NCLEX 2

Which discharge referral would be a priority for the nurse to make in order to promote continuity of care for a client following a colectomy and colostomy formation due to colon cancer? 1. Home health 2. Meals on Wheels 3. Hospice care 4. Registered dietitian

1

Which male client condition in the after-hours clinic should the nurse assess first? 1. Scrotal pain and edema. 2. Erection lasting for 2 hours. 3. Inability to void with a history of benign prostatic hyperplasia (BPH). 4. Purulent drainage from the penis.

1

A nurse from the maternity unit is pulled to the medical-surgical unit for the first four hours of the shift. Which clients would be appropriate for the charge nurse to assign to the nurse from the maternity unit? Select all that apply 1. Client with rheumatic fever 2. Client scheduled for an appendectomy 3. Client one day post cardiac catheterization 4. Client diagnosed with Methicillin-Resistant Staphylococcus Aureus 5. Client newly admitted with Guillian-Barre Syndrome

1,2,3

The home health nurse is assessing the home environment for threats to the safety of the toddler who lives in the home. Which observations should be included in this assessment? Select all that apply 1. Do stairs have guard gates? 2. Are safety covers on electrical outlet plugs? 3. Is the swimming pool inaccessible to the toddler? 4. Are cleaning supplies located out of the toddler's reach? 5. Are stairs brightly lit?

1,2,3,4

What developmental milestone does the nurse expect to see in an 18 month old toddler? Select all that apply 1. Says and shakes head "no". 2. Points to one body part. 3. Drinks from a cup. 4. Points to show someone what they want. 5. Kicks a ball. 6. Walks up and down stairs holding on.

1,2,3,4

A school nurse is planning to teach kindergarten students about oral health. Which points should the nurse include? Select all that apply 1. Do not drink soft drinks between meals. 2. Eat raw vegetables to help keep teeth clean. 3. Brush teeth twice a day with toothpaste that does not have fluoride. 4. Use a pea size amount of toothpaste. 5. Floss teeth daily.

1,2,4,5

The nurse is discussing obesity prevention with a group of parents who have 3 and 4 year old children. What should the nurse include? Select all that apply 1. Ensure at least 11 hour of sleep. 2. Do not put a TV in the child's bedroom. 3. Select a day care center that provides physical activity opportunities every 4 hours. 4. Limit 100% fruit juice to 6 ounces (180 mL) per day. 5. Walk after the evening meal while the child rides a bike or skates.

1,2,4,5

The nurse receives new primary healthcare provider prescriptions on a client diagnosed with Addison's disease. What prescription should the nurse question? Select all that apply 1. Weigh QD 2. IV of Normal Saline at 125 mL/hr 3. MRI of pituitary gland 4. Fludrocortisone acetate 0.1 mg by mouth T.I.W. 5. Dehydroepiandrosterone (DHEA) 5 mg by mouth every other day

1,4

The nurse is teaching a group of parents how to promote healthy teeth in their newborn. What should the nurse include? Select all that apply 1. Clean gums with a damp washcloth after feedings. 2. Use a firm-bristled toothbrush once teeth have erupted. 3. Beginning at birth use toothpaste the size of a pea. 4. Allow only milk bottles in bed. 5. Wean from bottle by 15 months.

1,5

The nurse is preparing discharge teaching instructions for a client post right radical mastectomy with reconstruction. What instruction should the nurse include? 1. Squeeze tennis ball with right hand every 2-4 hours while awake. 2. No blood pressure readings in right arm for one year. 3. Wear gloves when gardening. 4. Wear your watch on the left wrist. 5. Brush your hair with your left hand until pain free.

1., 3., & 4. Correct: Squeezing a tennis ball will help promote new circulation. Protect the hand and arm at all times. A tiny cut could turn into a major infection, so wearing gloves while gardening is a good idea. Since the mastectomy was on the right breast, the client can wear a watch on the left wrist. Do not wear anything constricting on the right wrist, or arm. 2. Incorrect: No blood pressure reading in right arm ever. 5. Incorrect: We want the client to use the affected arm when brushing hair. This will help promote new circulation and will help prevent frozen shoulder. So, this client should use the right hand to brush her hair. page 40 in student book

Which observations should the home health nurse discuss with the parents of a two year old regarding potential safety threats in the home? Select all that apply 1. Security gates at the stairs. 2. Cleaning supplies under sink cabinet. 3. No blinds on windows. 4. Use of space heaters. 5. Water heater temperature 140°F (60°C) 6. Use of tablecloths

2,4,5,6

A client is to begin external beam radiation for Ewing's sarcoma. What symptoms would the nurse teach the client to expect during radiation treatments? 1. Nausea and Vomiting 2. Skin shedding 3. Erythema with pain 4. Pancytopenia 5. Exhaustion

2., 3, 4 and 5. CORRECT. External beam radiation uses high energy proton rays to deliver radiation from outside the body. This therapy prevents cell reproduction and destroys cancer cells. Expected side effects can be topical or physiological, depending on the area radiated. Skin radiated by the beam becomes reddened (erythema), dry and peeling. Shedding skin and even blistering may occur because of multiple treatments. As radiation enters tissues, damage affects even healthy tissue like bone marrow. The client may eventually develop pancytopenia: a lack of all blood components, including red cells, white cells and platelets. As the body struggles with cancer and the effects of radiation, the client may experience severe or overwhelming fatigue which needs reported to the primary healthcare provider. 1. INCORRECT. Nausea and vomiting, along with other gastrointestinal symptoms, are usually associated with the use of chemotherapy and not necessarily radiation therapy. page 43 student book

After shift report, which client should the nurse see first? 1. Eight year old that is in skeletal traction. 2. Six year old who is 5 hours postop appendectomy. 3. Unattended two year old admitted for a sleep study. 4. Four year old cerebral palsy child with a tracheostomy admitted for urinary tract infection (UTI).

3

What would be the nurse's priority for a child who has arrived at the emergency department after sustaining a severe burn? 1. Start intravenous fluids. 2. Provide pain relief. 3. Establish airway. 4. Place an indwelling catheter.

3

A nurse walks into the medication area of a long-term care facility and sees a colleague taking a pill from a resident's supply of narcotics. The nurse says, "Please don't say anything. I need my job and I have a migraine." What actions should the nurse take? Select all that apply 1. Reassure the colleague that she won't tell this time. 2. Insist that the colleague get some help. 3. Report what was seen to the supervisor. 4. Send the colleague home. 5. Follow procedure to return medication to the resident's supply.

3,5

The nurse is teaching a group of female clients how to perform a self-breast exam. One client reports no family history of breast cancer and indicates disinterest in learning the technique. What is the most appropriate response by the nurse? 1. "You can ask your healthcare provider to do this with your yearly physical." 2. "If you have no family history of cancer, you won't need to worry about this." 3. "Self-breast exams may detect changes early enough for successful treatment." 4. "You have the right to refuse anything related to health because of client rights."

3. CORRECT. The nurse responds to this client's incorrect statement by presenting an accurate fact in a non-judgmental and open manner, allowing for further discussion about breast cancer facts. The nurse has a responsibility to provide the client important data about the topic of self-breast exams. I. INCORRECT. A breast exam completed only once a year is not often enough. Self-breast exams should be done monthly by both male and female clients. Some cancers are so aggressive that waiting a year could lead to a terminal diagnosis. 2. INCORRECT. This comment by the nurse is totally false. A family history of cancer is not a precursor to the occurrence of breast cancer. 4. INCORRECT. Though this closed-ended statement is accurate, the nurse has not provided the client with any information which could correct the client's misconceptions about breast-cancer.

A child is brought into the school nurse's office after a fall on the playground which resulted in a nose bleed. What initial action by the nurse is most appropriate? 1. Hold cup under nose and allow fluid to drip. 2. Place an ice pack on the back of the neck. 3. Have child lie down and elevate the feet. 4. Pinch the bridge of the nose for 10 minutes.

4

A school-aged child is being admitted for probable viral meningitis. What arrangement does the nurse need to make in order to prepare for this client? 1. Private room. 2. Negative air-flow room. 3. Droplet precautions including mask. 4. Needs standard precautions only.

4

An infant has been prescribed Bryant's traction for a diagnosis of developmental dislocated hips (DDH). At what degree of hip flexion should the nurse maintain the infant's hip for proper traction alignment? 1. 15 2. 30 3. 45 4. 90

4

The nurse admits a child with a history of cystic fibrosis (CF) with vomiting for 3 days, headache, and unusual behavior. What does the nurse anticipate the lab values will show? 1. Hypernatremia 2. Hypercalcemia 3. Hypocalcemia 4. Hyponatremia

4

The nurse is presenting a seminar to expectant teen parents regarding infant car seat safety. What statement from a teen parent indicates to the nurse that teaching was successful? 1. "It's okay to place the car seat up front as long as it faces backwards." 2. "The baby has to stay rear facing until at least 40 pounds or 40 inches." 3. "Regular seat belts can be used if the child does not like the booster seat." 4. "An infant must stay in the backseat, facing backward, till at least a year old."

4

The obstetrics nurse notes minimal variability with a late deceleration on the electric fetal monitor of a client that is 38 weeks gestation. Which action will the nurse take first? 1. Notify the primary healthcare provider 2. Apply 10 L O2 per nasal canula 3. Prepare for an emergency cesarean section 4. Reposition the client to the left side

4

A client admitted to the inpatient mental health unit asks if mail can be received from family. Which statement by the nurse indicates adequate understanding of client rights? 1. Clients can receive and send mail, but staff must check for hazards. 2. Clients are not allowed to receive mail while hospitalized. 3. Receiving mail from family is not encouraged. 4. Clients are allowed to send or receive mail after the first 72 hours after admission.

1

The nurse is performing a Denver Developmental Screening Test II on a 4 ½ year old. What behavior should the nurse expect the child to demonstrate? 1. Prepares own cereal without help. 2. Correctly copies a square. 3. Draws a person with at least 5 body parts. 4. Balances on each foot for more than 6 seconds.

1

The nurse is working on the inpatient mental health unit and determines that one of the clients has suicidal thoughts. The nurse initiates suicide precautions. Which rationale best validates the action? 1. The client has the right to a safe care environment. 2. The nurse may be sued for malpractice if injury occurs. 3. All clients on mental health units are placed on suicide precautions. 4. Clients are most likely to act on suicidal thoughts when energy is low.

1

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

1

What should the nurse teach the mother about appropriate sleep in teenagers? 1. Teens need about 8 to 10 hours of sleep each night. 2. Biological sleep patterns shift toward earlier wakening. 3. Typically do not require as much sleep as adults. 4. Teenagers do not exhibit the normal signs of sleep deprivation.

1

Which client should the RN assess first? 1. Client experiencing unstable angina. 2. Client with chronic emphysema experiencing mild shortness of breath. 3. Client five days post right-sided cerebral vascular accident. 4. Client diagnosed with Bell's palsy scheduled to be discharged.

1

Which statement by the client with children ages 5 months to 8 years old requires follow up by the clinic nurse? 1. "I give all my children a spoonful of honey at night when they have a cough." 2. "I serve my 8 year old a glass of orange juice with breakfast before school." 3. "I have children use Lavender scented soap to wash their hands before they eat. 4. "I play music for my children when it is time for them to take a nap."

1

A client who has terminal cancer tells the nurse that the opioid prescription, which is at the highest recommended dose, is not relieving the pain. What should the nurse tell the client? 1. "I will ask your primary healthcare provider to increase your dose of medication." 2. "You cannot have a higher dose of pain medication since you are at the maximum dose." 3. "Opioid addiction is a major concern. You don't want to take too much of this medication." 4. "Let's try some lemon essential oil to decrease your pain level."

1 1. Correct: There is no ceiling on the dose of an opioid for a cancer client. Dosage is only limited by side effects. It is client dependent, so this is an appropriate response by the nurse. 2. Incorrect: This statement is not true for the cancer client and would be an inappropriate response by the nurse. 3. Incorrect: This client is dying. We are not worried about addiction. We are worried about easing the pain and helping the client die with as little to no pain as possible. 4. Incorrect: Lemon essential oil is helpful in decreasing nausea. It is not useful in relieving pain. At this stage in the client's illness, opioid medication is the "gold standard". page 50

What signs/symptoms should the nurse assess for when caring for a client at risk for thrombocytopenia? 1. Conjunctival hemorrhage 2. Petechiae on inside of mouth 3. Purpura 4. Fever 5. Blood oozing from IV site

1,2,3,5 1., 2., 3., & 5. Correct: The problem is a low platelet count, so we are looking for signs/symptoms of bleeding such as conjunctival hemorrhage, petechiae on the arms, legs or inside the mouth, and ecchymosis or purpura. 4. Incorrect: Thrombocytopenia is a decrease in the number of circulating platelets in the blood. Fever is seen with neutropenia. page 52

A child weighing 75 lbs. (34.1 kg) is admitted to the unit with a diagnosis of bacterial meningitis. The child has been started on an IV of D5 NS at 100 mL per hour and IV antibiotic therapy has been initiated. Which assessment finding would need to be reported immediately to the healthcare provider? Select all that apply 1. Urinary output of 28 mL/hr. 2. Change in the level of consciousness. 3. Temperature of 101.2 degrees F (38.4 degrees C). 4. Increase of 5 mm Hg in systolic BP from baseline. 5. Sodium level of 130 mEq/L (130 mmol/L).

1,2,5

The nurse is participating in a presentation regarding adolescent violence to middle and high school faculty and staff. What risk factors for violence should the nurse include? Select all that apply 1. Attention deficit disorder 2. Diminished economic opportunities 3. Authoritative parenting style 4. Active in school sports 5. High parental involvement

1,2

What interventions would be appropriate for the nurse to make for a child who is in Bryant's traction? Select all that apply 1. Perform neurovascular checks every 2 hours. 2. Maintain hip flexion at 90 degrees with buttocks raised 1 inch (2.54 cm) off the bed. 3. Reposition child infrequently so that traction is maintained. 4. Place child prone for one hour daily to prevent contractures. 5. Remove adhesive traction straps daily to prevent skin breakdown. 6. Use wrist restraints to keep child from turning over.

1,2

A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident for assistive devices that will be needed upon discharge. Which resources should the case manager include for this client? Select all that apply 1. Plate guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip utensils 6. Large button closures on clothes

1,2,3,4,5

A nurse manager has several issues regarding staff maintaining proper infection control while caring for clients. What actions should the manager take regarding this issue? Select all that apply 1. Place colorful posters regarding infection control in conspicuous places on unit. 2. Monitor staff providing client care for the use of appropriate infection control. 3. Give staff a written test on proper infection control. 4. Have all staff read agency policy and procedures regarding infection control. 5. Dock pay of staff who do not maintain proper infection control. 6. Provide mandatory in-service sessions on infection control for every shift.

1,2,3,4,6

Which finding by the nurse would need to be reported to the primary healthcare provider immediately when caring for an infant who was born with a myelomeningocele? Select all that apply 1. High pitched cry 2. Eyes fixed downward 3. Increasing head circumference 4. Decrease in a feeding by 30 mL 5. Projectile vomiting

1,2,3,5

The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. The nurse received a client following surgery 8 hours ago. The first vital sign check was performed by the nurse. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. What was the rationale for this plan? 1. The nurse did not trust the new UAP. 2. The nurse prefers to check all vital signs on all clients. 3. The nurse is responsible for the assessment of all vital signs of post-op clients. 4. The nurse does not know the skills of the new UAP.

1,2,5

A client is placed on neutropenic precautions. What interventions should the nurse initiate? 1. Use antimicrobial soap for handwashing. 2. Post neutropenic precautions sign on door. 3. Administer acetaminophen for fever greater than 101 degree F (38.3 degrees C). 4. Administer platelets as prescribed. 5. Vital signs at least every 4 hours.

1,2,5 1., 2., & 5. Correct: We want to use antimicrobial soap to wash hands. Anyone planning to enter the client's room needs to know what to do prior to entering, so a sign with necessary instructions should be placed on the closed door. Vital signs should be done every 4 hours, minimally. If needed, take vital signs more frequently. 3. Incorrect: Don't administer acetamenophen. It can be toxic to the liver. 4. Incorrect: Platelets are not needed for a low white count. They are given when the client is thrombocytopenic. page 49

A client has returned to the room post stem cell transplant. What early signs of rejection should the nurse monitor for in the client? 1. Abdominal pain 2. Straw-colored urine 3. Jaundice 4. Pruritus 5. Diarrhea

1,3,4,5 1., 3., 4., & 5. These are early signs of rejection that the nurse must monitor for: abdominal pain, jaundice, pruritus or itching, and diarrhea. 2. Incorrect: There is nothing wrong with the color of this urine. A problem would be dark, tea colored urine. This indicates the breakdown of red blood cells. Page 47

Following chemotherapy for acute lymphocytic leukemia (ALL), the client's lab results indicate a white blood count of 1000 cells mm3. What measures should the nurse institute immediately? 1. Request to change IM antiemetic medication to oral pill. 2. Have client increase fresh fruits and vegetables in diet. 3. Obtain client's temperature at least every two hours. 4. Move client into isolation with a negative flow room. 5. Remove fresh flowers and limit visits from children.

1,3,5 1, 3 and 5. CORRECT. The client has neutropenia, an extreme decrease in the neutrophils of white blood cells. As the main infection fighting faction of WBCs, the client will be at great risk for infection. Reducing invasive procedures by eliminating an intramuscular injection is an important and positive change. Fever is generally an early sign of infection, so taking the client's temperature frequently may alert staff to problems before a serious complication occurs. Fresh flowers contain a variety of bacteria that could be deadly to this client while children are often carriers of viruses without actually showing indications of illness. 2. INCORRECT. Actually, clients with neutropenia are instructed to avoid fresh or raw fruits and vegetables since even proper handling and cleaning can leave traces of bacteria behind. 4. INCORRECT. Although the client should be placed in a private room with a closed door, negative airflow is not necessary. This type of room is reserved for those with active tuberculosis. Page 49

The nurse working in a pediatrician's office is teaching a couple with small children about proper medication administration for children. What statement by the couple would indicate that further teaching is needed? 1. We should carefully measure elixir medication with the provided dropper. 2. Our children should not watch us take medicine. 3. We tell our children the medicine is candy so they will take it without a fuss. 4. Even though medicine comes in a childproof container, we will put medication out of reach.

3

The pediatric nurse is assessing a child receiving an IV infusion of bleomycin for Ewing's sarcoma. Concerned about a decrease in the child's voiding, the nurse knows that the priority action is what? 1. Administer a prn diuretic. 2. Stop the infusion immediately. 3. Assess three shifts of intake and output. 4. Encourage sips of fluids every hour.

3

The nurse is preparing a class on cancer prevention. Which risk factor should the nurse discuss with the class as being a preventable risk factor? 1. Smoking tobacco 2. Drinking alcohol 3. Eating a high fiber diet 4. Increasing fish consumption 5. Protect skin from sunlight by using tanning beds

1., & 2. Correct: Tobacco is the #1 cause of preventable cancer. Alcohol plus tobacco are co-carcinogenic. 3. Incorrect: A low fiber diet is bad. You don't have much motility in your intestines, so you are retaining carcinogens longer. 4. Incorrect: Increasing fish consumption is a good thing. You want to avoid increased red meat consumption and animal fat. 5. Incorrect: Tanning beds are just as bad as exposure to sunlight. Both cause exposure to ultra-violet radiation. page 35 student book

Which goal is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit? 1. Reduction of anxiety 2. Referral to community resources 3. Identification of lifestyle changes 4. Verbalization of energy-conservation techniques

3

The nurse is educating a group of college students about cancer prevention and screening. Which secondary prevention actions should the nurse include? 1. Annual mamogram starting at age 40. 2. Maintain normal body weight. 3. Cancer support group. 4. Colonoscopy beginning at age 50. 5. Limit or eliminate alcohol intake.

1., & 4. Correct: Secondary prevention includes screenings to pick up on cancer early. Screening is very important because then we have a greater chance for cure or control. Annual mamogram starting at age 40 with two views of each breast is recommended if the client has no family history of breast cancer. Colonoscopy at age 50, then every 10 years after that if there has been no problem is also recommended. 2. Incorrect: Maintaining a normal body weight is considered primary prevention (ways to help prevent the actual occurrence of cancer). 3. Incorrect: Support groups and rehabilitation programs are considered tertiary prevention (focuses on the management of long term care for clients with complex treatments for cancer). 5. Incorrect: Limiting or eliminating alcohol intake is considered primary prevention. page 35-36 in student book

An 18 month old is admitted to the unit with a diagnosis of pertussis. The mother asks the nurse, "How did my child get this disease? I didn't think anyone got that anymore." What is the appropriate response by the nurse? 1. "Pertussis is a common childhood disease since there is no vaccine." 2. "Since not all children are immunized against pertussis, the disease has reemerged." 3. "Your baby got this disease because you didn't have your child immunized." 4. "Since your child is already sick, let's just focus on getting well."

2

A client is scheduled for surgery today. As the nurse prepares the pre-op medication, the client says, "I have changed my mind. I don't want to go through with the surgery." What should the nurse do first? 1. Convince the client to proceed with the plans for surgery. 2. Notify the surgery department to cancel surgery. 3. Notify the primary healthcare provider of the client's decision. 4. Suggest that the client talk over the decision with family members.

3

A concerned caregiver is asking the nurse about activities that would be best for her child who has been diagnosed with asthma. In order to minimize the risk of exercise-induced asthma, which activity would be best for the nurse to suggest? 1. Track 2. Basketball 3. Baseball 4. Soccer

3

A hospital has incorporated new equipment on all units without nursing or staff input. Frustrated staff members approach the nurse manager, requesting a resolution of the situation. What response by the nurse manager would be most appropriate? 1. "You are over-reacting to this new equipment." 2. "Perhaps you just need some further training." 3. "Unexpected changes can be difficult to accept." 4. "If we work together, everything will get better."

3

An LPN/VN has been floated to the emergency room following a chemical plant explosion. What task would be best to assign to the LPN/VN? 1. Identify and assess each incoming client. 2. Triage and assign color-coded tags to each client. 3. Gather and apply dressings to open wounds. 4. Initiate oxygen and IV lines as needed.

3

The nurse is planning care for a client admitted for chemotherapy. What interventions should the nurse initiate to prevent infection? 1. Change IV tubing every 48 hours. 2. Place supplies for client in room. 3. Limit nursing personnel in room. 4. Bathe perineum once daily. 5. Place in protective isolation.

2,3 2., & 3. Correct: They need their own cups; they need their own everything. You don't need to go to a general closet and get supplies for this client. They need their own blood pressure cuff and own stethoscope in the room. Their own stuff because you only want their bacteria in the room. Limit people in the room who could pass on an infection to the client. Limit visitors, nurses, and nursing personnel to only those necessary to care for the client. 1. Incorrect: IV tubings should be changed daily, not every 2 days. 4. Incorrect: Bathe warm moist areas like underarms, groin, and perineum twice a day. Moist areas are a great place for bacteria to grow. 5. Incorrect: There is no indication that this client needs to be in isolation. A private room is acceptable at this time. page 49

A client receiving chemotherapy reports nausea and vomiting after every treatment. What interventions should the nurse initiate to reduce this side effect? 1. Administer antiemetic immediately after treatment. 2. Provide music therapy. 3. Provide ginger ale to drink. 4. Apply acupressure bands to wrists. 5. Place peppermint essential oil diffuser in room.

2,3,4,5 2., 3., 4., & 5. Correct: All of these interventions will help prevent or decrease nausea and vomiting. Music therapy is a form of behavioral therapy that can help with relaxation and distraction. Ginger is a natural antiemetic, so providing ginger ale to drink is beneficial. Sea bands or acupressure bands on the wrist help to relieve nausea and vomiting. Peppermint is one essential oil that relieves nausea. It can be used in a diffuser so that client can smell the peppermint. 1. Incorrect: Antiemetic medications should be given one hour prior to chemotherapy rather than after receiving chemotherapy. page 47-48

The nurse is talking with a group of teenagers who have expressed an interest in getting a tattoo. What information about tattoos should the nurse provide? Select all that apply 1. Apply a moisturizer to the tattooed skin once a day. 2. Carefully consider the tattoo location as weight gain can distort the image. 3. Bloodborne risks of tattooing include Hepatitis and HIV. 4. Tattoo dyes can cause allergic skin reactions. 5. Tattoos can be inexpensively removed with little discomfort. 6. Make sure the tattoo artist removes the needle and tubes from sealed packages.

2,3,4,6 You want to moisturize more than once a day.

What developmental milestone does the nurse expect to see in a two month old baby? Select all that apply 1. Responds to own name. 2. Holds head up. 3. Rolls over from stomach to back. 4. Pushes down on legs when feet are on a hard surface. 5. Turns head towards sound. 6. Reaches for toy with one hand.

2,5

Which tasks can the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply 1. Reporting lab results to the client 2. Measuring intake and output 3. Discontinuing an IV 4. Discussing client condition with the client's spouse 5. Performing oral hygiene for an older client

2,5

A client had radiation seeds implanted to treat prostate cancer. When entering the room to initiate discharge teaching, the nurse observes the spouse emptying the client's urinal. What is the nurse's priority action? 1. Immediately escort spouse to ED to check radiation levels. 2. Begin discharge teaching to the client and spouse. 3. Have spouse wash hands thoroughly and apply sterile gloves. 4. Explain that spouse must remain outside the room until urinal is emptied.

2. CORRECT. Internal radiation, also called brachytherapy, is placed inside the body as close to the cancer as possible. Internal radiation therapy can be permanent or temporary as well as sealed or unsealed, which refers to the amount of radiation risk posed by the client. Implanted seeds used to treat prostate cancer are a type of sealed radiation, indicating the body fluids are not radioactive. Emptying the urinal poses no risk to the spouse. 1. INCORRECT. Implanted seeds are a type of sealed radiation. Therefore, the client's body fluids are not radioactive, though the spouse should use some precautions when in proximity to the client for a few days. No need to check the spouse for radiation levels. 3. INCORRECT. Even though the client will be immunosuppressed, there is no need for the spouse to use sterile gloves. However, washing hands and using regular gloves is always a good idea. 4. INCORRECT. The spouse does not need to remain outside the room, particularly since the client is about to be discharged home. The client's body fluids are not radioactive. page 41 student book

What action by the nurse, who is administering platelets to a client, would require the charge nurse to intervene? 1. Verifies prescription for platelet transfusion. 2. Confirm client has provided informed consent. 3. Hangs platelets immediately upon arrival from blood bank refrigerator. 4. Infuse platelets with normal saline solution.

3 3. Correct: The charge nurse needs to intervene here. NEVER infuse cold platelets, because the spleen will reject them if they are cold and not absorb them. So, room temperature for your platelets or they will do you no good. 1. Incorrect: The charge nurse does not need to intervene here. The nurse should check for a prescription to administer platelets. 2. Incorrect: This is also a correct action by the nurse, so there is no need for the charge nurse to intervene. 4. Incorrect: Normal saline is the acceptable fluid to hang with blood and blood products, so the charge nurse does not need to stop the nurse. page 53

The nurse is educating a group of college students about early signs and symptoms of cancer. When explaining the mnemonic "C-A-U-T-I-O-N", the nurse explains the 'N' stands for what sign/symptom? 1. Nausea 2. Nipple drainage 3. Nagging cough 4. Nose bleeds page 36 student book

3. CORRECT. The mnemonic "C-A-U-T-I-O-N" represents an easy way to recall the seven early warning signs and symptoms of potential cancer. Each letter indicates a specific body alteration that should be reported to the primary healthcare provider. 'N' stands for a nagging cough or hoarseness. 1. INCORRECT. Though indigestion and difficulty swallowing are considered among the seven warning signs of cancer, nausea and vomiting are vague symptoms which can be attributed to a variety of disorders. These do not represent the "N" in 'CAUTION'. 2. INCORRECT. While any type of drainage from the breast should be reported to the primary healthcare provider, drainage is represented under the "U" for unusual discharge or bleeding. This is not the correct interpretation for the "N". 4. INCORRECT. A nose bleed could be the result of many factors, including clotting issues or even a dry environment. This symptom does not represent an early sign of cancer. page 37 on student book

A client is scheduled to be admitted to the surgical unit post total laryngectomy. What nursing intervention should the nurse include in the plan of care? 1. Position left-side lying, supine. 2. Place on clear liquid diet after peristalsis returns. 3. Monitor tracheostomy for pulsations with heart beat. 4. Provide mouth care every 2 hours. 5. Maintain a humidified environment.

3.,4., & 5. Correct: If a client's trach is pulsating with the heartbeat, you need to notify the primary healthcare provider immediately, as this could lead to rupture of the innominate artery. Frequent mouth care will decrease the bacterial count in the mouth. We are trying to prevent pneumonia. When breathing in and out through a trach, the client will not be able to warm, filter, and humidify the air. The air is really dry, so it irritates the trach. That is why when the client first gets the trach it has a lot of secretions. A humidified environment will help. 1. Incorrect: Where is the surgery? At the neck. Swelling! So place mid-fowlers, head of bed 35-45 degrees. 2. Incorrect: Peristalsis can disrupt the suture line. NG tube feedings will be provided to protect the suture line. page 39-40 student book

The night nurse on a step down unit suspects another nurse may be intoxicated. What initial action should the nurse take? 1. Ask another nurse to confirm suspicions. 2. Call supervisor to report the intoxication. 3. Confront the nurse privately in person. 4. Discuss suspicions with unit nurse manager.

4

The nurse asks if the client has an advance directive. The client responds by saying, "I have heard of advance directives, but I do not have one. What is an advance directive?" Which response by the nurse is appropriate? 1. Specifies your wishes regarding your personal effects and finances should you become unable to make decisions. 2. Specifies your wishes regarding healthcare and your finances should you become incapacitated. 3. Similar to a will, it specifies your wishes for burial should you die during hospitalization. 4. A form of a living will. It specifies your wishes regarding healthcare and treatment options should you become incapacitated.

4

What does the nurse need to remember when caring for clients on the oncology unit who have a radiation implant? 1. Nursing assignments should be rotated weekly. 2. The nurse should care for no more than 3 clients with a radiation implant per shift. 3. Limit visitors to 60 minutes per day. 4. Wear film badge throughout assigned shift. 5. Educate visitors to stay at least 6 feet from the client.

4., & 5. Correct. Wear a film badge at all times so that you know how much radiation you are getting.Visitors should stay at least 6 feet from the source to decrease exposure to radiation. The closer you get the more radiation exposure. 1. Incorrect: Nursing assignments should be rotated daily, so that the nurse is not continuously exposed. 2. Incorrect: The nurse should only care for one client with a radiation implant in a given shift. 3. Incorrect: Visitors should be limited to 30 minutes per day in order to decrease exposure to radiation. page 41-42 in student book