior to infusion, so (A and B) are expected findings. (C) is within normal limits.

The practical nurse (PN) is caring for a client with chronic obstructive pulmonary disease (COPD). To reduce carbon dioxide ( CO 2 ) retention in the lungs, which information should the PN reinforce? Use pursed-lip and abdominal breathing. Maintain a sitting position with the arms supported. Drink at least 3 liters of fluid daily. Intersperse rest between periods of physical activity.

Use pursed-lip and abdominal breathing. Rationale Pursed-lip breathing used during diaphragmatic or abdominal breathing (A) provides mild resistance through partially closed lips to prolong exhalation and increase airway pressure, which delays airway compression and reduces air trapping. Although (B, C, and D) are helpful, a client with COPD should use this effort with expiration to reduce CO2 retention caused by the loss of elasticity of the alveoli.

The practical nurse (PN) is reviewing preoperative instructions with a male client who is having surgery today. What question should the PN ask the client to best evaluate his understanding of the surgery? Do you understand why you are having surgery? Have you undergone this type of surgery in the past? What do you know about the surgery you are having? What symptoms brought you to the hospital for surgery?

What do you know about the surgery you are having? Rationale Although it is the surgeon's responsibility to explain the surgery to the client, it is a nursing responsibility to determine whether the client understands what he has been told about his surgery. Asking open-ended questions is an important step in eliciting what the client understands (C). (A and B) are closed end questions and will elicit one word responses. (D) asks the client to explain the admission related to his need for surgery, but not his understanding about the procedure.

A client's prescription for warfarin (Coumadin) therapy was discontinued three weeks ago and returns to the clinic for follow-up laboratory tests. Which results should indicate to the practical nurse that the medication has been eliminated from the body? Reticulocyte count of 1%. Serum ferritin level of 350 ng/ml. International normalized ratio (INR) of 0.9. Total white blood count of 9,000/mm3.

International normalized ratio (INR) of 0.9. Rationale Warfarin therapy increases the INR. When the effects of warfarin are no longer present, the i (C). (A, B, and D) are inaccurate.

A male client who has been taking a four-drug regimen for tuberculosis (TB) tells the practical nurse (PN) that he has finished the first drug, isoniazid, and will start taking rifampin next. How should the PN respond? Observe for side effects, such as an orange discoloration of urine. A vitamin B supplement should be added to the daily medications. TB is contagious until all four medications are completed. The four-drug protocol should be taken concurrently.

The four-drug protocol should be taken concurrently. Rationale To prevent resistant strains of tuberculosis, a client with tuberculosis is initially prescribed a four-drug regimen, which requires strict compliance. Information about the concurrent administration of all of the four-drugs in this treatment plan (D) should be reinforced with the client and the healthcare provider notified of the client's past use of the protocol. (A and B) provide additional information for the client, but (D) is the most important information to convey to the client. Although partial use of the medication may be less effective (C), the client's use of the medication must be addressed.

A male client with diabetes mellitus calls the clinic to report left calf pain after walking around the block. Which additional information should the PN report to the healthcare provider? Muscle cramps occur at night when sleeping. Muscles are deconditioned from lack of regular exercise. Shooting pain occurs down the back of one leg when walking. The pain is immediately relieved when he sits down.

The pain is immediately relieved when he sits down. Rationale Atherosclerosis secondary to diabetes mellitus increases the client's risk for peripheral arterial disease, which is manifested by pain precipitated by walking. The pain is immediately relieved when the clients sits down to rest(intermittent claudication) (D) and should be reported. (A, B, and C) occur from different problems.

A male client with metastatic gastric cancer is being discharged home, but the client and family members are fearful of managing the client's symptoms at home. What action should the practical nurse provide? Ask the healthcare provider to tell the family about the care to give at home. Offer reassurance that they will be able to give daily care and medications. Re-enforce the steps that have been taught about home care for the client. Suggest a referral for the client to have hospice care provided in their home.

Suggest a referral for the client to have hospice care provided in their home. Rationale A client with metastatic gastric cancer who is terminally ill often experiences difficulty with emotional needs and physical symptoms that require specialized care during the dying process. Hospice services (D) in the home should be offered to the client and family to assist with both physical care and emotional adjustment with this stage of life and death. (A, B, and C) do not address the concerns voiced by the client and family.

An older client who has had a cataract in the right eye for several years tells the practical nurse (PN), "Now I have lost the sight in my right eye because I waited too long for treatment." What information should the PN provide? Prompt treatment can save the sight in both of eyes. Nothing can be done once sight is lost in the affected eye. Surgery can restore vision with corrective lens implants or glasses. Explain that surgery cannot provide optimal results immediately.

Surgery can restore vision with corrective lens implants or glasses. Rationale Removal of a cataract results in restoration of vision with corrective lenses based on the client's underlying error of refraction and retinal integrity. (A and D) are vague and do not focus on the client's fear and specific treatment. (B) is incorrect.

The practical nurse (PN) is evaluating the self-care of a client who is recovering at home after a laryngectomy. Which finding indicates to the PN that the client needs additional information? A cool mist humidifier is at the bedside. The salt water solution is dated 3 days ago. A Medic Alert bracelet is on the client's wrist. The client's stoma is covered with a crocheted scarf.

The salt water solution is dated 3 days ago. Rationale Salt water solution (B) should be changed daily to prevent bacterial growth. (A, C, and D) are within accepted parameters for care.

Which finding for a client who is 1-day postoperative for a partial thyroidectomy requires immediate follow-up by the practical nurse (PN)? High pitched expiratory sound. Throat pain rated "9." Voice is hoarse. Capillary refill is 4 seconds.

High pitched expiratory sound. Rationale Stridor indicates airway obstruction, which is a postoperative complication after thyroidectomy (A). (B, C, and D) should be addressed after preparing for interventions related to airway obstruction.

A 60-year-old client with benign prostatic hyperplasia (BPH) has been up to the bathroom six times during the night. The client asked the practical nurse (PN) if there is something the healthcare provider can do to help him with this problem before he has a transurethral resection of the prostate (TURP). What information should the PN offer? A prescribed diuretic can be taken in the morning to reduce night-time voiding. There are no other treatments unless there is evidence of cancer. Practicing pelvic floor exercises can reduce dribbling of urine. An indwelling catheter is sometimes prescribed to alleviate symptoms.

An indwelling catheter is sometimes prescribed to alleviate symptoms. Rationale To provide comfort and prevent urinary and kidney damage preoperatively, the insertion of an indwelling urinary catheter (D) can be prescribed to relieve urinary retention caused by the enlarged prostate that is encroaching on the urethra. (A, B, and C) are inaccurate information for the client's condition.

A client with newly diagnosed essential hypertension is learning to cope with stressful situations in his life. Which activity should the practical nurse (PN) implement to help the client learn constructive coping? Role play a situation the client identifies as stressful. Have the client list feelings indicating response to stress. Discuss with the client the behaviors used to respond to stress. Review maladaptive coping strategies that the client uses.

Role play a situation th client identifies as stressful. Rationale Role playing is an effective learning strategy that is useful in introducing and solidifying new coping mechanisms that the client can use. (B, C, and D) identify the client's stressors but are not effective learning activities.

Which finding is most important for the practical nurse (PN) to explore further for a client who had a total abdominal hysterectomy and bilateral oophorectomy yesterday? Right calf is 24 cm and the left calf is 21 cm. No bowel sounds or gurgles auscultated in the abdomen. No urine output 3 hours after the catheter is removed. Dried blood 3 cm in size noted on the abdominal dressing.

Right calf is 24 cm and the left calf is 21 cm. Rationale A client with major abdominal surgery is at risk for the complication of deep vein thrombosis (DVT) due to immobility, dehydration, and manipulation of major vessels. Unilateral leg swelling (A) is a classic sign of a DVT. Not having bowel sounds one day postoperatively (B) after a major abdominal surgery is an expected finding. (C) is not unexpected 3 hours after removal of a urinary catheter, and the PN should encourage the client to void 6 to 8 hours after the removal of a catheter before taking more aggressive actions. A small amount of dried blood is an expected finding (D). Which finding for a client who is 1-day postoperative for a partial thyroidectomy requires immediate follow-up by the practical nurse (PN)?

A client with epilepsy is having bilateral rhythmic jerking movements of all extremities. After calling for help, which action should the practical nurse (PN) do next? (Arrange the interventions from first to last.) 1. Maintain the client's airway. 2. Observe the client for incontinence. 3. Apply pads to the bedside rails. 4. Avoid stimulation during post-ictal phase.

1. Maintain the client's airway. 2. Apply pads to the bedside rails. 3. Observe the client for incontinence. 4. Avoid stimulation during post-ictal phase. Rationale During a tonic-clonic seizure (grand mal), the PN should maintain the client's airway. Next, the client should be protected from injury by padding the side rails. Observation of the client's behaviors, such as incontinence, should be noted during a seizure. Minimal stimulation should be maintained during the post-ictal phase to prevent precipitation of subsequent seizures.

The practical nurse (PN) is implementing a focused assessment of a client's musculoskeletal system. Which family history finding should the PN identify as an increased risk factor for the client? Osteoporosis. Osteomalacia. Osteomyelitis. Bony tuberculosis.

Osteoporosis. Rationale A familial predisposition is associated with an increased risk for osteoporosis (A). (B, C, and D) do not address the concepts of health and illness.

A client who was hit in the head with a baseball is admitted to the hospital for observation. Which finding requires the practical nurse (PN) to follow-up with further assessment? A negative Babinski reflex. Pupils respond to light equally. Headache rated "8" on a scale of 0-10. Reports the hospital room is an office.

Reports the hospital room is an office. Rationale The client's confusion about the hospital surroundings is an early sign of a change in mental status, which is consistent with findings associated with an increased intracranial pressure (D). (A and B) are normal findings. A headache is an expected finding due to trauma (C) and is not an indication of intracranial pathology.

The practical nurse (PN) is obtaining deep tendon reflexes for a client with type 1 diabetes mellitus. Which finding indicates to the PN that the client has peripheral neuropathy? Clonus noted at each ankle. Asymmetric reflex response. Hyperactive reflexes at the knee. Hypoactive reflexes at the Achilles tendon.

Hypoactive reflexes at the Achilles tendon. Rationale Diabetes mellitus can cause bilateral peripheral neuropathy indicated by hypoactive deep tendon reflexes (D) at the Achilles tendon. (A, B, and C) are inaccurate.

Which client medical diagnosis is a contraindication for peritoneal dialysis in a client with chronic renal failure? Anemia. Peritonitis. Diabetes mellitus. Hypercholesterolemia.

Peritonitis. Rationale Peritoneal dialysis is contraindicated for a client in renal failure with peritonitis (B), which compromises the effectiveness of the peritoneum as the semipermeable membrane for the exchange of solutes and waste products between the blood and peritoneal dialysate. (A, C, and D) are not contraindications for peritoneal dialysis.

A male client who had a stroke is incontinent of urine. Which action should the practical nurse (PN) implement in providing bladder training? Insert a Foley catheter at night to prevent accidents. Offer the client the commode or urinal every two hours. Decrease the client's oral fluid intake to one liter per day Instruct the client to hold his urine as long as possible.

Offer the client the commode or urinal every two hours. Rationale During a bladder training program, the commode or urinal should be offered every two hours (B) to establish a routine in bladder emptying and prevent urinary "accidents." (A, C, and D) are not indicated.

An adult client with otitis media has thick, yellow drainage from the right ear canal. What additional findings should the practical nurse (PN) expect to identify? Pain relief after ear drainage begins. Periauricle skin excoriation. Increased sensitivity to sound. Increased pain with movement of the pinna.

Pain relief after ear drainage begins. Rationale Otitis media is an infection of the middle ear that creates an increased pressure behind the tympanic membrane, which can rupture and drain purulent exudate. Acute ear pain (A) that lessens when ear drainage occurs is a sign of a ruptured tympanic membrane. (B, C, and D) are not expected findings with otitis media and acute tympanic membrane rupture.

Which finding should the practical nurse (PN) identify as typical for a client who is hypoxic? Temperature of 103 F. Hemoglobin of 10 grams/dl. PO2 of 80 mmHg. PCO2 of 30 mmHg.

Hemoglobin of 10 grams/dl. Rationale A decreased hemoglobin (B) reduces oxygen carrying capacity, causing tissue hypoxia. (A, C, and D) are not typical findings of hypoxia.

A client arrives at the oncology clinic for the next treatment in the prescribed course of chemotherapy (CT). The practical nurse (PN) reviews the client's laboratory results: white blood cells 700/mm 3 , red blood cells 2.8 million/mm 3 , hemoglobin 7.9 grams/dl, hematocrit 25.5%, and platelet count 14,000/mm 3 . Which action should the PN take first? Obtain the CT from the pharmacy for administration. Place an isolation mask on the client. Collect a blood sample for type and crossmatch. Notify the charge nurse of the client's results.

Place an isolation mask on the client. Rationale The client is experiencing significant bone marrow suppression, a potentially life-threatening complication of CT, and should be protected from airborne infectious agents. The PN should place a mask on the client until other precautions can be implemented (B). (A) should be withheld until further prescriptions are received. Although the client may need replacement of blood products (C), the priority is the prevention of infection. (D) should be implemented after providing the client with a mask to minimize risk for infection.

Which factor should the practical nurse (PN) identify that indicates a client needs to be screened for an aggressive breast cancer? Full and pendulous breast tissue. Pre-menopausal breast cancer in her mother. History of pubescent onset at 13 years of age. Breast feed before 20 years of age.

Pre-menopausal breast cancer in her mother. Rationale Pre-menopausal breast tumors are stimulated by estrogen and tend to be more aggressive tumors. Women with a first-degree relative who had pre-menopausal breast cancer are at a greater risk for a genetic link for aggressive breast cancer and should be screened early. The other findings are not factors indicating a client's need for early and regular screening for breast cancer.

A client who is 3 days postoperative after a laminectomy is coughing up thick green sputum and wheezing. What action is most important for the practical nurse (PN) to implement? Review need for consistent use of incentive spirometer. Encourage intake of oral fluids up to 3,000 ml daily. Reinforce the technique for effective coughing. Report the change in condition to the healthcare provider.

Report the change in condition to the healthcare provider. Rationale A productive cough of thick, green sputum is characteristic of a respiratory infection, so this change in the client's condition should be reported to the healthcare provider (D). (A, B, and C) should be implemented, but the priority is the need for additional treatment by the healthcare provider.

Which instructions should the practical nurse (PN) reinforce with a client who is preparing for discharge after placement of a permanent pacemaker implant? (Select all that apply.) Select all that apply Request the use of special hand scanning at airports. Avoid using cellular phones for long periods of time. Do not lean against the car while the engine is running. Keep the regularly scheduled follow-up appointments. Ingest a consistent amount of leafy green vegetables.

Request the use of special hand scanning at airports. Do not lean against the car while the engine is running. Keep the regularly scheduled follow-up appointments. Rationale A client who has a permanent pacemaker should receive reinforcement of instructions that prevent malfunction of the pacemaker (A and C). The client should implement (D) to ensure that no complications have occurred with the pacemaker. (B and E) are not indicated for a client with a pacemaker implant.

A client who received several units of blood for a hemorrhagic event is reporting muscle cramps and a tingling sensation. Which action should the practical nurse implement? Administer a PRN analgesic. Instruct client to breathe into a paper bag. Obtain blood specimens for hemoglobin and hematocrit levels. Review laboratory results for serum calcium and magnesium levels.

Review laboratory results for serum calcium and magnesium levels. Rationale Multiple transfusions can affect electrolyte balance because calcium-binding products are added to the units of blood to prevent coagulation. Serum calcium and magnesium levels (D) should be monitor to detect hypo-concentration of the electrolytes that contribute to neuromuscular irritability. The client's discomfort should be managed by correcting the electrolyte imbalance (A) before the onset of tetany. (B) is ineffective for these symptoms caused by hypocalcemia. (C) evaluates the client's response to the transfusion and are not specifically related to the client's onset of cramping and paresthesia after multiple transfusions.

What is the immediate assessment the practical nurse (PN) should implement for a client who returns to the unit after a cardiac catheterization? Evaluate color of toes. Assess apical pulse. Determine the IV infusion rate. Check the client's groin.

Check the client's groin. Rationale Cardiac catheterization is most commonly accessed using the femoral artery, so it is essential to check the groin puncture site (D) and pressure dressing for signs of hemorrhage or hematoma formation. Although (A, B and C) should be implemented during the postprocedure period, the risk for bleeding from the arterial puncture site is the first assessment.

Which action should the practical nurse take when handling a sample of cerebrospinal fluid (CSF) collected for diagnostic testing from a client? Implement standard precautions with the CSF specimen. Provide the client with instructions on droplet transmission. Use aseptic technique while transporting the collection tubes. Send specimen to the laboratory STAT to prevent sample deterioration.

Implement standard precautions with the CFS specimen. Rationale Standard precautions should be implemented for any potential contact with all body fluids (A). (B and C) are not indicated. (D) does not address the concept of safety.

While completing preoperative preparation for a client admitted for same-day surgery, what evaluation statement should the practical nurse identify as an important outcome? Reports optimal rest in the hours before surgery. Asks questions regarding the surgical experience. Leaves the nursing unit for the surgical department on time. Reads all surgical literature before the operation takes place.

Asks questions regarding the surgical experience. Rationale Preoperative preparation should be planned to allow the client and family time to ask questions and receive appropriate feedback (B). (A, C, and D) are not the most important client outcomes of preoperative care.

A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/minute. During the bed bath, the client complains of shortness of breath. Which action should the practical nurse (PN) implement? Increase the flow of oxygen by 2 L/min. Suction the trachea for several minutes. Document the symptoms after the bath. Assist the client into a Fowler's position.

Assist the client into a Fowler's position. Rationale Fowler's position (D) eases breathing by allowing greater expansion of the chest cavity. Both (A and B) increase the client's shortness of breath because an increased oxygen flow (A) reduces the respiratory drive for a client with COPD while suctioning (B) removes air from the airways. Although documentation (C) should be implemented, the client's distress should be addressed by repositioning the client.

The practical nurse (PN) is reviewing the health history of a client with coronary artery disease (CAD). Which finding should the PN identify that places the client at risk for stroke? Obesity. Breast cancer. Senile dementia. Atrial fibrillation.

Atrial fibrillation. Rationale Atrial fibrillation causes an increased incidence of microthrombi, which can become embolic and cause a cerebrovascular accident (CVA) or stroke (D). Although (A) is a risk factor for CAD, obesity is not directly related to cerebral infarction. (B and C) are not risk factors for stroke.

Which information should the practical nurse (PN) offer a female client who is at risk for recurrent urinary tract infection (UTI)? (Select all that apply.) Select all that apply Use vinegar solution douche regularly. Avoid wearing tight-fitting jeans. Limit caffeine and alcohol. Void before and after intercourse. Wipe the perineum from front to back.

Avoid wearing tight-fitting jeans. Limit caffeine and alcohol. Void before and after intercourse. Wipe the perineum from front to back. Rationale Correct selections are (B, C, D, and E). Voiding before and after intercourse (D), avoiding caffeine and alcohol (C), and not wearing tight jeans (B), as well as wiping the perineal area from front to back (E), reduce UTI risk. Frequent douching (A) does not reduce a client's risk for frequent UTIs.

The practical nurse (PN) is caring for a client with a chest tube connected to a closed chest drainage system to suction at 20 cm of water pressure. The sterile water in the suction chamber is gently bubbling at the water level of 15 cm. What action should the PN take? Increase the wall vacuum to cause vigorous bubbling in the suction chamber. Add sterile water to the suction control chamber to the 20 cm mark. Assess for an air leak after clamping the chest tube with a small hemostat. Encourage the client to breathe deeply and slowly every 2 hours.

Add sterile water to the suction control chamber to the 20 cm mark. Rationale The amount of suction applied to the chest wall is regulated by the amount of water in the suction control chamber, not by the amount of vacuum applied to the system. The gentle bubbling in the suction chamber causes water to evaporate and must be added periodically to the chamber (B) to the prescribed level of 20 cm. Turning the vacuum source higher (A) causes the bubbling to become vigorous and makes the water evaporate faster, but does not increase the amount of suction. An air leak is considered when there is continuous bubbling in the water-seal chamber, which is evaluated by clamping the chest tube momentarily for assessment (C). The client is encouraged to breathe deeply (D) to facilitate the lung expansion, but it does not affect the amount of negative pressure.

An older male with a history of emphysema arrives to the emergent care center with complaints of increasing dyspnea on exertion. The client's chest has an increased anteroposterior diameter, a dry, hacking cough, and pulse oximetry of 89%. What action should the practical nurse take? Encourage use of an incentive spirometer. Apply oxygen per nasal cannula at 2 L/minute. Check client's skin turgor and urine concentration. Provide client with a particulate respirator mask.

Apply oxygen per nasal cannula at 2 L/minute. Rationale Increased anteroposterior diameter of the chest (called barrel chest) is characteristic of emphysema. Oxygen levels should be given cautiously because a client with emphysema relies on a hypoxic drive to breathe, so low flow oxygen should be given (B) to maintain the oxygen saturation at 90%. Pursed lip breathing, not (A), is recommended. (C) provides information about the client's hydration status that may indicate a need for additional fluids to helps thin pulmonary secretions, but low flow supplemental oxygen should be provided. (D) is not indicated.

What information should the practical nurse (PN) reinforce with a client who is recently diagnosed with diabetes mellitus (DM)? Diabetes can be cured by the administration of insulin. Diabetes can accelerate the onset of presbyopia. Diabetes increases the risk for cardiovascular disease. Diabetes affects carbohydrate metabolism, not protein or lipids.

Diabetes increases the risk for cardiovascular disease. Rationale Glycemic control is vital with DM because hyperglycemia promotes lipid mobilization and hyperlipidemia, which increases the client's risk for damage to the lining of arteries, causing atherosclerotic cardiovascular disease (C). (A, B, and D) are inaccurate.

A client who has vomiting, dysuria, and urinary tract infection (UTI) arrives in the clinic and receives an IV antiemetic and a liter of IV fluids. The healthcare provider prescribes oral antibiotics for the client's discharge. Which finding is essential for the practical nurse to determine before the client is discharged? Temperature below 100.4 F (38 C). No vomiting with oral fluid intake. White blood cell (WBC) count below 13,000 mm3. Minimal dysuria with voiding.

No vomiting with oral fluid intake. Rationale The client must be able to tolerate oral fluids (B) to maintain hydration and take oral antibiotics at home. (A, C, and D) are expected findings of infection and are not criteria for discharge with a prescribed antibiotic regime.

Which finding for a client with heart failure (HF) should the practical nurse (PN) report to the charge nurse? Dry nonproductive cough. Respirations at 22 breaths/minute. Blood pressure of 145/90 mmHg. Distended neck veins while upright.

Distended neck veins while upright. Rationale A client who experiences jugular vein distention with the head of the bed elevated (D) is showing signs of increased preload associated with HF that indicates an increased workload on the heart. (A, B, and C) are not as significant as (D).

The practical nurse (PN) is visiting a male client with diabetes who has a new cast on his arm. The client's fingers are pale, cool, slightly swollen, and the radial pulse is strong. What should be the PN do first? Send client to the clinic so cast can be bivalved. Apply warm moist heat to the affected arm. Check the client's blood glucose level. Elevate the arm above the level of the heart.

Elevate the arm above the level of the heart. Rationale Arm casts can impinge circulation when in the dependent position, so the arm should be elevated above the level of the heart, ensuring that the hand is above the elbow, and reassess the extremity in 15 minutes (D). (A and B) are not indicated at this time. Blood glucose level (C) is not related to this circulatory issue.

Which client should the practical nurse consider at greatest risk for bacterial cystitis? A middle-aged female who has never been pregnant. An older female who does not use estrogen replacement. An older male with heart failure. A male who uses sildenafil (Viagra).

An older female who does not use estrogen replacement. Rationale Postmenopausal women who do not use hormone replacement therapy are at an increased risk for bacterial cystitis because of changes in the cells of the urethra and vagina (B). (A and C) are not relevant. Urinary tract infections (UTI) are reported in 3% of men on sildenafil (Viagra) (D) compared to the incidence of UTI in postmenopausal women.

After receiving report, the practical nurse (PN) begins assessment for a client with chronic obstructive pulmonary disease (COPD) who has just completed a respiratory treatment. The PN finds the client sitting upright in bed with oxygen at 6 liters/minute per nasal cannula. Which intervention is most important for the PN to implement? Auscultate anterior and posterior lung sounds bilaterally. Institute measures to reduce oxygen consumption. Decrease oxygen flow rate to 2 liter/minute and attach pulse oximeter. Verify the oxygen flow rate with the healthcare provider's prescription.

Decrease oxygen flow rate to 2 liter/minute and attach pulse oximeter. Rationale The PN should question the flow rate at 6 liters/minute for a client with COPD, which can reduce the respiratory drive and cause respiratory arrest. The first action is to reduce the oxygen flow rate and determine the client's pulse oximetry reading. (A and B) can be implemented after reducing the oxygen flow rate. Although the oxygen flow rate should be verified with the healthcare provider's prescription (D), the client's respiratory drive has been reset by a chronic elevated CO2 level caused by COPD and high levels of supplemental oxygen should not be given.

The practical nurse (PN) is reviewing the plan of care for a client scheduled for a surgical amputation of the left lower leg. Which nursing diagnosis should the PN use as the highest priority for this client after the surgery? Impaired walking. Impaired adjustment. Disturbed body image. Ineffective health maintenance.

Disturbed body image. Rationale The psychological impact of the removal of a limb results in a "Disturbed body image" (C), which is the highest priority after surgery that affects the client's ability to cope with walking, adjustment, and health maintenance. The client's perception of alterations in body image influences how the client achieves outcomes related to impaired walking (A), impaired adjustment (B), and ineffective health maintenance (D).

A male client is admitted with lower right abdominal pain for the past two days. During the focused assessment, the practical nurse (PN) observes that the client's abdomen is rigid with tense positioning. Which action should the PN implement? Withhold opioid use that contributes to constipation. Ask the client if he recently ate any gluten products. Determine if the client has biliary colic pain. Keep the client NPO for possible surgery.

Keep the client NPO for possible surgery. Rationale The client's symptoms of prolonged lower right abdominal pain accompanied by tenseness and guarding are indicative of possible appendix perforation and peritonitis. The client is should be NPO and prepared for possible surgery (D). (A, B, and C) are not indicated.

Which behavior demonstrates hopelessness in an older client with a terminal disease? Demanding extra attention. Seeking alternative care activities. Complaining about the treatment plan. Failing to follow medical recommendations.

Failing to follow medical recommendations. Rationale Hopeless individuals tend to be passive and uninterested in seeking care or following through with recommendations. The other behaviors are not as likely to be manifested by a client who is terminal and hopeless.

A male client is one day postoperative for surgical repair of a fractured femur when he suddenly experiences dyspnea, coughing, chest pain, and hemoptysis. Based on this data, what nursing diagnosis should the practical nurse address for this client? Knowledge deficit related to smoking cessation noncompliance. Anxiety related to internal cues that symbolize an aspect of trauma. Decreased cardiac output related to dysrhythmia. Impaired gas exchange related to altered blood flow to alveoli.

Impaired gas exchange related to altered blood flow to alveoli. Rationale Pulmonary embolism is a postoperative complication that results when a clot becomes mobilized and lodges in the pulmonary capillary bed. Impaired gas exchange (D) results from the infarction of pulmonary tissue. (A, B, and C) are not related to this client's presenting signs and symptoms.

A client with heart failure (HF) takes a daily tablet of furosemide (Lasix) and lisinopril (Zestril). Which finding during the clinic visit should indicate to the practical nurse that the client's condition is worsening? Dizziness when changing position. Reports urgency with urination. Sharp chest pain with arm movement. Sleeps with two additional pillows.

Sleeps with two additional pillows. Rationale Clients with worsening HF often require additional pillows to sleep comfortably at night (D) resulting from a deceased cardiac output that causes fluid backup into the alveoli when supine. Since ACE inhibitors can cause postural hypotension, clients should be advised to change positions slowly (A). Lasix can cause urinary urgency (B) when the bladder fills as a result of diuresis. (C) is likely related to muscle strain because the pain is movement-induced and not related to cardiac hypoxia.

A client with type 2 diabetes mellius (DM) presents in the clinic with a leg laceration that has not healed in two weeks. Which client data is most important for the practical nurse to collect? Serum electrolyte results. Use of vitamin C supplements. Daily administration of insulin. Fingerstick glucose level.

Finger stick glucose level. Rationale Poor wound healing is often a sign of uncontrolled diabetes mellitus, so a fingerstick glucose level should be obtained first (D). Although (A) should be monitored during diabetic ketoacidosis, the priority is to determine the client's glucose level in response to poor wound healing and possible infection. Vitamin C (B) intake can influence wound healing, but managing the client glucose level is the priority. Type 2 DM is usually managed with oral antidiabetic agents, and (C) maybe indicated to promote healing based on the client's serum glucose.

What complication is most important for the practical nurse to monitor for in a client who has a total hip replacement? Depression. Infection. Immobility. Contractures.

Infection. Rationale Infection associated with total joint replacement is a serious complication that can delay the client's rehabilitation in usual activities of daily living, so monitoring the client for signs of infection (B) is the priority observation. (A, C, and D) are postoperative problems secondary to infection that can be minimized by early physical therapy and activities that maximize the client's range of motion and prevent complications of bed rest.

A male client who is 6 hours post radical nephrectomy has a urine output of 20 ml/hour and his blood pressure has changed from 134/90 to 100/56 in the past hour. Which action should the PN implement? Notify the healthcare provider of the changes. Check the urinary catheter for kinks or blockage. Obtain the client's vital signs and output in one hour. Verify the patency and rate of the IV infusion.

Notify the healthcare provider of the changes. Rationale These findings indicate bleeding and poor renal perfusion, so the healthcare provider should be notified (A). (B, C, and D) should be implemented, but the client needs immediate prescribed treatment from the healthcare provider.

A male client with a crushing injury of the right lower leg from a tractor accident complains of numbness and tingling is his right leg and foot. The practical nurse (PN) determines the right leg is pale and he has a weak pedal pulse. What action should the PN take? Elevate the leg on pillows. Notify the healthcare provider. Apply warm, moist packs. Document the assessment.

Notify the healthcare provider. Rationale Acute compartment syndrome is characterized by marked sensory deficits, such as paresthesia, which precede vascular and motor signs consistent with compromised neurovascular integrity. Immediate notification of the healthcare provider (B) is essential. Elevation (A) and warm, moist packs (C) are ineffective. Although the findings should be document (D), the findings should be promptly reported to the healthcare provider for emergent care.

Which intervention is most important for the practical nurse to implement after giving a client an initial injection for the screening for allergies? Have the client remain on-site for 30 minutes after the injections. Remind the client to call the healthcare provider if a rash develops. Assess vital signs every 15 minutes for 1 hour after the injections. Teach the use of epinephrine injection if an allergic reaction occurs.

Have the client remain on-site for 30 minutes after the injections. Rationale In skin testing for allergies, symptoms of sensitivity to antigen exposure usually occur within 15 to 30 minutes of exposure. The client should remain on-site (A) at least 30 minutes after receiving the intradermal injection of an antigen to ensure the client's safety and determine the client's sensitivity response. Although reporting a rash (B), teaching injection of epinephrine (D), and monitoring of vital signs (C) may be provided, the most important action is to evaluate the client's initial reaction after exposure to the antigen.

An older female client with osteoporosis asks the practical nurse (PN) to explain why she is now 2 inches shorter than when she was younger. What information is best for the practical nurse (PN) to provide? Loss of calcium in the bones causes the change. Bones get shorter with age due to wear and tear. Less fluid in each of the disks between the vertebrae occurs with degeneration. It is a combination of wear and tear and calcium loss that causes the change.

It is a combination of wear and tear and calcium loss that causes the change. Rationale A biological theory of aging includes the wear-and-tear theory, which explains that after repeated use and damage, body structures and functions wear out because of stress. A normal spine at 40 years of age and osteoporotic changes at 60 and 70 years of age can cause a loss of as much as 6 inches in height. Small losses in the thickness of each of the intervertebral disks, which results from changes in disk consistency, erosion, and osteoporosis, can lead to significant changes in height (D). Calcium changes (A) and wear and tear (B and C) alone do not support significant height loss in aging, but a basic explanation of disk degeneration that combines several factors provides the client with the best information.

An older male client with osteoarthritis complains of stiffness and pain in his hips, knees, and feet each morning and asks the practical nurse (PN) why just these joints bother him. Which explanation should the PN provide? Advanced age eventually causes generalized joint pain. Poor circulation may cause pain in the lower extremities. Joint damage can occur from years of weight-bearing stress. Cartilage of the lower extremities is more likely to wear out.

Joint damage can occur from years of weight-bearing stress. Rationale Osteoarthritis (degenerative joint disease) causes degeneration of articular cartilage with hypertrophy of the underlying and adjacent bone and results from excessive wear and tear to cartilage in weight bearing joints (C). Poor circulation does not affect joint stiffness (B). (A and D) do not provide the client with specific information about his disease.

The practical nurse (PN) receives a report on a group of clients assigned for the day. Which priority assessment should the PN implement? Check the pulse oximeter for a client with myasthenia gravis. Assess a client with multiple sclerosis for bowel incontinence. Determine the presence of nuchal rigidity in a client with resolving meningitis. Perform Glasgow Coma Scale (GCS) assessment for a client with a concussion.

Check the pulse oximeter for a client with myasthenia gravis. Rationale Myasthenia gravis results in weakness of the upper body muscles, including the muscles involved in swallowing and respirations, so assessing the client for adequate oxygenation is essential (A). Bowel and bladder incontinence are anticipated symptoms of multiple sclerosis and are not urgent assessments (B). (C) and (D) are important assessments, but checking the oxygenation level of a patient with the possibility of respiratory compromise is most important.

A client who is 2-days postoperative for abdominal surgery has a nasogastric tube (NGT) to low continuous suction. The client tells the practical nurse (PN) his mouth is so dry that he has been drinking water to quench his thirst. Which potential imbalance should the PN monitor for development in the client? Fluid volume excess. Metabolic alkalosis. Hyperkalemia. Hypercalcemia.

Metabolic alkalosis. Rationale The continuous gastric suction and the fluids the client drank increase the washing out gastric hydrochloric acid, which places the client at risk for metabolic alkalosis (B). (A, C, and D) are unlikely with gastric suction.

The practical nurse (PN) is performing a shift assessment of a client with a fractured left hip that occurred in a motor vehicle collision 36 hours ago. Which finding should the PN report to the charge nurse? Both feet are cool to the touch. Pain rated "7" on a scale of 1-10. Pinpoint rash on upper chest that does not blanch. Ecchymosis 10 mm x 5 mm on left trochanter area.

Pinpoint rash on upper chest that does not blanch. Rationale The PN should report the presence of petechiae, a pinpoint rash that does not blanch (C) that occurs due to fat embolism, a complication related to long bone fractures, which can cause respiratory compromise and should be reported to the charge nurse. (B and D) are expected findings related to traumatic injuries and fractures. Additional assessment is needed to determine the significance of (A).

During the daily assessment of a client with emphysema, the practical nurse (PN) identifies that the client's chest is barrel-shaped and he is demonstrating pursed-lip breathing. Which additional finding requires follow up by the PN? Pulse oximetry is 90% on room air. White blood cell (WBC) count is 9,900 mm3. Dyspnea when ambulating in the hall. Rales auscultated bilaterally.

Rales auscultated bilaterally. Rationale Barrel chest and pursed-lip breathing are classic signs of chronic obstructive pulmonary diseases (COPD), such as emphysema. The presence of bilateral rales (D) indicates that is client has pulmonary congestion or an infection which can easily overwhelm a client with the disease and requires follow up. (A and C) are common findings for a client with COPD. (B) is within normal limits (norm WBC is 5,000-10,000 mm3 ).