NCLEX-PN

An older male client who is incontinent receives a prescription for a condom (external) catheter. Which step(s) should the practical nurse implement when applying the external catheter? (Select all that apply.) A. Wrap the adhesive strip in a spiral around the penis. B. Shave the perineal area before beginning. C. Apply skin prep to the penile shaft and allow to dry. D. Leave 1 to 2 inches between the tip of the penis and condom catheter.

(A,C,D) are correct. Spiral application of the adhesive strip (A) minimizes the risk of constricting blood flow to the penis. A skin prep to the skin of the penile shaft (C) ensures condom adhesion to the skin surface and prevents leakage. Adequate space between the tip of the penis and the end of the condom catheter (D) allows urine to drain (B,E) are unnecessary.

Which of the following patient populations are NOT candidates for the intranasal flu vaccine? A. A 2-year old male B. A 26-year old female with diabetes C. A 45-year old male with hypertension D. A 30-year old female that is 20 weeks pregnant

A 30-year old female that is 20 weeks pregnant Rationale: A 30-year old female that is 20 weeks pregnant. The live, attenuated intranasal flu vaccine may be given to people 2 through 49 years of age, who are not pregnant.

A woman in labor has been pushing for one hour and is not making progress. Which of the following conditions could be hindering the descent of the fetus in the second stage of labor? A. A full bladder B. A paracervical block administered during the first stage of labor C. Mother lying in a side-lying position D. Fetus in left occiput anterior position

A. A full bladder

A client develops a loud, brassy cough after a burn. What ordered intervention by the nurse is a priority? A. Administer oxygen as ordered B. Give the client small quantities of ice chips to suck on C. Request an order for an antitussive agent D. Tell the respiratory therapist to give the client humidified oxygen

A. Administer oxygen as ordered Rationale: Brassy cough and wheezing signs seen of inhalation injury. The first action by the nurse is to administer oxygen.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply A. Administering oxygen B. Inserting a Foley catheter C. Administering furosemide (Lasix) D. Administering morphine sulfate intravenously E. Transporting the client to the coronary care unit F.Placing the client in a low-Fowler's side-lying position

A. Administering oxygen B. Inserting a Foley catheter C. Administering furosemide (Lasix) D. Administering morphine sulfate intravenously

What is the priority nursing action after a subtotal thyroidectomy? A. Airway obstruction B. Hemorrhage C. Tetany D. Edema

A. Airway obstruction Rationale: A priority nursing action after a subtotal thyroidectomy is airway assessment because airway obstruction may occur postoperatively. It is a medical emergency and resuscitative equipment must be readily available in the client's room.

Which is the most common cause of postoperative hypoxemia? A. Alveolar collapse B. Bronchospasm C. Aspiration D. Pulmonary Edema

A. Alveolar collapse Rationale: The most common cause of hypoxemia after surgery is atelectasis.

A client with a right arm cast for fractured humerus states, "I haven't been able to straighten the fingers on my right hand since this morning." What action should the nurse take? A. Assess neurovascular status to the hand B. Ask the client to massage the fingers C. Encourage the client to take the prescribed analgesic D. Elevate the right arm on a pillow to reduce edema

A. Assess neurovascular status to the hand Rationale: This finding is suggestive of neurological injury as a result of pressure on nerves and soft tissue because of swelling.

Which ethical principle is the nurse utilizing when supporting the decision of a client to terminate chemotherapy treatments? A. Autonomy B. Confidentiality C. Fidelity D. Justice

A. Autonomy Rationale: The ethical principle supported in this situation represents the client's autonomy or right to make his/her own decisions.

Which ethical principle is the nurse utilizing when supporting the decision of a client to terminate chemotherapy treatments? A. Autonomy B. Confidentiality C. Fidelity D. Justice

A. Autonomy The ethical principle supported in this situation represents the client's autonomy or right to make his/her own decisions.

Cardiovascular drugs whose typical actions block the sympathetic stimulation to the heart and decrease the heart hate are called? A. Beta blockers B. Catecholamines C. Steroids D. Benzodiazepines

A. Beta blockers Rationale: Beta blockers such as propranolol (Inderal) target the beta cells in the heart thereby slowing it down.

A patient arrives in the emergency department with severe chest pain. Which assessment finding would indicate the need for cautious use of nitrates and nitrites? A. Blood pressure of 96/66 mm Hg B. History of hepatitis C. History of congestive heart failure D. History of heart attack 1 year ago

A. Blood pressure of 96/66 mm Hg Rationale: Hypotension is a possible contraindication to the use of nitrates because the medications may cause the blood pressure to decrease.

During teaching, the nurse discusses the major effects of beta-blockers during initial therapy. Which laboratory result should the nurse report? A. Blood sugar 60 mg/dL B. Potassium 4.0 mEq/L C. Hemoglobin 14 mg/dL D.WBC 6000/mm3

A. Blood sugar 60 mg/dL Rationale: Beta-blockers can mask the signs and symptoms of hypo/hyperglycemia.

An 82 year old female is brought to the ER with new onset of confusion. She typically lives alone and is independent. She does have incontinence and wears depends. What orders do you anticipate? A. CBC, U/A, IV antibiotic B. CT of head C. Admission for observation and neurology evaluation D. New diagnosis of dementia

A. CBC, U/A, IV antibiotic In the elderly, confusion may be the only sign of a UTI. Wearing wet depends may increase the risk the UTI. The CBC will assist in determining if urosepsis is present.

The practical nurse knows that human papillomavirus infection (HPV) can lead to: A. Cervical cancer B. Infertility C. Pelvic inflammatory disease (PID) D. Rectal cancer

A. Cervical cancer Rationale: HPV can lead to cervical cancer due to changes of the cervix from the genital warts. There is no known connection between HPV and infertility, PID, or rectal cancer.

When communicating with children, what most important factor should the nurse take into consideration? A. Development level B. Physical development C. Nonverbal cues D. Parental involvement

A. Development level Rationale: In order to engage in effective communication with children, nurses must take into consideration the developmental level of the child.

A patient is in the Emergency Department and reports a recent tick bite. The physician confirms that the patient has Rocky Mountain Spotted Fever. Which of the following drugs is the first line of therapy in this disease? A. Doxycycline B. NSAIDs C. Flagyl D. Acetaminophen

A. Doxycycline Rationale: Doxycycline is the first line treatment for adults and children of all ages, and is most effective if started before the fifth day of symptoms. Use of antibiotics other than doxycycline is associated with a higher risk of fatal outcome.

The nurse has made an error in documenting client care. Which appropriate action should the nurse take? A. Draw a line through error, initial, date and document correct information B. Document a late addendum to the nursing note in the client's chart C. Tear the documented note out of the chart D. Delete the error by using whiteout

A. Draw a line through error, initial, date and document correct information Rationale: An error in documentation requires that the nurse draw a single line through the error, initial and date the line, then document the factual and correct documentation in the medical record.

Which menu items are good choices for a client on hemodialysis? A. Egg white omelet, toasted plain bagel, and apple juice B. Oatmeal with skim milk, half a banana, and coffee C. Lentil soup, whole-grain toast, and whole milk D. Swiss cheese sandwich, cream of broccoli soup, and orange juice

A. Egg white omelet, toasted plain bagel, and apple juice Rationale: Egg white omelet provides high-quality protein, and the apple juice is very low in potassium.

During the initial 24 hours after an above-the-knee amputation, the nurse performs which priority action to properly manage the surgical site? A. Elevate the residual limb B. Loosen the dressing every 4 hours C. Maintain the residual limb in a dependent position D. Change the dressing as often as needed

A. Elevate the residual limb Rationale: Elevating the limb during the first 24 hours facilitates venous return, decreases swelling and promotes comfort.

Which of the following interventions is used to prevent compartment syndrome in a patient with a newly casted right lower extremity? A. Elevation of right lower extremity B. Application of heat C. Encourage ambulation to increase circulation D. Monitoring for symptoms of DVT

A. Elevation of right lower extremity Rationale: Compartment syndrome is caused by edema. Elevation of this extremity and application of ice are the best interventions to decrease edema

During a one-to-one conversation with a nurse, a client says, "I'm worried about my medication.'' The nurse replies, "Tell me more about that." The nurse's response is an example of: A. Focusing B. Clarifying C. Reflecting D. Refocusing

A. Focusing

What type of pelvis is most favorable for labor? A. Gynecoid B. Android C. Anthropoid D. Platypelloid

A. Gynecoid Rationale: The gynecoid type pelvis is a normal female pelvis that is transversely rounded or blunt. This is the most favorable for successful labor and birth.

Which technique should the practical nurse (PN) use to most accurately assess a client's baseline blood pressure during routine health examination? A. Measure the pressure in each arm while the client sits with the arm supported at heart level. B. Calculate the average blood pressure using readings obtained in both arms. C. Obtain the blood pressure first with client lying and then while standing. D. Take additional measurements for reading with 10 mm Hg difference.

A. Measure the pressure in each arm while the client sits with the arm supported at heart level. The blood pressure should be taken initially in both arms while the client is seated or supine with the arm bared, supported and positioned at the level of the heart (A). (B,C) are inaccurate in establishing a baseline blood pressure reading. Accurate assessment of baseline blood pressure is best obtained with sequential reading at 2 minute intervals when there is difference of 5mm Hg, instead of 10 mm Hg (D).

Which intervention should the practical (PN) use to prevent obstruction of a gastric feeding tube? A. Obtain a prescription for a liquid drug from instead of crushing tablets. B. Instill an acidic juice, such as cranberry, between intermittent feedings. C. Flush the feeding tube with an effervescent cola product to relieve clogs. D. Use an asepto syringe to plunge and aspirate the contents of the tube.

A. Obtain a prescription for a liquid drug from instead of crushing tablets. The administration of liquid medications rather than crushed medications, which do not always dissolve well, helps prevent clogging (A). (B,C,D) are not measures to prevent gastric feeding tube obstruction.

A 38 year old female client has undergone a right modified radical mastectomy for breast cancer. Post operatively, she experiences incisional pain and swelling and limited movement of her right arm. The surgeon has informed her that four of the lymph nodes were positive for cancer and that she will have to undergo chemotherapy. As the nurse caregiver for this client, which of the following is an immediate problem related to potential health? A. Pain B. Impaired mobility of arm C. Disturbed body image D. Grieving

A. Pain The pain postoperatively must be evaluated and treated prior to any of the other options.

A 38 year old female client has undergone a right modified radical mastectomy for breast cancer. Post operatively, she experiences incisional pain and swelling and limited movement of her right arm. The surgeon has informed her that four of the lymph nodes were positive for cancer and that she will have to undergo chemotherapy. As the nurse caregiver for this client, which of the following is an immediate problem related to potential health? A. Pain B. Impaired mobility of arm C. Disturbed body image D. Grieving

A. Pain The pain postoperatively must be evaluated and treated prior to any of the other options.

The nurse is caring for a pt. with a urinary catheter. The nurse should do which of the following to prevent a urinary tract infection? (select all that apply) A. Provide perineal care each day and after each bowel movement B. Change the catheter every day C. Encourage the pt. to drink fluids D. Ask the physician to prescribe prophylactic antibiotics E. Assess the pt. every shift for signs of infection

A. Provide perineal care each day and after each bowel movement C. Encourage the pt. to drink fluids E. Assess the pt. every shift for signs of infection

Patient presents with right sided rib pain after a fall. He complains of constant pain that is worse with deep inspiration. The CXR reveals a 5th right rib fracture. He is on 24 hour oxygen therapy and a history of asthma and chronic bronchitis. The physican orders pain medication. As a nursing measure you perform the following: A. Provide the patient with an incentive spirometer and teach him to perform incentive spirometry every hour while awake. B. Nothing further is needed. C. Instruct the patient to take his pain medication only at night so that he can sleep. D. Instruct the patient to move as little as possible to decrease pain.

A. Provide the patient with an incentive spirometer and teach him to perform incentive spirometry every hour while awake. The patient has comprised lung function causing increased risk for respiratory complications. The rib fracture pain will cause the patient to take more shallow breaths. Incentive spirometry will cause the patient to take deep breaths to prevent respiratory complications such as pneumonia.

A patient calls his primary care physicians office requesting an appointment. While talking with the patient he reports that about 5 weeks ago he experienced a TIA. He reports that he was discharged from the hospital with plavix 75mg. He states he took one tablet daily as prescribed and completed all 30 tablets. You do the following: A. Schedule the patient ASAP to resume Plavix B. Inform the patient that a 30 day course of plavix is the usual course of treatment post TIA C.Schedule the patient for a 6 month follow up appointment D. Advise the patient that no follow up is needed unless he is having a problem

A. Schedule the patient ASAP to resume Plavix. Plavix is an anti- platelet that is needed in order to prevent further TIAs or CVA and should be continued.

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse should check the client for which next? A. Smoking history B. Recent exposure to allergens C. History of recent insect bites D. Familial tendency toward peripheral vascular disease

A. Smoking history Rationale: The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger's disease). This is a relatively uncommon disorder, characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young men who smoke. The cause is unknown but is suspected to have an autoimmune component.

You are caring for a child with cerebral palsy. You notice that the child's movements are very stiff, and it is very difficult for him to move his joints. What types of cerebral palsy does this child exhibit? A. Spastic cerebral palsy B. Ataxic cerebral palsy C. Athetoid cerebral palsy D. Coritcate cerebral palsy

A. Spastic cerebral palsy Rationale: Spastic cerebral palsy causes stiffness and movement difficulties. Athetoid cerebral palsy leads to involuntary and uncontrolled movements. Ataxic cerebral palsy causes a disturbed sense of balance and depth perception.

You are caring for a child with cerebral palsy. You notice that the child's movements are very stiff, and it is very difficult for him to move his joints. What types of cerebral palsy does this child exhibit? A.Spastic cerebral palsy B. Ataxic cerebral palsy C. Athetoid cerebral palsy D. Coritcate cerebral palsy

A. Spastic cerebral palsy Rationale: Spastic cerebral palsy causes stiffness and movement difficulties. Athetoid cerebral palsy leads to involuntary and uncontrolled movements. Ataxic cerebral palsy causes a disturbed sense of balance and depth perception.

The nurse is explaining fetal circulation to a patient in the clinic. The nurse correctly educates the patient by stating the following: A. The umbilical cord contains two arteries and one vein B. The arteries carry oxygenated blood to the fetus C. The veins carry deoxygenated blood from the fetus D. The arteries provide nutrients to the fetus

A. The umbilical cord contains two arteries and one vein Rationale: The umbilical cord contains two arteries and one vein. The arteries carry deoxygenated blood and waste products from the fetus. The vein carries oxygenated blood and provides oxygen and nutrients to the fetus.

A patient has a chest tube placement post right thoracotomy. During assessment the nurse expects all of the following findings except: A. Use of accessory muscles with respirations. B. Water level in the chamber rises and falls with each respiration. C. Chest drainage flows into the first chamber. D. Evaluate tidaling by disconnecting chest tube from wall suction.

A. Use of accessory muscles with respirations. Use of the accessory muscles is an abnormal finding that could indicate air in the pleural sac.

A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The nurse responds that this procedure may stimulate which? A. Vagus nerve to slow the heart rate B. Vagus nerve to increase the heart rate C. Diaphragmatic nerve to slow the heart rate D. Diaphragmatic nerve to increase the heart rate

A. Vagus nerve to slow the heart rate Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The other maneuvers are the Valsalva maneuver of inducing the gag reflex and asking the client to strain or bear down. Medication therapy is often needed as an adjunct to keep the rate down or maintain the normal rhythm.

The nurse on the day shift reports that the narcotic count is incorrect. What is the most appropriate nursing action? A.Report discrepancy to nurse manager and pharmacy immediately B. Report the incident to the local board of nursing C. Do a recount with another staff nurse D. Report the incident to the state nurses association

A.Report discrepancy to nurse manager and pharmacy immediately Rationale: The nurse manager and pharmacy must be alerted immediately of any discrepancy in the narcotic count. These substances are regulated by the Drug Enforcement Agency. An incident report must also be completed.

The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client states which? A. "Smoking cessation is very important." B. "Moving to a warmer climate should help." C. "Sources of caffeine should be eliminated from the diet." D. "Taking nifedipine (Procardia) as prescribed will decrease vessel spasm."

B. "Moving to a warmer climate should help." Rationale: Raynaud's disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.

A client with a history of mechanical heart valves on warfarin (Coumadin) has an international normalized ratio (INR) of 2.5. Which priority action should the nurse implement? A. Assess for bleeding B. Administer the dose as ordered C. Give vitamin K (Aqua-Mephyton) D. Hold the dose and notify the provider

B. Administer the dose as ordered Rationale: Therapeutic range while on warfarin (Coumadin) therapy is to maintain the INR between 2-3, however, a client with mechanical heart because of the high risk for blood clots requires more anticoagulation, therefore the INR must be maintained between 2.5 to 3.5.

A nurse witnesses a nursing assistant push a client into a chair. Which element can the nursing assistant be charged with? A. Assault B. Battery C. Negligence D. Malpractice

B. Battery Battery is the unintentional touching the person without consent.

The nurse is caring for a client after receiving burns to more than 40% of the body. Which laboratory result is a priority to report in the first 24 hours? A. Serum glucose 115mg/dL B. Blood urea nitrogen 30 mg/dL C. Hematocrit 36% D. White blood count 10,000/mm3

B. Blood urea nitrogen 30 mg/dL Rationale: The rate at which the glomerular filters [GFT] will be diminished in the first 24 hour in response to extensive burns along with shift in fluid status.

A client has had an open reduction internal fixation (ORIF) of the right hip two days ago. There is a Jackson-Pratt (JP) suction device for drainage at the site and staple sutures which are open to air. Which assessment finding needs to be reported to the provider immediately? A. Absence of draining into the Jackson-Pratt B. Bright red drainage from the suture site C. A temperature of 98.0F D. pain scale rating of 6 out of 10

B. Bright red drainage from the suture site Rationale: Bright red drainage from the suture site indicates that hemorrhage is occurring and must be reported immediately to the surgeon.

A client with congestive heart failure is being discharged home on a diet restricting sodium to 2000 milligrams per day. The client demonstrates adequate knowledge of the discharge instructions by avoiding which of the following foods? A. Plain nuts B. Canned sardines C. Spinach D. Whole milk

B. Canned sardines Rationale: Canned sardines have the highest sodium content.

The nurse notes spasms of the right hand while checking the client's morning blood pressure. Which action should the nurse take? A. Assess the blood pressure B. Check the calcium level C. Perform a neurovascular assessment D. Notify the provider

B. Check the calcium level Spasms of the hand during blood pressure read is indicative of a Trousseau sign which is manifested when the Calcium level is below 8.6 mEq/L.

The nurse is to apply an Ace wrap to the client's right lower leg. Which action should the nurse take to ensure that the dressing is not too tight: A. Remove it every hour and reapply B. Check the pedal pulses C. Obtain a Doppler study to determine circulation D. Allow the wrap to remain in place for a minimum of 24 hours

B. Check the pedal pulses Rationale: To ensure that the Ace wrap is not too tight, the nurse should check the pulse, color, and temperature of the extremity.

Which client has the highest risk for a bacteremia? A. Client with a peripherally inserted central catheter (PICC) line B. Client with a central venous catheter (CVC) C.Client with an implanted infusion port D. Client with a peripherally inserted intravenous line

B. Client with a central venous catheter (CVC) Rationale: Central venous catheter insertion are placed into a vein in the neck or chest with the tip resting in the superior vena cava and carry the highest risk for bacterial infection of the bloodstream.

You are performing a skin assessment on a geriatric patient. Which of the following does not contribute to the findings? A. Loss of resiliency B. Collagen fibers are replaced by elastin fibers C. More fragile due to loss of subcutaneous fat. D. Capillary blood flow decreases which slows wound healing time.

B. Collagen fibers are replaced by elastin fibers Rationale: With age, elastin fibers are replaced by collagen fibers. This results in a loss of skin elasticity.

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally? A. Rhonchi B. Crackles C. Wheezes D. Diminished breath sounds

B. Crackles Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema.

During a neurologic examination, the notes the client's upper extremities are flexed, and internally rotated with plantar flexion of the lower extremities. What should the nurse document? A. Contractures B. Decorticate posturing C. Decerebrate posturing D. Tetany

B. Decorticate posturing Rationale: Decorticate posturing is a sign indicating that the client is neurologically decompensating. The client's upper extremities will be flexed, and internally rotated with plantar flexion of the lower extremities.

An older male client is sedentary complains of not having a formed bowel movement in four days and tells the practical (PN) that he feels rectal pressure and has a constant headache. The PN determines the client is having frequent small, liquids stools. Which nursing action should the PN take first? A. Provide frequent intake of oral liquids. B. Digitally assess for impacted stool. C. Give prescribed stool softener. D. Administer a mild analgesic.

B. Digitally assess for impacted stool. The presence of liquid stools with a pattern of no formed bowel movement for more than 3 days is indicative of an impaction, which should be determined by digital exam (B). After digital removal of the impaction (A,C,D) should be implemented.

When irrigating the eyes of a client, which action should the practical nurse implement? A. Instill the irrigant solution in the center of the eye so it flows out both sides of the eye. B. Direct the irrigation flow from the inner canthus to the outer canthus of the affected eye. C. Massage the irrigation fluid over the anterior surface of the eye using the upper eyelid. D Instruct the client to blink repeatedly as the irritant is place in the cognitive sac.

B. Direct the irrigation flow from the inner canthus to the outer canthus of the affected eye. Directing the flow from the inner canthus to the outer canthus (B) allows irrigation of the greatest area of the eye surface as the client lies on the affected side, which moves the fluid by the gravity and away from the nasolacrimal duct. (A,C,D) are incorrect.

The AIDS virus can be transmitted under specific conditions and through infected bodily fluids except: A. Blood B. Feces C. Semen D. Breast Milk

B. Feces Rationale: Feces is correct because it is the only answer mentioned in this question that is a bodily fluid but does not transmit the HIV virus.

A client develops sudden onset dyspnea, a respiratory rate of 36 breaths per minute, and pink, frothy sputum. Which diuretic should the nurse anticipate administering as ordered? A. Acetazolaminde (Diamox) B. Furosemide (Lasix) C. Mannitol (Osmitrol) D. Spironolactone (Aldactone)

B. Furosemide (Lasix) Rationale: The client is manifesting signs of pulmonary edema such as pink, frothy sputum, sudden onset difficulty breathing and rapid respiratory rate. The diuretic indicated is Furosemide (Lasix). Lasix is a potent loop diuretic used for rapid depletion of fluids.

Which laboratory diagnostic is useful when evaluating improvement in kidney function for a client with acute kidney injury (AKI)? A. Blood urea nitrogen (BUN) level B. Glomerular filtration rate (GFR) C. Serum creatinine level D. Urine output

B. Glomerular filtration rate (GFR) Rationale: GFR is the preferred diagnostic method for evaluating renal function.

A patient who is receiving lovastatin [Mevacor] experiences chest pain. CK level is 580 units/mL (CK-MM 99%) and troponin T 0.02 g/mL. Which organ is a priority for the nurse to monitor? A. Brain B. Heart C. Lungs D. Kidney

B. Heart Rationale: Troponin and CK-MM are specific to the heart.

A doctor is preparing to remove a chest tube from a client. Before removing the tube, the nurse should instruct the client to: A. Breathe normally B. Hold breathe and bear down C. Take a deep breath D. Cough on demand

B. Hold breathe and bear down Rationale: The client should be asked to hold breathe and bear down which prevents changes in pressure until an occlusive dressing is applied.

Treatment of breast cancer involves many modalities. All of the answers below are correct EXCEPT: A.Staging which shows the size and spread of the malignancy B.Identifying the presence of the BRCA ½ factor predicting risk for optimum treatment C.Performing breast-sparing surgery (lumpectomy) D.incorporating chemotherapy as an adjunct to surgery

B. Identifying the presence of the BRCA ½ factor predicting risk for optimum treatment. Identification of the BRCA ½ factor is used in the screening of breast cancer not in the treatment phase

All of the following effects on cardiac output(CO) are true EXCEPT: A.If the heart rate is decreased the cardiac output is decreased B. If strove volume is increased the cardiac output is decreased C. If there is a decrease in preload the stroke volume will be decreased D.If the afterload is decreased there is an increase in cardiac output

B. If strove volume is increased the cardiac output is decreased Rationale: When the stroke volume is increased, the cardiac output is increased.

Your patient falls out of the bed and you suspect a leg fracture. What is the first thing you should do? A. Call for STAT x-ray B. Immobilize the leg before moving the patient C. Fill out incident report D. Call patient's family

B. Immobilize the leg before moving the patient Rationale: The most important thing to do first is to immobilize her leg before moving her.

In which situation should the nurse accept an assignment but complete a protest of assignment? A. Floating to another unit B. Insufficient staffing C. Strike D. Mass disaster

B. Insufficient staffing If an assignment is to care for clients than what is reasonable, it needs to be brought to the attention of nursing manager/and or supervisor. Protest of assignment do not relief a nurse of their responsibility but the nurse is attempting to act reasonable.

Which medication use by the client with a history of chronic kidney disease (CKD) requires further teaching? A. Liquid iron B. Milk of magnesia (MOM) C. Calcium phosphate (PhosLo) D. Ascorbic acid (Vitamin C)

B. Milk of magnesia (MOM) Rationale: Pharmacokinetically, magnesium is excreted by the kidneys. A client with chronic kidney disease should not use any products containing magnesium.

What effects of angiotensin-converting enzyme (ACE) inhibitors most often results in the provider changing the treatment plan to an angiotensin receptor blocker [ARB]? A. Orthostatic hypotension B. Nagging nonproductive cough C. Fatigue D. Hyokalemia

B. Nagging nonproductive cough Rationale: Due to the release of bradykinin , ACE Inhibitors cause a nagging, dry, hacking nonproductive cough.

Which action should the practical nurse (PN) follow when applying an elasticized bandage to a client's leg? A. Secure the end with metal clips B. Overlap turns of the bandage equally. C. Adjust the tension as needed. D. Wrap from the proximal to distal end.

B. Overlap turns of the bandage equally. The overlapping turn of the elasticized bandage should be evenly wrapped (B). Metal clips (A) may release and cause injury to the client. Tension (C) should be consistent through out the application of the bandage. The bandage should be applied from the distal end to the proximal end of an extremity, not (D).

During a neurologic assessment, a client demonstrates swaying with eyes closed. Based on this finding, which condition should the nurse suspect? A. Positive Babinski B. Positive Romberg sign C. Positive Weber test D. Negative Romberg

B. Positive Romberg sign Rationale: Swaying with eyes closed is indicative of a positive Romberg sign indicating a condition known as proprioception.

A patient presents for a 2 week blood pressure check after his metoprolol tartrate was increased to 50 mg in the morning and 25mg in the evening. The patient's blood pressure is 150/78. He denies any signs of hypertension. Prior to the patient having any further adjustments in his medication what additional information is needed? A. Nothing B. Pulse rate C. Labs D. Orhtostatic blood pressures

B. Pulse rate. Metoprolol slows the heart rate and any further increase could not be made if the patient's heart rate is low.

A 65 year old African American female has been diagnosed with lung cancer and is scheduled for a left thoracotomy. As the nurse caring for this client you understand that the major determining factor of this client's health is the fact that A. She is African American and lacks health insurance B. She chose to smoke all of her adult life C. Her mother died of lung cancer at about the same age D. She has limited ability to understand and act on health information post-operation

B. She chose to smoke all of her adult life She chose to smoke all of her life which influences the rest of her health going forward.

A 65 year old African American female has been diagnosed with lung cancer and is scheduled for a left thoracotomy. As the nurse caring for this client you understand that the major determining factor of this client's health is the fact that: A. She is African American and lacks health insurance B. She chose to smoke all of her adult life C. Her mother died of lung cancer at about the same age D. She has limited ability to understand and act on health information post-operation

B. She chose to smoke all of her adult life she chose to smoke all of her life which influences the rest of her health going forward.

To facilitate drainage of oral secretions in a child who had cleft lip repair, the nurse should place the child in what position? A. Supine B. Side-lying C. Trendelenburg D. High-Fowler's

B. Side-lying Rationale: After repair of a cleft palate, the child should be placed in a side-lying position. This position helps promote drainage and maintain an open airway.

When assessing an elderly patient's skin turgor, you note that it is decreased. This means that: A. The patient is overweight B. The patient is dehydrated C. This is normal for an elderly patient due to normal skin changes D. The patient needs to eat more protein

B. The patient is dehydrated Rationale: Decreased skin turgor is an indicator of dehydration.

A patient with suspected ulcers is scheduled for a diagnostic gastroscopy. During the insertion of the scope the patient experiences a vasovagal response. The nurse should expect all except: A. The pt. is given atropine before the procedure. B. The pt.'s pupils become dilated. C. A pt. has an increase in gastric secretions D. The pt. has a decrease in heart rate.

B. The pt.'s pupils become dilated. Rationale: Stimulation of the vagus nerve does not dilate the pupils.

A patient is started on dopamine (Inotropin) via peripheral intravenous access site. Which effect should the nurse monitor while on this therapy? A. Hypotension B. Tissue necrosis C. Pitting edema D. Petechiae

B. Tissue necrosis Rationale: The infiltration of dopamine can cause extravasation and lead to tissue necrosis and sloughing.

A patient presents with a 2 week history of progressive increase in SOB with activity, increase in chest congestion and episodes of sweating so much that his shirt is soaked. He reports a productive cough of large amounts of green sputum. Upon assessment: T=98.2, P=110, R=24, B/P=138/70, POX=85% on RA. Lungs with inspiratory and expiratory wheezes. He appears to be in no distress. You anticipate the following orders: A. PO antibiotics and discharge to home B. Breathing treatment, CXR, IV antibiotic, oxygen, hospital admission C. Prepare for intubation or BiPap D. Home oxygen order

B.. Breathing treatment, CXR, IV antibiotic, oxygen, hospital admission. The patient is exhibiting signs of a respiratory infection such as pneumonia or exacerbation of COPD. The episodes of sweating indicate fever.

Treatment of breast cancer involves many modalities. All of the answers below are correct EXCEPT: A. Staging which shows the size and spread of the malignancy B. Identifying the presence of the BRCA ½ factor predicting risk for optimum treatment C. Performing breast-sparing surgery (lumpectomy) D. incorporating chemotherapy as an adjunct to surgery

B.Identifying the presence of the BRCA ½ factor predicting risk for optimum treatment. Identification of the BRCA ½ factor is used in the screening of breast cancer not in the treatment phase.

A patient tells the nurse that he enjoy eating garlic "to help lower his cholesterol level." Which drug has a potential interaction with the garlic? A. Acetaminophen (Tylenol) B.Warfarin (Coumadin) C.Digoxin (Lanoxin) D.Phenytoin (Dilantin)

B.Warfarin (Coumadin) Rationale: When using garlic, it is recommended to avoid any other drugs that may interfere with platelet and clotting function.

A client has a blood pressure of 140/70 after cardiac surgery. Based on the measurement, what is the mean arterial pressure (MAP)? A. 40 B. 80 C. 100 D. 300

C. 100 Rationale: To determine the mean arterial pressure: MAP= systolic + diastolic x2 MAP= 140 mm Hg + 2 (80 mm Hg) MAP= 300 mm Hg/3 MAP+ 100 mm Hg

You are the nurse working in an obstetrical clinic and assessing a patient who is 16 weeks pregnant. As you are assessing for fetal heart tones, you would expect a normal fetal heart rate if it were which of following? A. 70 beats per minute B. 100 beats per minute C. 140 beats per minute D. 200 beats per minute

C. 140 beats per minute Rationale: 140 beats per minute. Normal heart rate for a fetus is 120-160 beats per minute. If the heart rate is too high or too low, it could indicate that the fetus is in distress.

Ben was burnt by a chemical explosion. His face, chest, and front of both arms are burnt. What percentage of his body is burnt? A. 50% B. 31.5% C. 36% D. 49%

C. 36% Rationale: Based on the rules of 9's, face is 9%, chest 18%, front of both arms 9% (4.5% per arm) = 36%.

A patient presents with complaints of generally not feeling well for 2 weeks, fatigue and occasional dizziness. The patient is placed on a cardiac monitor which shows a regular ventricular rate of 33 and more P waves than QRS complexes that do not seem to be associated. The patient is most likely experiencing: A. 1st degree heart block B. Sinus bradycardia C. 3rd degree heart block D. Junctional rhythm

C. 3rd degree heart block In 3rd degree heart block there are more P waves than QRS complexes and there is no association between the P waves (atrial contraction) and QRS complexes (ventricular contraction).

A patient presents with complaints of generally not feeling well for 2 weeks, fatigue and occasional dizziness. The patient is placed on a cardiac monitor which shows a regular ventricular rate of 33 and more P waves than QRS complexes that do not seem to be associated. The patient is most likely experiencing: A. 1st degree heart block B. Sinus bradycardia C. 3rd degree heart block D. Junctional rhythm

C. 3rd degree heart block Rationale: In 3rd degree heart block there are more P waves than QRS complexes and there is no association between the P waves (atrial contraction) and QRS complexes (ventricular contraction).

Following a cholecystectomy, a client asks the practical nurse (PN) about dietary restrictions that may need to be followed. Which diet should the PN recommend? A. A low-cholesterol and high carbohydrate diet. B. Restricted sodium and increased fluid intake. C. A well-balance diet with no other restrictions. D. Small, frequent meals to reduce indigestion.

C. A well-balance diet with no other restrictions. Following a cholecystectomy, bile enters the small intestine continually rather than in response to food in the gastrointestinal tract, so a well-balanced diet with no specific restrictions should be recommended (C). (A,B,D) are not indicated.

You are caring for a patient who has hemophilia and fell during a 5K race. The patient's right knee is very swollen. Which would be the most appropriate immediate nursing action? A. Start an IV and prepare for administration of cryoprecipitate B. Type and cross patient for possible blood transfusion C. Apply ice pack and compression dressings to the knee D. Monitor the patient for increased swelling

C. Apply ice pack and compression dressings to the knee Rationale: Apply ice pack and compression dressings to the knee. RICE (rest, ice, compression, elevation) and priority actions for joint injuries, even with hemophilia patients. You would continue to monitor for additional swelling, but the first action would be to minimize additional swelling and stop the source.

The home hospice nurse visits a patient that is actively dying. The family reports that the patient has moist rattle with breathing. What medication will help the moist respirations? A. Roxanol sublingual B. Ativan PO C. Atropine eye drops sublingual D. Valium suppositories

C. Atropine eye drops sublingual Atropine eye drops sublingual will dry the secretions.

RBC 4.9 million, WBC 8,000, platelets 146,000, Hgb 16 g. Based on this lab report, which function of the blood is impaired? A. Oxygen carrying B. Infection fighting C. Blood clotting D. Size of RBC's

C. Blood clotting Rationale: Normal platelet count is from 200,000 - 400,000. The rest of the lab work falls in normal range.

A patient presents with a one week history of dizziness, left lower quadrant abdominal discomfort and 2 or 3 three black stools. You anticipate the following orders: A. Pain medication, PO antibiotics, discharge home. B. Home occult blood test for the stool, increase in fluids, return in one week for re-evaluation. C. CBC and CT scan to rule out diverticulitis. D. Bed rest, IV fluids, admission for observation.

C. CBC and CT scan to rule out diverticulitis Left lower quadrant pain and signs of GI bleeding may indicate diverticulitis. A CBC would assist in determining not only anemia but infection as well.

The nurse is caring for a diabetic patient and when making rounds, notices that the patient is trembling and stating they are dizzy. The next action by the nurse would be: A. Administer patient's scheduled Metformin B. Give the patient a glass of orange juice C. Check the patient's blood glucose D. Call the physician

C. Check the patient's blood glucose Rationale: Check the patient's blood glucose. The signs and symptoms appear to be that of hypoglycemia, but they could also represent other conditions. The first step in the nursing process is to assess and gather all the required information. Obtaining the blood glucose reading would be beneficial before giving the diabetic patient orange juice or metformin.

Which assessment should the practical nurse (PN) make to the best evaluate a client's fluid status? A. Skin turgor B. Intake and output C. Daily body weight D. Serum electrolyte levels

C. Daily body weight Daily weights are the best indicator of fluid status (C) because a sudden increase or decrease in weight in 24-hours provides an estimate of fluid volume retention or fluid loss. Skin turgor (A) is used to measure a client's hydration status. Although in take and output (B) and serum electrolytes (D) provide supportive data of a client's fluid and electrolyte balance, variations in 2 pounds from one day to the next is the best indicator of fluid retention or loss.

Which of the following drug levels are not therapeutic? A. Digoxin 1.8 B. Theophylline 15 C. Dilantin 25 D. Lithium 1.4

C. Dilantin 25 Rationale: The normal range for Dilantin is 10-20 mcg/dl.

A patient with chronic low back pain is on extended release morphine twice a day for pain control. The patient has a pain contract in place. He requests a refill for his pain medication. Upon review of his request for pain medication refills you note that he has requested his pain medication at least 10 days later than expected the last three times. You have the patient come in to assess his use of the pain medication. He reports that he takes the pain medication once a day and he only uses the second dose if needed. What do you anticipate next? A. Authorization of a refill for his medication B. Instruction for use of extended release medication, review of the pain contract, decrease in dose to once a day C. Discontinuation of medication D. Change in the orders for one tablet of the extended release morphine daily with a second tablet daily as needed

C. Discontinuation of medication Extended release narcotics for chronic pain are meant to be taken on schedule and not as needed. A pain contract typically indicates that the narcotic will be taken as prescribed.

A patient with chronic low back pain is on extended release morphine twice a day for pain control. The patient has a pain contract in place. He requests a refill for his pain medication. Upon review of his request for pain medication refills you note that he has requested his pain medication at least 10 days later than expected the last three times. You have the patient come in to assess his use of the pain medication. He reports that he takes the pain medication once a day and he only uses the second dose if needed. What do you anticipate next? A. Authorization of a refill for his medication B.Instruction for use of extended release medication, review of the pain contract, decrease in dose to once a day C. Discontinuation of medication D. Change in the orders for one tablet of the extended release morphine daily with a second tablet daily as needed

C. Discontinuation of medication Extended release narcotics for chronic pain are meant to be taken on schedule and not as needed. A pain contract typically indicates that the narcotic will be taken as prescribed.

A nurse is taking care of a patient with leukemia. The nurse has just received an order to place the patient on neutropenic precautions. The nurse understands that the patient cannot have the following in his room: A. Toothbrush B. Bowl of vegetable soup C. Fresh floral arrangement from family D. Hand sanitizer

C. Fresh floral arrangement from family Rationale: Vase water and soil in plants contain large concentrations of potential pathogens, and decaying organic matter may contain fungus. Live plants and flowers are restricted from immunocompromised patient rooms. A person suffering from neutropenia often cannot eat fresh fruits or vegetables because of the bacteria they contain. Their food must be well cooked (soup is fine since it is heated thoroughly). That is because their immune system cannot tolerate the presence of the otherwise harmless bacteria that are ingested with fresh fruits and vegetables.

A patient presents requesting a nicotine replacement patch for smoking cessation. He reports that he is a long time smoker of 1 pack per day and that he is usually up once a night to smoke a cigarette. Based on this information the patient: A.Can quit cold turkey without any problems B. Requires a low dose patch C. Has a high level of nicotine addiction D. Will not be able to stop smoking

C. Has a high level of nicotine addiction. A patient waking up at night for a cigarette indicates a higher level of addiction to nicotine.

A nurse caring for a client with a platelet count of 60,000 should observe for which initial finding indicative of bleeding? A. Heart rate 58 beats per minute B. PaO2 80 mmHg C. Heart rate 118 beats per minute D. Blood pressure 110/60

C. Heart rate 118 beats per minute Rationale: In thrombocytopenia, the client will experience tachycardia because the heart has to beat faster to compensate for the drop in the amount of circulating volume and number of oxygen-carrying red blood cells.

A nurse is teaching a client about stroke prevention. Which risk factors should the nurse include in the teaching plan as the most important factor contributing to a stroke? A. Active lifestyle B. Alcohol use C. Hypertension D. Smoking

C. Hypertension Rationale: A complication of hypertension is a cerebral vascular accident and the client is at an increased risk for a stroke.

A client is shifted to the recovery unit after amputation of the left leg. Which of the following is the priority nursing action in the immediate postoperative period? A. Monitor Vital Signs B. Assess the proximal pulse at the amputated part C. Keep a surgical tourniquet t the bedside D. Administer IV fluids

C. Keep a surgical tourniquet t the bedside Rationale: Hemorrhage is the most concerning primary immediate complication of amputation. Therefore, a surgical tourniquet is kept at the bedside in case of acute bleeding.

Which lab value would you expect to be normal for a patient diagnosed with hyperparathyroidism? A. Calcium B. Parathyroid hormone C. Magnesium D.Phosphorus

C. Magnesium Rationale: With hyperparathyroidism, parathyroid hormone and calcium levels are increased and phosphorous levels are decreased.

The practical nurse (PN) is checking the surgical dressing for a client who arrived on the postoperative unit an hour ago. The dressing has an increase in the accumulation of serosanguinous drainage. What nursing action should the PN take? A. Reinforce the dressing with clean gauze sponges and tape. B. Change the surgical dress immediately to prevent infection. C. Mark the outlined area of drainage with date, time and initials. D. Collect a sample of the drainage for a culture and sensitivity.

C. Mark the outlined area of drainage with date, time and initials. The area of bleeding on the dressing should be outlined, dated, timed and initialed for future comparison and evaluation. (C). (A) is not necessary at this time. (B,D) are not indicated and require a prescription.

A client experiences an episode of pulmonary edema because the nurse forgot to administer the morning dose of furosemide (Lasix). Which legal element can the nurse be charged with? A. Assault B. Slander C. Negligence D. Tort

C. Negligence Rationale: The nurse committed an act of omission (Breach of Duty) thereby constituting an act of negligence.

Which element legally defines the nursing scope of practice for nursing? A. Healthcare providers B. Hospital standards of care C. Nurse practice Acts D. Professional nursing organizaetions

C. Nurse practice Acts Rationale: The State Practice Acts help determine the legal nursing scope of practice for nurses in each state.

As a nurse, you are at risk for musculoskeletal injuries. Which of the following is a modifiable risk factor you can address? A. History of musculoskeletal injury B. Aging C. Obesity D. Menopause

C. Obesity Rationale: Obesity is the only listed risk factor that is modifiable. The others are non-modifiable risk factors.

Which finding should the nurse report to the provider prior to a magnetic resonance imaging MRI? A. History of cardiovascular disease B. Allergy to iodine and shellfish C. Permanent pacemaker in place D. Allergy to diary products

C. Permanent pacemaker in place Rationale: In clients with implanted metallic devices such as pacemakers, an MRI is contraindicated.

Which condition would be a cause for secondary hypertension in a client? A. Urinary tract infection B. Syphilis C. Pheochromocytoma D. Acute pyelonephritis

C. Pheochromocytoma Rationale: Pheochromocytoma is a tumor of the adrenal glands. It causes increased production of adrenaline and norepinephrine which leads to long-term high blood pressure that is resistant to treatment.

A client admitted to the floor 3 days ago after a bowel resection suddenly develops chest pain and shortness of breath. Assessment of the client reveals rales, BP 160/40, and severe tachycardia. The nurse's first action should be to: A. Apply 02 at 2L/minute via mask B. Begin CPR C. Place the client in high Flower's position D. Administer a prescribed sedative

C. Place the client in high Flower's position Rationale: The client during the post-operative period with a widening pulse pressure, SOB, and rales may have a pulmonary emboli. To facilitate breathing, he should be placed in high Flowler's position. Oxygen would the be applied.

A client with cancer who has been taking opioid analgesics for two years now requires increased does to obtain pain relief. The client expresses fear about becoming addicted to these drugs. What information should the practical nurse (PN) provide? A. Opioid use with cancer does not cause addiction. B. Addiction is easily reversed if it occurs during pain management. C. Prescribed opiates for cancer pain relief improve qualify of life. D. Opioid dosages can be tapered if a client fears addiction.

C. Prescribed opiates for cancer pain relief improve qualify of life. The goal of pain management for clients with cancer using opiates is to minimize pain and maintain quality of life (C), making pain relief, rather than addiction, the primary goal. (A,B,D) do not provide accurate information.

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The nurse understands that a life-threatening complication of this condition is which? A. Pneumonia B. Pulmonary edema C. Pulmonary embolism D. Myocardial infarction

C. Pulmonary embolism Rationale: Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension

Among the reasons for a primary risk assessment for the development of cancer in women are all of the following EXCEPT: A. Detecting a trait or characteristic of cancer can be associated with the development of cancer B. Identifying the client who has started menses before age 12 as a risk factor in the development of cancer C. Recognizing that living in certain areas of the United States have been found to be conclusive risk factors for developing cancer D. Understanding that the discovery of a family history that includes at least one family member who has been diagnosed with cancer as a risk factor

C. Recognizing that living in certain areas of the United States have been found to be conclusive risk factors for developing cancer. Cancer occurrence in various parts of the USA is a risk factor due to various carcinogens, but it is by no means conclusive.

Which of the following is true about ovarian hormones, follicle-stimulating hormone and luteinizing hormone? A. They are released from the adrenal glands B. They stimulate the formation of milk C. Secretion leads to changes in the endometrium D. Secretion means the female is pregnant

C. Secretion leads to changes in the endometrium Rationale: Secretion leads to changes in the endometrium. FSH and LH are released by the anterior pituitary gland. They produces changes in the ovaries and the secretion of ovarian hormones leads to changes in the endometrium.

A patient with Parkinson's disease is noted to be at risk for Falls related to an abnormal gait. The nurse would observe what type of gait with a patient with Parkinson's disease? A. Unsteady and staggering B. Wide base and waddling C. Shuffling and propulsive D. Dragging of one foot

C. Shuffling and propulsive Rationale: The patient with Parkinson's Disease has a gait that is characterized by short, accelerating, shuffling steps. 16/30 38%

A client is admitted to the hospital with possible rheumatic endocarditis. The nurse should check for a history of which type of infection? A. Viral infection B. Yeast infection C. Streptococcal infection D. Staphylococcal infection

C. Streptococcal infection Rationale: Rheumatic endocarditis, also called rheumatic carditis, is a major indicator of rheumatic fever, which is a complication of infection with group A β-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis. Options 1, 2, and 4 are incorrect.

What position should the practical nurse (PN) place a client in who is receiving an enteral tube feeding? A. Sitting upright B. Laying on the side C. Supine with the head of the bed elevated 30 to 45 degrees. D. Fowler's with the head of the elevated at 45 to 60 degrees.

C. Supine with the head of the bed elevated 30 to 45 degrees. To prevent the risk of aspiration during an enteral tub feeding, a client should be positioned with the head of the bed elevated 30 to 45 degrees (C), which uses gravitational flow to reduce reflux. Sitting upright (A) places pressure on the abdomen, including the stomach, and contributes to gastric reflux via the esophagus to the trachea. A side lying position (B) does not ensure the client's head of the bed is elevated. (D) places pressure on the stomach, as does (A), and increases the risk for gastric reflux and subsequently aspiration.

A nurse caring for a client diagnosed with a stroke is started on clopidrogrel (Plavix). Which adverse effect of the medication should the nurse monitor in the client? A. Hot flashes B. Confusion C. Tarry stools D. Abdominal pain

C. Tarry stools Rationale: The nurse must monitor for signs of bleeding in a client taking the antiplatelet medication, clopidrogrel (Plavix).

A patient has recently been diagnosed with a peptic ulcer. Upon reviewing lab data, the nurse notices that the patient's Helicobacter pylori titer is elevated. Which of the following would indicate the best understanding of the data? A. Treatment will be to continue to assess and monitor Helicobacter pylori titers B. Treatment involves educating the patient to avoid solid foods C. Treatment will consist of Ranitidine and Antibiotics D. Treatment will involve surgical intervention

C. Treatment will consist of Ranitidine and Antibiotics Rationale: One of the causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the gastric and duodenal mucosa which decreases the gastric epithelium's resistance to acid digestion. Giving antibiotics will control the infection and Ranitidine, which is a histamine-2 blocker, will reduce acid secretion that can lead to an ulcer.

The nurse is caring for a pt. with Raynaud's phenomenon. The nurse should emphasize that the pt. can reduce symptoms of this disease by: A. Increase coffee to three cups each day B. Keeping the house at 68 degrees F. C. Wearing gloves when handling frozen foods D. Running cold water over her hands during an episode

C. Wearing gloves when handling frozen foods Rationale: Raynaud's phenomenon is characterized by vasospasm caused by extreme changes in temperature. Wearing gloves when handing cold caused by extreme changes in temperature. Wearing gloves when handing cold foods can help prevent the problem. This phenomenon is exacerbated by caffeine so the pt. should not increase caffeine intake. A house temperature of 68 degrees F is likely to increase vasospasm. During a vasospastic incident, the pt. can run warm water over her hands.

A patient presents to the emergency room with the following symptoms: Anxiety, dyspnea, rhonchi, fever, Oxygen saturation of 88%, and a pH of 7.21. The nurse realized that the patient suffering from: A. Respiratory Alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis

C.Respiratory acidosis Rationale: One of the key symptoms of respiratory distress syndrome is the inability of the respiratory system to exchange gases, resulting in respiratory acidosis.

Which lab value is abnormal? A. BUN 20 B. BUN 8 C. BUN 10 D. BUN 25

D. BUN 25 Rationale: normal lab value for BUN is 7-22.

A patient with a thermal burn comes to the clinic. Which is untrue regarding thermal burns? A. Most common type of burns B. Caused by flash or flame C. Caused by scalding D. Caused by vesicants

D. Caused by vesicants Rationale: Burns that are caused by vesicants are classified as chemical burns.

A client explains to the nurse that they have been using a complementary medicine to control their cancer pain. As the caregiver to this client the nurse understands that all of the statements below regarding complimentary medicine are true EXCEPT: A. Complementary and alternative medicines are in direct contract to one another B. Complimentary therapies are adjuncts to conventional care C. Complimentary therapies are used by cancer patients with the belief that the therapies will control pain and improve physical or emotional well-being D. Complimentary medicine substitute conventional therapies

D. Complimentary medicine substitute conventional therapies Complimentary medicinal therapies are used in conjunction with standard methods of cancer care.

A client explains to the nurse that they have been using a complementary medicine to control their cancer pain. As the caregiver to this client the nurse understands that all of the statements below regarding complimentary medicine are true EXCEPT: A. Complementary and alternative medicines are in direct contract to one another B. Complimentary therapies are adjuncts to conventional care C. Complimentary therapies are used by cancer patients with the belief that the therapies will control pain and improve physical or emotional well-being D. Complimentary medicine substitute conventional therapies

D. Complimentary medicine substitute conventional therapies. Complimentary medicinal therapies are used in conjunction with standard methods of cancer care.

The American Nurses Association definition of nursing identifies which of the following activities that are in congruence with the Nurse Scope of Practice: A. Explaining the danger involved in a surgical procedure B. Discussing the risk of taking an investigational medication C. Determining the amount of IV fluid replacement needed for a patient admitted after a motor vehicle accident D. Contributing evidence to nursing research through nursing based studies on the effects of health policies on various cultural populations

D. Contributing evidence to nursing research through nursing based studies on the effects of health policies on various cultural populations Rationale: All of the other options are not in the nurses' scope of practice.

Nurses caring for the female cancer patient must be acquainted with a special perspective that focuses on the female. These perspectives include all EXCEPT: A. Coping skills supporting family interactions B. Emotional support regarding questions about changes in body image C. Informational support regarding lifestyle changes D. Decision making support regarding the type of surgery that best suites the clients cancer

D. Decision making support regarding the type of surgery that best suites the clients cancer. Helping the client make a decision about the type of surgery she must undergo is clearly not in the nurses' scope of practice.

A patient is diagnosed with acute pancreatitis. Which of the following is the best choice for pain control? A. Morphine B. Ibuprofen C. Fentanyl D. Demerol

D. Demerol Rationale: Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice because it is less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic.

The nurse is caring for a patient with multiple sclerosis. Which of the following symptoms is NOT indicative of the disease? A. Muscle weakness B. Trouble with coordination and balance C. Thinking and memory problems D. Hearing Loss

D. Hearing Loss Rationale: Hearing Loss. Common symptoms of MS include fatigue, weakness, spasticity, balance problems, bladder and bowel problems, numbness, thinking/memoray problems, vision loss, tremors and depression.

A symptom that a client is developing a complication of heart failure is: A.Increased weight gain B. Development of ascites C. Restless and confusion D. Increased liver enzymes

D. Increased liver enzymes Rationale: All of the symptoms mentioned are found in heart failure; however increased liver enzymes indicate congestion in the heart has reached the liver.

When irrigating the external ear canals of an older adult client, which action should the practical nurse (PN) use to soften dry cerumen for removal? A. Heat the container of irrigation solution to body temperature. B. Instill mineral oil in the external auditory canal overnight before irrigation. C. Use a 50 ml irrigation syringe to increase the force of flow. D. Insert a wick into the auditory orifice for 30 minutes before draining the solution.

D. Insert a wick into the auditory orifice for 30 minutes before draining the solution. Mineral oil (B) should be placed in the external auditory canal overnight to soften dry, impacted cerumen and facilitate removal. (A,C) can be implemented after the cerumen is softened for removal (D) is not effective

Which laboratory result would increase the risk of Torsades? A. Potassium 3.4 mEq/L B. Potassium 5.4 mEq/L C. Sodium 132 mEq/L D. Magnesium 1.0 mEq/L

D. Magnesium 1.0 mEq/L Rationale: Normal Mg is 1.5-2.5 mEq/L. Low magnesium levels increases the risk of Torsades a ventricular dysrhythmia.

Which situation necessitates the use of restraints on a client? A. Insufficient staffing on the unit B. The client is confused and combative C. Family request to make sure client is safe D. Medical evaluation and written provider orders

D. Medical evaluation and written provider orders Rationale: A medical evaluation and written healthcare provider orders that are timed and dated as per agency policy is required for the use of restraints.

A client in sickle crisis asks the nurse about food choices. Which food source should the nurse recommend to the client? A. Hamburger with French fries B. Pancakes with syrup C. Hot chocolate D. Orange popsicle

D. Orange popsicle Rationale: A priority for a client in a sickle cell crisis is hydration. The nurse should recommend food selection that will hydrate the patient such as ices, Popsicle, water, and gelatin. The client should avoid foods or caffeinated drinks.

The charge nurse has assigned a client with an open burn wound to the licensed practical nurse (LPN). Which instruction should the charge nurse give to the licensed practical nurse (LPN)? A. Administer a tetanus toxoid vaccine as ordered B. Assess wounds for signs of infection C. Tell the client cough and breathe deeply D. Perform hand washing upon entering room.

D. Perform hand washing upon entering room Rationale: Hand washing is the most effective for preventing infection transmission especially with a burn client.

The practical nurse (PN) observes a client who begins to choke during a meal. After determining that the client cannot speak, what action should the PN implement? A. Initiate cardiopulmonary resuscitation (CPR). B. Administer four upward abdominal thrusts. C. Sweep the airway with a hooked index finger. D. Place a fist halfway between the xiphoid process and umbilicus.

D. Place a fist halfway between the xiphoid process and umbilicus. After confirming a victim with foreign body airway obstruction(FBAO) cannot speak, the first should be placed between the xophoid and umbilicus (D), and a rapid sequence of abdominal thrust should be administered until the FBAO is relieved, not (B and C). If the victim becomes unresponsive, CPR (A) should be initiated after activating EMS.

A client diagnosed with acute pericarditis has a nursing diagnosis of pain related to pericardial inflammation. The appropriate nurse involvement would include: A. Administering opioids every four hours as directed B. Encouraging relaxation exercises such as deep breathing C. Positioning the client on the left side with head elevated 20 degrees D. Positioning the client in a Fowler position with an over-the-bed table to lean on

D. Positioning the client in a Fowler position with an over-the-bed table to lean on Rationale: Relief from pericardial pain is often obtained by sitting up and leaning forward.

A client on digoxin [Lanoxin] reports nausea, vomiting, and seeing yellow halos. Which laboratory finding should the nurse report immediately? A. BUN 8 mg/dL B. Magnesium 1.4 mEq/L C. pH 7. 46 D. Potassium 3.2 mEq/L

D. Potassium 3.2 mEq/L Rationale: The client on digoxin [Lanoxin] is at risk for digoxin toxicity as a result of hypokalemia. Toxicity is manifested by nausea, vomiting, abdominal cramps, anorexia and visual disturbances, such as halos.

Which of the following is not a part of the 6 rights of medication administration? A. Right time B. Right route C. Right medication D. Right reason

D. Right reason The six rights are right medication, dose, patient, route, time, and documentation

Which information should the practical nurse (PN) provide a client who is selecting a site for self-injection of insulin? A. Avoid a abdomen because absorption is irregular. B. Choose a different site at random for each injection. C. Give the injection in the same area each time to promote consistent absorption . D. Rotate sites within the same location for a week before choosing a new location.

D. Rotate sites within the same location for a week before choosing a new location. Intra-site rotation (within one anatomic site) (D) is preferred to rotation from one site to another (B) to prevent day-to-day changes in absorption. The preferred site is the abdomen. Which provided the most rapid insulin absorption not (A), followed by the deltoid, thigh and buttocks. Rotating injections sites prevents lipohypertrophy (increase fat deposits in skin) or lipoatrophy (Loss of fatty tissue, leaving an uneven appearance) both of which cause absorption inconsistencies, not (C).

Tests commonly incorporated in the diagnostic workup of women's cancer include all EXCEPT: A. Cancer-related checkups including examinations for thyroid, skin, lymph node and ovarian cancer B. Clinical breast exam (CBE), a manual breast examination performed by a trained clinician C. Mammography, an x-ray allowing visualization of a the internal structure of the breast D. Screening done on symptomatic clients to evaluate authenticity of disease process

D. Screening done on symptomatic clients to evaluate authenticity of disease process Screening is done on asymptomatic clients in the diagnostic workup stage.

Tests commonly incorporated in the diagnostic workup of women's cancer include all EXCEPT: A. Cancer-related checkups including examinations for thyroid, skin, lymph node and ovarian cancer B. Clinical breast exam (CBE), a manual breast examination performed by a trained clinician C. Mammography, an x-ray allowing visualization of a the internal structure of the breast D. Screening done on symptomatic clients to evaluate authenticity of disease process

D. Screening done on symptomatic clients to evaluate authenticity of disease process. Screening is done on asymptomatic clients in the diagnostic workup stage.

A post-operative hip replacement patient is having his dressing changed. The nurse is least concerned with: A. Inflammation B. Redness C. Purulent drainage D. Serous drainage

D. Serous drainage Rationale: Serous drainage does not indicate wound infection as the other symptoms do.

A patient is ordered metformin 1000mg twice a day for his diabetes. While talking with the patient he states "I never eat breakfast so I take a ½ tablet at lunch and a whole tablet at supper because I don't want my blood sugar to drop." As his primary care nurse you: A. Tell him he has made a good decision and to continue B. Tell him to take a whole tablet with lunch and with supper C. Tell him to skip the morning dose and just take the dose at supper D.Tell him to take one tablet in the morning and one tablet in the evening as ordered

D. Tell him to take one tablet in the morning and one tablet in the evening as ordered. The patient should take the metformin as ordered. Metformin does not cause low blood sugars due to the way it is metabolized.

A patient with COPD is given a Z-Pak for an exacerbation. He has an albuterol inhaler (MDI) at home ordered as 2 puffs 4 times a day as needed. The patient was instructed to use his MDI 2 puffs four times a day on schedule until he completes his antibiotic. The patient states I only use the inhaler when I go for a walk because I don't want to get hooked on it. You reply: A.You're correct; don't use the inhaler unless you absolutely have to use it. B. You will not become addicted if you stop using the inhaler 4 times a day as soon as you're antibiotic is done. C. The inhaler is not addictive when taken with an antibiotic D. The inhaler is not addictive at all and should be used more frequently during an exacerbation of COPD.

D. The inhaler is not addictive at all and should be used more frequently during an exacerbation of COPD. Albuterol is not addictive. It will help with SOB, coughing and clearing of secretions. It should be used more frequently and even on schedule during an exacerbation of COPD.

Knowledge of the breasts and their functions include: A. The breasts are supported by and attached to the chest wall, resting on the major scapular chest muscle B. The areolas deliver milk through the opening in the nipple C. Fibrosis, cysts, mastitis, contribute more than 70% added risk to developing breast cancer D. The major hormones affecting the breast are estrogen, progesterone, and prolactin

D. The major hormones affecting the breast are estrogen, progesterone, and prolactin The other statements are false.

The nurse is caring for a patient taking furosemide (Lasix). Which finding is most indicative of an adverse effect with this drug? A. Na 136 mEq/L B. Potassium 3.6 mEq/L C. Chloride 98 mEq/L D. Uric acid 15 mg/dL

D. Uric acid 15 mg/dL Rationale: Hyperuricemia is an adverse effect of furosemide [Lasix]. Uric acid levels are extremely elevated.

A nurse is taking the health history of a client. What information would she consider significant in regards to cardiovascular health? A. A history of metastatic cancer B. Frequent viral bronchitis C. Use of calcium supplements D. Use of recreational drugs

D. Use of recreational drugs Rationale: The use of recreational drugs, especially stimulants such as cocaine is a growing cause of heart irregularities.

Cancer can occur in the lining of the uterus, the endometrium. Women must be alert to the fact that these disorders of the endometrium can cause the same symptoms whether the disease is benign or malignant. A symptom that occurs in endometrial cancer that is different from endometriosis is: A. Irregular menstrual bleeding B. Lower back or pelvic pain C. Painful urination D. Vaginal bleeding between periods

D. Vaginal bleeding between periods The most common symptom of endometrial cancer is vaginal bleeding between periods.

Cancer can occur in the lining of the uterus, the endometrium. Women must be alert to the fact that these disorders of the endometrium can cause the same symptoms whether the disease is benign or malignant. A symptom that occurs in endometrial cancer that is different from endometriosis is: A.Irregular menstrual bleeding B. Lower back or pelvic pain C.Painful urination D. Vaginal bleeding between periods

D. Vaginal bleeding between periods The most common symptom of endometrial cancer is vaginal bleeding between periods.

Knowledge of the breasts and their functions include: A. The breasts are supported by and attached to the chest wall, resting on the major scapular chest muscle B. The areolas deliver milk through the opening in the nipple C. Fibrosis, cysts, mastitis, contribute more than 70% added risk to developing breast cancer D. The major hormones affecting the breast are estrogen, progesterone, and prolactin

D.The major hormones affecting the breast are estrogen, progesterone, and prolactin. The others statements are false.

Nurses caring for the female cancer patient must be acquainted with a special perspective that focuses on the female. These perspectives include all EXCEPT: A. Coping skills supporting family interactions B. Emotional support regarding questions about changes in body image C. Informational support regarding lifestyle changes D. Decision making support regarding the type of surgery that best suites the clients cancer

Decision making support regarding the type of surgery that best suites the clients cancer. Helping the client make a decision about the type of surgery she must undergo is clearly not in the nurses' scope of practice.

Which medication can be used in a client with chronic kidney disease (CKD) to help stimulate red blood cell production? A. Epoetin (Epogen) B. Filgrastim (Neupogen) C. Cobalamin (Vitamin B-12) D. Warfarin (Coumadin)

Epoetin (Epogen) Rationale: Erythropoietin controls red blood cell production. It is used to treat anemia as a result of diminished endogenous production of erythropoietin in clients with chronic kidney disease.

A nurse is caring for a client admitted with left-sided heart failure. Which assessment finding supports the diagnosis? A. Dry mucous membranes B. Hypotension C. White frothy sputum D. Moist crackles

Rationale: Most crackles are associated with client in fluid volume overload as a result of left-sided heart failure.

Among the reasons for a primary risk assessment for the development of cancer in women are all of the following EXCEPT: A. Detecting a trait or characteristic of cancer can be associated with the development of cancer B. Identifying the client who has started menses before age 12 as a risk factor in the development of cancer C. Recognizing that living in certain areas of the United States have been found to be conclusive risk factors for developing cancer D. Understanding that the discovery of a family history that includes at least one family member who has been diagnosed with cancer as a risk factor

Recognizing that living in certain areas of the United States have been found to be conclusive risk factors for developing cancer. Cancer occurrence in various parts of the USA is a risk factor due to various carcinogens, but it is by no means conclusive.