NCLEX PRACTICE QUESTIONS

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The nurse is wearing PPE (personal protective equipment). Place the steps to removing the PPE in the correct sequence. A. Remove gown B. Remove gloves and perform hand hygiene. C. Remove mask D. Remove eye protection. E. Perform hand hygiene.

(B,D,A,C,E) The gloves harbor the largest number of microorganisms from the client, and should be removed first. The nurse's hands may come in contact with the microorganisms while removing gloves, so hand hygiene should now be performed. The protective eyewear is no longer needed, and may be removed prior to any other action. The gown should now be removed, just prior to exiting the room. The mask is the last item of PPE to be removed, and should be removed at the doorway of the client's room. Once out of the room, perform hand hygiene because the hands may have come into contact with microorganisms in the process of removing the PPE.

Primary fluids used in hypovolemic shock

0.9% NaCl and Lactated Ringers

[A] pediatric client is seen in a clinic for treatment of attention-deficit/ hyperactivity disorder (ADHD). Medication has been prescribed for the client along with family counseling. The nurse is teaching the parents about the medication and discussing parenting strategies. Which statement by the parents indicate[s] that further teaching is necessary? 1. "We will give the medication at night so it doesn't decrease appetite." 2. "We will provide a regular routine for sleeping, eating, working, and playing." 3. "We will establish firm but reasonable limits on behavior." 4. "We will reduce distractions and external stimuli to help concentration."

1 is correct. "We will give the medication at night so it doesn't decrease appetite."—CORRECT: incorrect information; stimulants (methylphenidate hydrochloride) used; side effects: insomnia, palpitations, growth suppression, nervousness, decreased appetite; give 6 hrs before bedtime. "We will provide a regular routine for sleeping, eating, working, and playing."— true. "We will establish firm but reasonable limits on behavior."— true. "We will reduce distractions and external stimuli to help concentration."— true

When developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease (COPD), the nurse should advise the client to expect to: 1. Develop respiratory infections easily. 2. Maintain current status. 3. Require less supplemental oxygen. 4. Show permanent improvement.

1 is correct. A client with COPD is at high risk for development of respiratory infections. COPD is slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.

The nurse is caring for a client receiving an albuterol/ipratropium nebulized breathing treatment. Which report from the client should the nurse note as an expected side effect of this combination medication? 1. "I feel like my heart is racing." 2. "I feel more bloated than usual." 3. "My eyes have been watering lately." 4. "I haven't had a bowel movement in 4 days."

1 is correct. Albuterol/ipratropium is a combination agent- one is a beta 2 adrenergic agonist and the other is an anticholinergic medications, and in combination they produce an overall bronchodilation effect. Common side effects include headache, dizziness, dry mouth, tremors, nervousness, and tachycardia. Therefore, option 1 is correct. Test-taking strategy: can begin by eliminating option 2 and 4 first, noting they are comparable or alike. Next, eliminate option 3 because this medication causes anticholinergic effects such as dry eyes and dry mouth.

A client admitted with a diagnosis of pneumonia is receiving gentamicin. For this client, which of the following laboratory values would be most important for the nurse to monitor? 1. Blood urea nitrogen and creatinine. 2. Hemoglobin and hematocrit. 3. Sodium and potassium. 4. Prothrombin time and bleeding time.

1 is correct. Blood urea nitrogen and creatinine—CORRECT: gentamicin is nephrotoxic; proteinuria, oliguria, hematuria, increased blood urea nitrogen, decreased creatinine clearance. Hemoglobin and hematocrit— gentamicin can cause anemia, but is less common. Sodium and potassium— hypokalemia is an infrequent problem with gentamicin therapy. Prothrombin time and bleeding time— prothrombin time not affected; thrombocytopenia is a risk with gentamicin therapy

A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal. The nurse should alert the health care provider because the vital sign changes and client assessment are most consistent with which compilation? Refer to chart below: Time Pulse RR BP 11:00 92 24 140/88 11:15 96 26 128/82 11:30 104 28 104/68 11:45 118 32 88/58 1. Cardiogenic shock 2. Cardiac tamponade 3. Pulmonary embolism 4. Dissecting thoracic aortic aneurysm

1 is correct. Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension; a rapid pulse that becomes weaker; decreased urine output; and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are accompanied by back pain.

The nurse is caring for a client with a possible bowel obstruction who has been prescribed a nasogastric tube that is attached to low suction. If the client's HCO3- is 30, which additional value is most likely to be noted in this client? 1. pH 7.52 2. pH 7.36 3. pH 7.25 4. pH 7.20

1 is correct. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid (HCl), an acid secreted in the stomach. This occurs as HCO3 rises above normal. Thus, the loss of hydrogen ions in the HCl results in alkalosis. A pH above 7.45 would be noted.

A nurse is caring for an adult client who is a victim of intimate partner abuse. The client does not wish to report the violence to law enforcement. Which of the following nursing actions is the highest priority? 1.Develop a safety plan which includes the location of women's shelters. 2.Encourage the client to participate in a support group for victims of abuse. 3. Implement case management to coordinate community and social services. 4. Educate the client about the use of stress management techniques.

1 is correct. The client's safety is the highest priority. Therefore, the development of a safety plan that includes the identification of safe places to live is the priority nursing action. It is appropriate to encourage participation in a support group. However, this does not address the greatest risk to the client and is therefore, not the priority nursing action. It is appropriate to implement case management, however this doesn't address the greatest risk to the client. It is also appropriate to educate on stress management, but this also doesn't address the greatest risk to the client.

The hospitalized client has a history of weekly moderate alcohol use. Which symptoms, assessed by the nurse, indicate that the client may be experiencing alcohol withdrawal? Select ALL that apply. 1. Agitation 2. Hypotension 3. Tachycardia 4. Hallucinations 5. Tongue Tremor

1,2,4,5 Alcohol withdrawal is a very dangerous event. It leads to increased activity of post-synaptic N-methyl-D-aspartate (NMDA) receptors in the brain, resulting in agitation. Option 1 is a correct response. Alcohol withdrawal leads to elevated blood pressure, not hypotension, so option 2 is incorrect. Alcohol withdrawal, as noted above, leads to increased NMDA receptors in the brain, leading to tachycardia, hallucinations, and tongue tremor. Test-taking tip: Think about increased activity in the brain as a mechanism in all but one of the possible responses.

A client develops a lower intestine bowel obstruction. Which finding does the nurse anticipate when assessing the client? 1. Nausea, vomiting, abdominal distention. 2. Explosive, irritating diarrhea. 3. Abdominal tenderness with rectal bleeding. 4. Mid-epigastric discomfort, tarry stool.

1. Lack of GI motility will cause nausea, vomiting, and abdominal distention. There would be no stool because motility distal to the obstruction would cease.

The nurse fails to obtain scheduled VS at 0200 hours for the client who had cardiac surgery 2 days ago. After assessing the client at 0600 hours, the nurse documents the 0600 HR for both the 0200 and 0600 VS. Which conclusion should the supervising charge nurse make about the nurse's actions? Select all that apply. 1. The nurse's action was acceptable; neither complications nor harmful effects occurred. 2. The nurse's action is legally concerning; the nurse fraudulently falsified documentation. 3. The nurse's action demonstrates beneficence; the nurse decided what was best for the client. 4. The nurse's action is extremely concerning; it involves the ethical issue of veracity. 5. The nurse's action demonstrates distributive justice; other clients' needs were priority.

2 (Documenting VS that the nurse did not obtain is a legal concern because documents were falsified) and 4 (ethical issue of veracity or telling the truth Rationale: Focus on the nurse's behavior of falsifying documentation, and avoid reading into the question! Despite the unit's being unusually busy, there is no information as to what the nurse was doing during the shift. Eliminate the options that are suggestive of nurse actions other than the behaviors presented. Even if harm had not occurred, the nurse's behavior of falsifying documentation poses an ethical-legal concern and is never the correct action. NEVER DO THIS. Documenting VS that the nurse did not obtain is a legal concern because documents were falsified and the nurse was untruthful regarding obtaining the VS. Beneficence means doing good. There is no information to indicate the nurse did what was best for the client. The nurse's actions involve the ethical issue of veracity or telling the truth. The nurse was untruthful regarding obtaining the HR at 0200 hour. Distributive justice is the distribution of resources to clients. There is no information about the resources available to the nurse

The nurse enters the room of a client who has been diagnosed having a myocardial infarction (MI) and finds the client quietly crying. After determining the there is no physiological reason for the client's distress, how would the nurse best respond? 1. "Do you want to call your daughter?" 2. "Can you tell me a little about what has you so upset?" 3. "Try not to be so upset. Psychological stress is bad for your heart." 4. "I understand how you feel. I'd cry, too, if I had a major heart attack."

2 is correct. Clients with MI often have anxiety or fear. The nurse allows the client to express concerns by showing genuine interest and concern and facilitating communication using therapeutic communication techniques. The correct option provides the client with an opportunity to express concerns. The remaining options do not address the client's feelings or promote client verbalization.

When planning care for a client hospitalized with depression, the nurse includes measures to increase the client's self-esteem. Which of the following actions should the nurse take to meet this goal? 1. Encourage [the] client to accept leadership responsibilities in milieu activities. 2. Set simple, realistic goals designed to help the client achieve success. 3. Help the client to accept the illness and the required adjustments. 4. Assure the client that previous activities can be resumed after discharge.

2 is correct. Encourage [the] client to accept leadership responsibilities in milieu activities—too demanding. Set simple, realistic goals designed to help the client achieve success—CORRECT: gives sense of accomplishment. Help the client to accept the illness and the required adjustments—may help with coping but does not necessarily improve self-esteem. Assure the client that previous activities can be resumed after discharge—offers false reassurance

The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. The nurse should assess this client for: 1. Anorexia. 2. Tachycardia. 3. Weight Gain. 4. Cold skin.

2 is correct. Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.

Which comment made by the parents of a male infant who will have a surgical repair of a hernia indicates a need for further teaching by the nursing? 1. "I understand that surgery will repair the hernia." 2. "I don't know if he will be able to father a child when he grows up." 3. "The day nurse told me to give him sponge baths for a few days after surgery." 4. "I'll need to buy extra diapers because we need to change them frequently now."

2 is correct. The anatomical location of a hernia frequently causes more psychological concern to the parents than does the actual condition of treatment. The remaining options all indicate accurate understanding associated with the surgery. The correct option is an incorrect comment requiring follow-up. Test taking strategy: Focus on the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect statement. Options 1,3, and 4 do not require follow-up, whereas option 2 reflects parental fear and identifies a need for further assessment.

A female client presents in the emergency room with right lower quadrant abdominal pain and pain in her right shoulder. She has no vaginal bleeding, and her last menses was 6 weeks ago. Which action should the nurse take first? 1. Assess for abdominal rebound pain, distention, and fever. 2. Obtain vital signs and IV access, and notify the healthcare provider. 3. Observe for recent musculoskeletal injury, bruising, or abuse. 4. Collect specimens for pregnancy test, hemoglobin, and white blood cell count.

2 is correct. The nurse should first evaluate the client for vital sign changes of shock due to ruptured ectopic pregnancy (an obstetrical emergency). A vascular access is vital in an emergency situation, and the provider should be notified immediately. Bleeding related to an ectopic pregnancy may present with pain and fever, but the nurse should first assess the client for hypovolemic shock. Looking for injury or abuse may be part of the assessment, but life-threatening conditions are ruled out first. Pregnancy test and CBC should be collected, but the provider should first be notified of the client's status such as vital signs and symptoms.

2 is correct. The nurse should monitor and supervise the client's activities to prevent binging, purging, or avoiding meals. Self-expression of feelings is important, but reestablishing normal eating habits and physiological integrity is the priority intervention. The client should be included in daily agroups, but the priority is physiological needs and monitoring meals. The client should be given opportunities to socialize, but monitoring activities during the day, especially meals, is the priority.

The nurse is calculating the IV flow rate for a postoperative client. The client is to receive 3,000 mL of lactated Ringer's solution IV infused over 24 hours. The IV administration set has a drop factor of 10 drops per milliliter. The nurse should regulate the client's IV administration set to deliver how many drops per minute? 1. 18. 2. 21. 3. 35. 4. 40.

2 is correct: Remember the formula to calculate IV flow rate: Total volume × drop factor divided by the time in minutes. You will have a drop-down calculator on the computer to use while taking the NCLEX-RN examination. 21— CORRECT: (3,000 × 10) divided by (24 × 60) = 30,000 divided by 1,440 = 20.8 = 21

The nurse is performing visual acuity screenings. Which student comments does the nurse recognize as indicating possible myopia? Select all that apply. "I can see my teacher better if I sit in the back of the classroom." "I have to hold my book close to my face so that the words are clear." "If I squint or close one eye, I can read the road signs when we travel." "My parents always tell me that I am sitting too close to the television." "Sometimes, I have to ask my parents if I've chosen socks that match."

2, 3, 4 Myopia, or nearsightedness, is reduced visual acuity when viewing objects at a distance. Myopia occurs when the eye structure causes images to focus before they arrive at the retina. Near vision is usually intact, and many clients with myopia report needing to hold objects near their face or sit near objects to see clearly. Myopia in pediatric clients may first be discovered by the nurse during routine visual acuity testing. Children often report headaches, dizziness, and the need to squint the eyes to see clearly. School performance may be affected because of impaired ability to see class presentations. Option 1: Reduced visual acuity when viewing objects up close with intact distance vision is associated with hyperopia. Clients with hyperopia may report having to hold materials far away to read or sit at a distance to have clear vision. Option 5: Impaired ability to perceive and differentiate colors (e.g., red, green, blue, and yellow) is associated with color vision deficiency, a congenital impairment of cone function in the retina. Children with color deficiency may have difficulty selecting matching clothing or appropriate colors for school assignments. Client Need: Physiological Adaptation Integrated Process: Communication and Documentation Cognitive Level: Analysis

The nurse receives change-of-shift report on four clients. In which order will the nurse assess the clients? Arrange from first to last. All options must be used. 1. An immobile client is requesting to be repositioned in bed. The client was last repositioned in bed five hours ago. 2. A client experiencing opiate withdrawal has been in the restroom for an hour. 3. A client who states, "I'm afraid I was given the wrong blood pressure medication this morning." 4. A client diagnosed with diabetes mellitus is reporting polydipsia and polyuria.

2, 4, 1, 3

The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. 1. The child has symptoms of a cold. 2. The child has a previous anaphylactic reaction to the vaccine. 3. The mother reports that the child is having intermittent episodes of diarrhea. 4. The mother reports that the child has not had an appetite and has been fussy. 5. The child has a disorder that caused a severely deficient immune system. 6. The mother reports that the child has recently been exposed to an infectious disease.

2, 5 are correct. The general contraindications for receiving live virus vaccines include a previous anaphylactic reaction to a vaccine or a component of a vaccine. In addition, live virus vaccines generally are not administered to individuals with a severely deficient immune system, individuals with a severe sensitivity to gelatin, or pregnant women. A vaccine is administered with caution to an individual with a moderate or severe acute illness, with or without a fever.

The hospitalized client with heart failure is receiving dobutamine intravenously. Which of the following responsibilities is most appropriate for the RN to delegate to an experienced nurse aide? 1.Teaching the client about the reasons for remaining on bedrest. 2.Taking the client's vital signs every hour, and reporting them to the RN. 3.Turning off the infusion pump if the client becomes hypotensive. 4.Notifying the physician that the client's urine output is less than 30 ml/hr.

2. The scope of practice for a nurse aide, no matter how experienced, does not include medication management. Turning off the infusion pump would also entail stopping the dobutamine, and altering the medication administration. This is not an appropriate task for the RN to delegate. Teaching about the need for bedrest involves explaining the intervention (bedrest), the specifics of the client's condition, and how the intervention supports healing. This is beyond the knowledge base of the nurse aide. Finally, the decreased urine output is only part of the assessment data that the physician will need to interpret the client's status. The RN will need to collect and report more assessment data, and the RN may receive orders in response to the physician's interpretation of the data.

The nurse is caring for a client immediately after a bronchoscopy. The client received intravenous sedation and a topical anesthetic for the procedure. Which priority nursing intervention would the nurse perform to provide a safe environment for the client at this time? 1. Place pads on the side rails. 2. Connect the client to a bedside ECG. 3. Remove all food or fluids within the client's reach. 4. Place a water-seal chest drainage set at the bedside.

3 is correct. After this procedure, the client remains nothing by mouth (NPO) until the cough, gag, and swallow reflexes have returned, which is usually in 1 to 2 hours. Once the client can swallow and the gag reflex has returned, oral intake may begin with ice chips and small sips of water. No information in the question suggests that the client is at risk for a seizure. Even though the client is monitored for signs of any distress, seizures would not be anticipated. No data are given to support that the client is at increased risk for cardiac dysrhythmias. A pneumothorax is a possible complication of this procedure, and the nurse should monitor the client for signs of distress. However, a water-seal chest drainage set would not be placed routinely at the bedside.

The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention? 1. Ask direct questions to encourage talking 2. Leave the client alone so as to minimal external stimuli 3. Sit beside the client in silence with simple open ended questions 4. Take the client to the dayroom with other clients to provide stimulation

3 is correct. Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking simple open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. Although overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client's safety is not the responsibility of other clients. Test-taking strategy:Note the strategic word: most appropriate. Eliminate options either that are non therapeutic or could result in overstimulation. Also eliminate options that are not examples of therapeutic communication. The correct option provides for client supervision and communication as appropriate.

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats per minute. On the basis of this finding, what is the priority nursing action? 1. Document the finding. 2. Check the mother's heart rate. 3. Notify the obstetrician (OB). 4. Tell the client that the fetal heart rate is normal.

3 is correct. The FHR depends on gestational age and ranges from 160-170 beats per minute in the first trimester, but slows with fetal growth to 110 to 160 beats per minute. If the FHR is less than 110 beats per minute or more than 160 beats per minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the OB. Options 2 and 4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the OB needs to be notified. Test-taking strategy:Focus on the data in the question and note the strategic word, priority. Then, note if an abnormality exists. Also not the FHR and that the client is at 38 weeks of gestation. Remember that the normal FHR is 110-160 beats per minute.

The client is on a heparin drip preoperatively. Postoperatively, the surgeon writes "Resume heparin at 1600 hours; do not bolus". Then the cardiologist writes an order: "Restart heparin protocol, no bolus, previous rate, at 0700 tomorrow if OK with surgeon". Later, an on-call surgeon writes "Clarification: resume heparin drip tonight - no bolus, at previous rate". What intervention should the nurse implement? 1. Start the heparin at 25 mL/hr because that is the initiation rate on the protocol. 2. Bolus with 5000 units and begin the drip at 31 mL/hr because that is the first line on the protocol. 3. Contact the surgeon to determine the rate at which the heparin drip should be started because the order is not clear. 4. Start the heparin drip at 28 mL/hr per protocol and obtain an aPTT in 6 hours to re-establish the baseline.

3. Contact the surgeon to determine the rate at which the heparin drip should be started because the order is not clear.

A 5-year-old receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the school-based health clinic. The parent returns home and calls the clinic to report that the 5-year-old has developed swelling and redness at the site of the injection. Which intervention should the nurse suggest to the parent? 1. Monitor the child for a fever. 2. Bring the child back to the clinic. 3. Apply a hot pack to the injection site. 4. Apply a cold pack to the injection site.

4 On occasion, tenderness, redness, or swelling may occur at the site of the DTaP injection. This can be relieved with cold packs for the first 24 hours, followed by warm or cold compresses if the inflammation persists. Bringing the child back is unnecessary. Option 1 may be appropriate but is not specific to the subject of the question. Hot packs are not applied and can be harmful by causing burning of the skin. Test strategy: Focus on the subject, a localized reaction at the injection site. Option 1 can be eliminated because it does not relate specifically to the subject of the question. Eliminate option 2 next as an unnecessary intervention.

The home care nurse visits a client with chronic obstructive pulmonary disease (COPD) who is on home oxygen at 2L per nasal cannula. The client's respiratory rate is 22 breaths per minute, and the client reports increased dyspnea. The nurse would take which initial action? 1. Determine the need to increase the oxygen. 2. Call emergency services to come to the home. 3. Reassure the client that there is no need to worry. 4. Collect more information about the client's respiratory status.

4 is correct. Note the strategic word, initial. Completing the assessment and collecting additional information regarding the clien'ts respiratory status is the initial action. The oxygen is not increased without validation of the need for further oxygen and the approval of the primary health care provider. Calling emergency services is a premature action. Reassuring the client is appropriate, but it is inappropriate to tell the client not to worry. Use the steps of the nursing process to answer correctly-assessment is first. Can also use ABCs to direct you to 4.

A client with a diagnosis of depression states to the nurse, "I should have died. I've always been a failure." Which therapeutic response would the nurse make to the client? 1. "You don't see anything positive?" 2. "You still have a great deal to live for." 3. "Feeling like a failure is part of your illness." 4. "You've been feeling like a failure for some time now?"

4 is correct. Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. Options 1, 2 and 3 block communication because they minimize the client's experience and do not facilitate the exploration of the client's expressed feelings.

The nurse is caring for a pregnant client who has been hospitalized for stabilization of diabetes mellitus. The client tells the nurse that her husband is caring for their 2-year-old daughter. Which short-term psychosocial outcome should the nurse develop for the client? 1. Be alert to the risks of early labor and birth. 2. Protect the client from injuries that can result from seizures. 3. Teach the client and family about diabetes and its implications. 4. Provide emotional support and education about interrupted family processes.

4 is correct. The short-term psychosocial well-being of the family is at risk as a result of the hospitalization of the client. Options 1 and 2 are unrelated to diabetes mellitus and are more related to gestational hypertension. Teaching about diabetes mellitus is a long-term goal related to diabetes. Test-taking strategy: Eliminate options 1 and 2 because they are unrelated to diabetes mellitus. Next, note the ords short-term psychosocial outcome and focus on the data in the question to direct you to option 4. In addition, the incorrect options are comparable to alike in that they are all physiological outcomes.

The nurse manager is concerned about the potential for staff injury and harm on a behavioral health unit. In assessing the unit milieu, what finding should be immediately addressed, because it is a predictive factor for violence?Two clients have a history of spousal abuse.Several clients have lost smoking privileges.The unit is at less than full client capacity.A nurse from a medical unit has been floated to work on the unit.

4, a nurse from a medical unit has been floated to the behavioral unit. Rationale: Inexperienced staff members are a significant environmental predictor of violent behavior of clients. This is not to say that inexperienced staff cannot be excellent clinicians, but the combination of lack of experience and other staff being concerned about lack of experience can lead to violent behaviors. A client's previous violent behavior, such as with the two clients who have histories of spousal abuse, are predictors of potential violence, but they are individual factors, not milieu. The same rationale applies to loss of individual privileges, such as smoking. Finally, overcrowding is a predictor of potential violence, but being at less than capacity is an ameliorative factor.

The client has grown very fond of the nurse. Which items may the nurse accept from the client? Select all that apply. 1. A token gift from the client to the individual nurse 2. The client's permission to be a contact on a social networking site. 3. A position as a private duty nurse for the client upon the client's discharge. 4. A hug from the client upon the client's discharge. 5. A thank-you basket of candy and fruit from the client for the unit staff.

4. Accepting a hug from the client is okay as long as it does not become a physical relationship, and 5. giving food or candy to a nursing unit as a thank you. Rationale: The nurse client relationship may not exceed certain boundaries. The nurse must avoid becoming emotionally attached to the client, any physical or sexual relationship with the client, financial gain, or accepting gifts or tips from the client. A gift directed at the individual nurse is inappropriate, even if a token, and should be declined. Additionally, the nurse and client becoming contacts on a social networking site is not advisable; this exceeds professional boundaries. The American Nurses Association has specific prohibitions about posting any photos or information about a patient on the nurse's social media network, and recommends against "friending" patient or patient families on social media. Accepting a position as a private duty nurse may be seen as a financial gain and should be avoided; this exceeds professional boundaries. Accepting a hug from the client is okay as long as it does not become a physical relationship, and often the client or families send food or candy to a nursing unit as a thank you. This type of gesture is long-standing in many facilities and seen as acceptable.

A client has just had a catheter placed in their chest for the purpose of total parenteral nutrition (TPN) administration. The chest x-ray shows that the catheter has slipped and caused a leakage of air into the pleural space. What is this condition called? a. Pneumothorax b. Hemothorax c. Hydrothorax d. Pneumonia

A is correct: A leakage of air into the pleural cavity outside of the lungs is called a pneumothorax. This may happen as a complication of central line placement for TPN. Hemothorax results when blood is leaked into the pleural cavity. Hydrothorax refers to a leakage of water into the pleural cavity. Pneumonia is an infection that forms in the lungs as the result of an infectious organism and may cause fluid to accumulate in the bases of the lungs.

The nurse is caring for a client who recently underwent radiation therapy to his abdomen. Based on the location of the radiation, the nurse expects which of the following side effects? a. Diarrhea b. Fatigue c. Trembling d. Muscle aches

A is correct: Based on the abdominal location of the radiation therapy, it is likely that the patient will experience gastrointestinal symptoms, including diarrhea, nausea, and vomiting, as a side effect. Fatigue, trembling, and muscle aches are possible with radiation therapy but not specific to the organs of the abdomen.

A nurse is planning care for a client who has postrenal AKI due to metastatic cancer. The client has a blood creatinine of 5 mg/dL. Which of the following interventions should the nurse include in the plan? (Select all that apply.) A. Provide a high-protein diet. B. Assess the urine for blood. C. Monitor for intermittent anuria. D. Weigh the client once per week. E. Provide NSAIDS for pain.

A, B, C are correct. A-Provide a high-protein diet due to the high rate of protein breakdown that occurs with acute kidney injury. B-Assess urine for blood, stones, and particles indicating an obstruction of the urinary structures that leave the kidney. C-Assess for intermittent anuria due to obstruction or damage to kidneys or urinary structures. D-Weigh the client daily to monitor for fluid retention due to acute kidney injury. E. Do not administer NSAIDs, which are toxic to the nephrons in the kidney.

Elevated INR related to DIC

An extremely elevated INR reflects abnormal clotting time and coagulation. To correct this quickly would require replacement of the clotting factors which are contained in fresh frozen plasma. Platelets are given for thrombocytopenia or decreased platelets.

4. Generate Solutions: Highlight which outcome(s) each intervention listed would result in. Taking Albuterol and Advair inhalers Adequate gas exchange Prevention of asthma attacks Staying away from triggers, such as cigarette smoke Adequate gas exchange Prevention of asthma attacks Sitting upright Adequate gas exchange Prevention of asthma attacks Remaining up to date with vaccinations Adequate gas exchange Prevention of asthma attacks

Answer 1: Adequate gas exchange and prevention of asthma attacks Rationale: A long-acting inhaler being prescribed with a short-acting inhaler helps control asthma symptoms long-term, as well as short-term flare-ups, such as when exercising or playing sports. Long-acting inhalers alone may not solely treat asthma attacks, but short-acting inhalers can. Short-acting asthma attacks will not help control asthma symptoms long term as long-acting inhalers can. Answer 2: Prevention of asthma attacks Rationale: Cigarette smoke, including second-hand smoke, can be a significant trigger of asthma attacks. Smoke causes the airways to narrow, swell, and fill with sticky mucus. These symptoms, on top of being asthmatic, cause commonly cause an asthma flare-up. It is important to understand potential triggers to minimize exposure and flare-ups. Answer 3: Adequate gas exchange Rationale: Sitting upright in a chair or bed allows the lungs to fully expand and optimize maximum oxygen-CO2 exchange. Answer 4: Prevention of asthma attacks Rationale: Although vaccinations are extremely important to the general public, they are even more beneficial to those with underlying health conditions, such as asthma. The flu, pneumococcal, and COVID-19 vaccine are important to get in these patients because having asthma not only puts individuals at a higher risk for getting sick with these illnesses, but it can also make their symptoms more severe, as they are already compromised with respiratory issues. Getting vaccines, especially the flu vaccine, each year can help reduce the "September Asthma Epidemic," as kids are re-introduced to allergens and infections during the beginning of the new school year. Remaining up to date with vaccines is a part of asthma treatment, as the only treatment provided is aimed toward reducing and preventing attacks and flare-ups.

3. Take Action: Drop Down Cloze: Choose the correct responses that accurately complete the statements below. The patient is given two inhalers for his new diagnosis of asthma. The nurse is educating the patient and his mother about these medications. The nurse explains that the albuterol inhaler works by _________. 1. Curing asthma 2. Being used every 12 hours 3. Constricting the bronchi 4. Dilating the bronchi The patient's mother needs further education when she states, _____. 1. "He should take his Advair inhaler before he plays soccer." 2. "He should take his Advair inhaler twice a day, 12 hours apart." 3. "He should rinse his mouth each time he uses his Advair inhaler." 4. "He may experience more headaches when taking his Advair inhaler."

Answer 1: Widening the bronchi Rationale: Albuterol is a short-acting inhaler that works by widening or expanding the bronchi within the lungs to promote adequate oxygenation. Asthma cannot be cured, only treated by minimizing symptoms and flare-ups. Albuterol should be used on an as needed basis. Therefore there is no time limit for how often this medication should be used, but experts recommend waiting at least 4-6 hours between each use. Constricting the bronchi would further reduce oxygenation and would lead to further complications. Answer 2: "He should take his Advair inhaler before he plays soccer." Rationale: Advair is a long-acting medication that helps control asthma symptoms over time. Therefore, this inhaler should not be taken before activity because it is not intended to help acute asthma flare-ups. Albuterol should be used before activity, as it is a short-acting medication. When taking Advair, the patient should take this inhaler twice a day, 12 hours apart, he should rinse his mouth after each use to prevent oral thrush, and he may experience additional headaches from this medication.

A client receiving an intravenous fluid infusion of 0.9% normal saline at 150 mL/hour develops restlessness, rapid respirations, crackles in both lung fields, and distended neck veins. Which action does the nurse take first? 1. Clamp the IV fluids. 2. Contact the health care provider. 3. Administer diphenhydramine as prescribed. 4. Place the patient in the Trendelenburg position.

Answer: 1

A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal. The nurse should alert the primary health care provider because the vital sign changes and client assessment are most consistent with which complication? Refer to the chart. 1. Cardiogenic shock 2. Cardiac tamponade 3. Pulmonary embolism 4. Dissecting thoracic aortic aneurysm

Answer: 1 Cardiogenic shock occurs with extreme damage (more than 40%) to the left ventricle. Classic signs include hypotension, a rapid heartbeat that becomes weaker, decreased urine output, cold clammy skin. Resp rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck muscles. Pulmonary embolism presents suddenly severe dyspnea accompanied by chest pain. Dissecting aortic aneurysms are usually accompanied by back pain.

The client states "I can't wait for anyone to take me to the bathroom or I will wet my pants". What should the nurse plan to do? Select all that apply. Assess the client's risk for a fall, using a rating scale. Document that the client is frequently incontinent. Ensure an immediate response to the client's call light. Educate the client regarding fall prevention strategies. Place a note on the door stating "Bathroom every 2 hours". Request that the HCP prescribe the placement of a urinary catheter.

Answer: 1 (assess for risk of falls); 3 (ensure an immediate response to client's call light); 4 (educate the client about strategies to prevent a fall) Rationale: A comprehensive falls-risk assessment, such as the Hendrich II, STEADI, or Morse, should be completed to identify other factors that increase the client's risk for falls so the nurse can address as many of the factors as possible. Working with the other staff to ensure that the client gets immediate assistance to get to the toilet is also important (although not likely in many settings). The client should also be educated on factors that increase falls risk, and how to prevent or lessen the probability of a fall. Good lighting, non-skid footwear or flooring, and clearing a path to the toilet are all possible interventions. There is no evidence presented that the client is incontinent, so documenting this would be inaccurate. Placing a note on the door is a violation of the client's privacy, and an indwelling catheter is unnecessary, inappropriate, and potentially dangerous (increased infection).

The nurse manager is observing care for the older adult client. Which observations require that the nurse manager to intervene because it increases the client's risk for developing skin breakdown? Select all that apply. The nursing assistant (NA) applies a perfumed lotion to the client's skin. The NAs are elevating the client's heels off the bed surface. A family member brings the client custard from home. The nurse applies an alcohol-based hand lotion to the client's hands. The nurse tells the client to push with the heels to move up in bed.

Answer: 1 (perfumed lotion), 4 (alcohol-based hand wash), 5 (pushing up with the heels to move up in bed).Rationale: There are several changes in the skin and underlying structures that occur with normal aging. The subcutaneous fat under the skin thins, so there is less "cushioning"; the skin loses elasticity, making it more fragile; and total body water decreases, leaving the skin drier, and more vulnerable to damage. Perfumed lotions can be irritating to skin, hastening breakdown, AND most perfumes have an alcohol base, leading to further drying of the skin. Because there is less cushioning of the skin from subcutaneous fat, the bony prominences of the body and the bed can put more pressure on the skin by catching it between the two surfaces. Custard, a high-protein food, provides nutritional support for all body tissues. Alcohol-based hand washes are effective at decreasing pathogens on the skin, but are drying to already-dry skin - offer soap and water, pat dry, and add a non-perfumed moisturizer cream. The loss of skin elasticity, coupled with the loss of the supporting subcutaneous layer, makes the older adult prone to shearing injuries. A shearing injury occurs when the body moves, and the skin doesn't, causing superficial "splits" in the skin. Using one's heels to push up in bed is a classic mechanism for a shearing injury.

Multiple clients present to the emergency department. Which client should the triage nurse prioritize for diagnostic testing and definitive care? 1. 26-year-old IV drug user reporting fever and right arm redness and swelling 2. 32-year-old kidney transplant client reporting low-grade fever and generalized body pains 3. 69-year-old with diverticulosis reporting left lower quadrant pain and fever 4. 74-year-old with right knee replacement reporting fever and right knee swelling

Answer: 2 The kidney transplant client is likely immunocompromised by steroids and anti-rejection drugs (cyclosporine, tacrolimus). In general, organ transplant clients will have a blunted response to infection, such as a low-grade fever. This client has systemic symptoms, which may indicate a serious underlying infection. Some of these clients develop fulminant sepsis within a few hours if the antibiotics are delayed. As a whole, management of systemic signs/symptoms takes priority over that of localized signs/symptoms. Option 1: This client likely has cellulitis from IV drug use and will need cultures and antibiotics. However, this should not be prioritized over an immunosuppressed client. Option 3: This elderly client with diverticulosis likely has diverticulitis (infection of the diverticula) and will need bowel rest and antibiotics. However, this should not be prioritized over an immunosuppressed client. Option 4: This client with fever and right knee swelling after knee replacement likely has a prosthetic joint infection. The joint needs to be tapped, and the client will need antibiotics and potential prosthesis removal. However, this is not immediately life-threatening. However, this should not be prioritized over an immunosuppressed client.

The nurse is planning to complete noon assessments for four assigned clients with Type 1 diabetes mellitus (T1DM). All of the clients received subcutaneous insulin aspart at 0800 this morning. Place the clients in the order of priority for the nurse's assessment: 60 year old client who is nauseated, and just vomited for the second time 45 year old client who is dyspneic and has chest pressure and new-onset atrial fibrillation 75 year old client with a fingerstick blood glucose level of 300 mg/dL 50 year old client with a fingerstick blood glucose level of 70 mg/dL

Answer: 2, 1, 3, 4 (the 45 year old client with dyspnea and chest pressure; 60 year old client with nausea and vomiting; 75 year old client with fingerstick blood glucose of 300 mg/dL; 50 year old client with fingerstick blood glucose of 70 mg/dL)Rationale: All four clients received rapid acting insulin 4 hours ago. Diabetes mellitus dramatically increases the risk of CAD (coronary artery disease) and MI (myocardial infarction), so the nurse must have a high index of suspicion for cardiac-related symptoms, as in the 45 year old client who is short of breath, with chest pressure a a-fib. In addition, ABCs dictate considering airway and circulation needs urgently. The next most at-risk client is the 60 year old with nausea and vomiting. Aspart is a rapid acting insulin, and if the client did not consume enough nutrients, the client is at risk for hypoglycemia. Left untreated, hypoglycemia may become life-threatening. The 75 year old client with the fingerstick blood glucose level of 300 mg/dL is experiencing hyperglycemia. It is not immediately life-threatening, but can progress. This client needs to be assessed, and receive treatment to lower the blood glucose as soon as possible. The last client to assess is the 50 year old with a fingerstick blood glucose of 70 mg/dL. That level of blood glucose is in the normal range.

A nurse prepares to teach a health promotion class to a group of adult clients at a community event. Which recommendation does the nurse include regarding cancer screening?1. Clients should have a colonoscopy every 10 years starting at age 40.2. Clients should have a fecal occult blood test every year starting at age 30.3. Women should have a Papanicolaou test every 3 years between ages 21 and 29.4. Women should have a clinical breast exam every 5 years between ages 20 and 40.

Answer: 3 Colonoscopy: every 10 years starting at 50 Fecal occult blood test: every year starting at 50 Breast exam: every three years between 20-40

The nurse is beginning a shift on the cardiac step-down unit. The nurse receives report for four clients. Prioritize the order, from most urgent to least urgent, that the nurse should assess the clients. 1. 56 year old client who was admitted 1 day ago with chest pain, receiving intravenous heparin, and has a partial thromboplastin time (PTT) due back in 30 minutes. 2. 62 year old client with end-stage cardiomyopathy, BP of 78/50 mm Hg, urine output of 20 ml/hr, a "Do Not Resuscitate" (DNR) order, and whose family has just arrived. 3. 72 year old client who was transferred 2 hours ago from the ICU following a coronary artery bypass graft (CABG) and has new onset atrial fibrillation with rapid ventricular response. 4. 38 year old post-operative client who had an aortic valve replacement 2 days ago. BP 114/72 mm Hg, heart rate 100 beats/min, respiratory rate 28 breaths/min, and temperature 101.2 F (38.4 C).

Answer: 3 (the 72 year old client transferred from ICU after CABG), 4 (38 year old client 2 days post-op from valve replacement surgery, 1 (56 year old client with chest pain and IV heparin), and 2 (62 year old client with end-stage cardiomyopathy). Rationale: When prioritizing patient needs, consider life-threatening situations first, then use ABC to prioritize the rest. The 72 year old client who was recently transferred from the ICU after CABG surgery has new-onset atrial fibrillation, and rapid ventricular response. This is an unstable rhythm that may quickly become a life-threatening rhythm. The next most urgent client is the 38 year old who is two days post-op from valve replacement surgery. Although the BP is not concerning, the client has a heart rate at the high end of the normal range, is tachypneic, and has an elevated temperature. Respiratory rate is the first vital sign to respond to altered physiological states. The increased respiratory and heart rate both put additional demands on the heart, and elevated temperature is worrisome for possible infection. After these first two clients are assessed, the nurse should assess the 56 year old patient with chest pain and IV heparin. The PTT results are not due from the lab for 30 minutes, These results may affect the client's need for care. Finally, the 62 year old client with end-stage cardiomyopathy can be assessed after the family has had some private time with the client. The nurse will then be able to provide informational and emotional support for the client and family.

The nurse is notifying the HCP of the client's change in status using the SBAR format. In which order should the nurse place the statements? "I suggest that the client be transferred to the critical care unit, and I would like you to come evaluate the client." "The client is deteriorating, and I'm afraid the client is going to arrest." "I am calling about {client name and location}. Vital signs are BP=100/50, P=120, RR=30, T=100.4°F (38°C)." "The client is becoming confused and agitated. The skin is pale, mottled, and diaphoretic. The client is very dyspneic with an oxygen saturation of 85% despite placing a nonrebreather mask."

Answer: 3, 4, 2, 1 Rationale: Statement 3, "I am calling about {client name and location}. Vital signs are BP=100/50, P=120, RR=30, T=100.4°F (38°C)" describes the situation and what is happening at the present time. This represents the S of SBAR. The next part of the SBAR is statement 4, "The client is becoming confused and agitated. The skin is pale, mottled, and diaphoretic. The client is very dyspneic with an oxygen saturation of 85% despite placing a nonrebreather mask", because it describes the Background of what has occurred leading up to the situation. The third part of the communication is statement 2. "The client is deteriorating, and I'm afraid the client is going to arrest" is the nurse's assessment of the primary problem and represents the A of SBAR. Finally, statement 1 is the recommendation: "I suggest that the client be transferred to the critical care unit, and I would like you to come evaluate the client" and describes the recommendations for correcting the problem.

A new parent of a full-term, 7 pound newborn asks the nurse how to ensure that her baby is taking the correct amount of formula at each feeding. The nurse explains that the infant needs approximately 3 ounces of fluid per pound of body weight per day. How many ounces of formula should the infant be eating every 4 hours? Record to the nearest 1/10 (0.1) of an ounce.

Answer: 3.5 ounces per feeding. Rationale: It is first important to read the question carefully - you are being asked for the number of ounces per FEEDING, not for the day. The infant is fed every 4 hours, or 6 times per day. The total amount of required formula is 7 pounds X 3 ounces per pound = 21 ounces. Divide 21 by 6 to get 3.5 ounces.

The nurse is caring for the infant who experienced asphyxiation at birth, and is having seizure activity. The infant, weighing 4 kg, is to receive phenobarbital, 4 mg/kg/day in divided doses every eight hours (q8h). To provide one dose, how many milligrams should the nurse administer? Record your answer rounded to the nearest tenth (0.1) mg.

Answer: 5.3 mg. Rationale: Reading the question carefully is essential. There is no solution strength, and you are not being asked to calculate how much solution to give - just the number of milligrams. You do not have to do any conversions between metric and English units. You are being asked for the number of milligrams per dose, not per day. Multiply the weight in kilograms (4) times the dose in milligrams per kilogram per day (4) to get 16 mg per day. A frequency of q8h means the infant is receiving 3 doses per day, so divide the total daily amount of 16 mg by 3 doses to get 5.3 mg per dose.

The client is on a heparin drip preoperatively. Postoperatively, the surgeon writes "Resume heparin at 1600 hours; do not bolus". Then the cardiologist writes an order: "Restart heparin protocol, no bolus, previous rate, at 0700 tomorrow if OK with surgeon". Later, an on-call surgeon writes "Clarification: resume heparin drip tonight - no bolus, at previous rate". Using the protocol and orders from above, the nurse consults another nurse to verify the heparin infusion and rate, based on the heparin protocol and their interpretation of the physicians' orders. The heparin infusion is restarted and the client suffers a massive intracranial hemorrhage. What unintentional wrongful act may the nurse be legally liable for? Answer in 3-5 words.

Answer: Negligence or malpractice Rationale: Negligence is the failure to do what a reasonably prudent nurse would do in similar circumstances. Malpractice is the failure to provide care based on the standards of nursing practice, in this case, failure to clarify the order with the prescribing physician. Nurses are responsible for the SAFE implementation of physician orders. If the order is unclear, or if the order is counter to the nurse's knowledge, the nurse has a legal and ethical obligation to contact the prescriber before any other action.

The nurse wants to interact therapeutically with a cognitively impaired client whose agitated behavior is escalating. Which nursing actions demonstrate therapeutic communication? Select all that apply. Saying, "Mr. Smith, will you look at me, please?" Saying, "You seem upset. How can I help you?" Presenting the client with detailed expectations Turning off the TV in the room to reduce noise Saying, "Getting angry will not help you get what you want." Speaking loudly to ensure that the client hears what is being said

Answer: The therapeutic responses are 1, "Mr. Smith, will you look at me, please?", 2. Saying, "You seem upset. How can I help you?", and 4. Turning off the TV in the room to reduce noise. Rationale: There are two important factors in the question that will affect your answer: the client is cognitively impaired, and the nurse wants to be therapeutic. Calling the client by name and achieving eye contact may have a calming effect for a cognitively impaired, agitated client by recognizing them and responding with respect. Acknowledging the client's agitation may help the client regain control, and also recognizes the client's feelings. People with cognitive impairment have difficulty managing multiple stimuli, so turning off the TV meets that criterion. It may be calming, in of itself, and just makes it easier to hear. Options 3 (offer detailed explanations)and 6 (speaking loudly) increase sensory stimuli. Option 5, "getting angry won't get you what you want" is essentially scolding the client, can be interpreted as challenging, and is unlikely to end well. .

Following a thoracotomy to remove a cancerous tumor from the ling, the nurse is preparing the client for discharge to home. What information should the nurse include in the discharge teaching? Select all that apply.Avoid lifting more than 20 pounds.Gradually build up exercise endurance.Continue to exercise even when short of breath.Expect normal strength in about one month.Make time for frequent rest periods.

Answers: 1 (limit lifting to 20 pounds), 2, (gradually increase exercise level), and 5 (take frequent rest periods)Rationale: To avoid injury to the incision, the client should be instructed to limit tension on the incision until healing is complete. Full healing of all tissues takes approximately 6 weeks. To avoid overuse of muscles that may have been affected by surgery, the client should gradually increase the amount and intensity of exercise. In the same line of thinking, the client should be encouraged to stop for a break when feeling dyspneic. Alternating activity and rest will help conserve energy. Recovery from surgery, both in strength and stamina, can take 3 - 6 months. Some of that is due to healing, and the need to rebuild muscle strength, but some is related to lingering effects of general anesthesia. In a small percent of clients, side effects of anesthesia may last for over 12 months.

A nurse on a pediatric unit is reviewing interventions for a toddler. Which of the following are appropriate activities to minimize the effect of hospitalization on a toddler? 1. Integrate preferred snack foods in the day's routine 2. Plan quite play prior to usual nap time 3. Point out body changes that may occur 4. Post a daily schedule of labs by the child's bed 5. Provide 1 or 2 options when choosing toys

Answers: 1, 2, 5 Toddlers (1-3) display an egocentric approach as they strive for autonomy. They attempt to control their experiences through intense emotional displays, such as temper tantrums or forceful negative responses ("no!"). Hospitalization results in loss of a toddler's usual routines and rituals, often resulting in regressive behavior. The toddler may also be frequently separated from the parents, leading to separation anxiety. Nursing care activities should be similar to home routines, such as providing preferred snacks and anticipating nap time. The toddler should be given options rather than asked yes/no questions to limit the potential negative responses. It is also important to encourage participation and presence of the parents whenever possible.

A patient with a Swan-Ganz catheter in the ICU is being assessed by the nurse for the first time during the shift. The nurse notices which number on the hemodynamic profile is abnormal and needs further investigating? a. Mean arterial pressure: 75 mmHg b. Cardiac output: 2L/min c. Central venous pressure: 5 mmHg d. Pulmonary capillary wedge pressure: 6 mmHg

B is correct: The patient's cardiac output is very low, suggesting a possible bleed or hypotensive crisis. Normal cardiac output falls between 4 and 8 L/min. All the other values listed are within normal range. Normal mean arterial pressure is between 70 and 100 mmHg. Normal central venous pressure is between 2 and 6 mmHg. Normal pulmonary capillary wedge pressure is between 4 and 12 mmHg.

A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8 C (100 F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions. A. Administer antibiotics. B. Administer oxygen therapy. C.Perform a sputum culture. D.Instruct the client to obtain a yearly influenza vaccination.

B, C, A, D. B-The client's respiratory and heart rates are elevated, and oxygen saturation is 91% on room air. Using the ABC priority framework, providing oxygen is the first intervention. C- Obtaining a sputum culture is the second nursing intervention. It should be done prior to administering oral medications to obtain an accurate specimen. A-Administration of antibiotics is the third action the nurse should take. Sputum culture should be obtained prior. D. The last action the nurse should take is to instruct the client to receive yearly influenza vaccinations, to reduce the risk of acquiring influenza that can lead to pneumonia

When reviewing their knowledge of the stages of infections, the nurse knows that which period precedes the first symptoms of the infection? a. Entry of pathogen b. Colonization of organism c. Incubation period d. Convalescent period

C is correct: The incubation period is the point in time where the organism has already invaded the person's body through a portal of entry, is multiplying, and is getting ready to manifest the first symptoms of infection. The colonization occurs right after entry into the body where the organism takes up residence in the host and prepares to multiply. The convalescent period is when the person is recovering from the illness.

A nurse is assessing a client. Which of the following findings indicates that the client has experienced a left-hemispheric stroke? A. Impulse control difficulty B. Poor judgement C. Inability to recognize familiar objects D. Loss of depth perception

C. A-A client who has experienced a right-hemispheric stroke will experience difficulty with impulse control. B-A client who has experienced a right-hemispheric stroke will experience poor judgement. C- A client who has experienced a left-hemispheric stroke will demonstrate the inability to recognize familiar objects, known as agnosia. D. A client who has experienced a right-hemispheric stroke will experience a loss of depth perception.

The client being admitted to the ED reports feeling weak and having "almost passed out." The client was gardening in an outside temperature of 100°F (41.3°C). Assessment findings reveal poor skin turgor, dry and dull mucous membranes, HR 120 bpm, and BP 92/54 mm Hg. Which problem is the nurse's priority? 1. Impaired mucous membranes 2. High risk for falls 3. Decreased cardiac output 4. Fluid volume deficit

Correct Answer: 4, fluid volume deficit Rationale: Although the nurse should moisturize the client's dry, dull mucous membranes, this is not the priority, and falling is a concern, especially after feeling weak and faint, but the client is talking now. There are no symptoms of decreased cardiac output. The client's MAP is 67, suggesting adequate cardiac output for tissue perfusion ([systolic BP + 2 diastolic BP] ÷ 3). That leaves you with the priority problem of fluid volume deficit. Signs of dehydration and hypovolemia are evident (weakness, syncope, poor skin turgor, dry and dull mucous membranes, hypotension).

The CNA plans to deliver the meal tray to the client experiencing dysphagia. Which food item should the nurse ask that the CNA remove from the client's meal tray? Corn Custard Pureed meat Moist pasta

Correct Answer: The correct response is Corn. Rationale: The nurse should ask the CNA to remove the corn from the meal tray of the client with dysphagia. Chunky vegetables, such as corn, should be avoided due to the risk of choking. Custard that is flavorful or well chilled will stimulate the swallowing reflex, as will moist pasta. Pureed foods, such as pureed meats, are easier to swallow and prevent choking. None of these are particularly appetizing, and the nurse may consult with the dietitian on ways to make the meal more palatable. If you did not know what dysphagia meant, try deconstructing the word. "Dys" refers to an abnormal or altered process. "Phagia" refers to ingestion; think of esoPHAGUS, PHAGOcytosis, microPHAGE.

A nurse receives an end of shift report. Which of the following client assessment findings should the nurse address first? A. Blood pressure of 105/70 in a client who is dehydrated B. New onset of confusion in a client who has a left femur fracture C. Blood glucose of 140 mg/dL in a client who has diabetes mellitus D. Decreased bowel sounds in a client who is 2 days postoperative

Correct answer is B. New onset of confusion is not an expected finding. Confusion can be an indication of hypoxemia and requires immediate assessment to prevent additional complications.

The client states, "I can't wait for anyone to take me to the bathroom, or I will wet my pants." What should the nurse plan to do? Select all that apply. 1. Assess the client's risk for a fall using a rating scale. 2. Document that the client is frequently incontinent. 3. Ensure an immediate response to the client's call light. 4. Educate the client regarding fall prevention strategies. 5. Place a note on the door stating, "Bathroom every 2 hours." 6. Request that the HCP prescribe placement of a urinary catheter.

Correct answer: 1 (assess falls risk), 3 (immediate response to call light), and 4 (educate on falls risk) Rationale: The nurse should assess the client for factors related to voiding urgency and fall risk. The nurse cannot infer from the client's statement that the client is incontinent, and should not document that the client is frequently incontinent. The nurse should ensure an immediate response to the client's call light, and inform other caregivers of the client's need. The nurse should educate the client about strategies to prevent a fall, such as calling for help, wearing non-skid slippers, and ensuring appropriate lighting, while also encouraging requests for assistance. A note placed on the client's door stating bathroom every 2 hours violates the client's right to privacy and should not be completed. It may be appropriate to implement a toileting schedule, but document that in the EHR. Requesting urinary catheter placement is inappropriate, and increases the client's risk for an infection.

The nurse assigned to care for multiple clients is reviewing the laboratory reports. Based on the information provided, in which sequence should the nurse assess the clients? Prioritize the order in which the nurse should plan to assess the clients. Normal values: Potassium: 3.5 - 5.0 mEq/L Sodium: 135 - 145 mEq/L Osmolality: 275 - 295 mOsm/Kg pH: 7.35 - 7.45PaCO2: 38 - 42 mm HgHCO3: 18 - 22 mEq/L 1. The client with renal insufficiency whose serum potassium level is 5.2 mEq/L 2. The client with hyperemesis whose serum sodium level is 122 mEq/L 3. The client recovering following head trauma whose serum osmolality is 290 mOsm/kg 4. The client with DM whose ABG results are pH = 7.22, PaCO2 = 35 mm Hg, HCO3 = 15 mEq/L

Correct answer: 4 (client with DM), 2 (client with hyperemesis), 1 (client with renal insufficiency), 3 (client with head trauma) Rationale: The client with DM whose ABG results are pH = 7.22, PaCO2 = 35 mm Hg, HCO3 = 15 mEq/L is the highest priority. The ABG results indicate metabolic acidosis. A compensatory mechanism will include Kussmaul respirations to eliminate excess acid. Airway assessment is priority, and further assessment is needed to determine the underlying cause for the metabolic acidosis. The next priority is the client with hyperemesis whose serum sodium level is 122 mEq/L. This client is experiencing severe hyponatremia with serum sodium below the normal range of 135 to 145 mEq/L and is at risk of seizures. Safety is a major concern. Next is the client with renal insufficiency whose serum potassium level is 5.2 mEq/L. This client's serum potassium level is slightly above the normal of 3.5 to 5.0 mEq/L and should be assessed for signs of hyperkalemia. This is a very common finding among clients with kidney disease. Finally, assess the client recovering following head trauma whose serum osmolality is 290 mOsm/kg. The serum osmolality level is within the expected range. This client is the most stable. Remember that NCLEX will provide the normal range of values for you, but you must know what to do with them!

As the nurse is receiving reports on her patients for the day, she knows that which patient will take top priority in being assessed and treated? a. 33-year-old female who is nauseous and needs an antiemetic administered b. 49-year-old female who is scheduled for a cardiac catheterization and needs to sign the informed consent c. 55-year-old male who is being discharged later today and has a question about his care at home d. 78-year-old male who is complaining of shortness of breath

D is correct: The nurse will see the patient who is complaining of shortness of breath first. Airway, breathing, and circulation are always the highest priority for the nurse to address, as they can quickly become life-threatening situations. Maintaining proper respiration is a vital function to the patient's well-being, and stabilization is necessary immediately. The woman who is nauseous and needs antiemetics such as Zofran is the second priority, as she is actively ill and there is something the nurse can do to help her symptoms. The nurse's third priority will be the patient who needs to sign the informed consent. The nurse needs to ensure she gets that signed before the patient leaves the floor, although there are nurses in the cardiac catheterization lab who can obtain the consent if need be. The patient who has a question about discharge is the last priority, as there is no immediate threat to his health and the doctor will need to see the patient before he is discharged anyway.

A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take to assess for this finding? A. Stroke the lateral aspect of the sole of the foot. B. Ask the client to blink both eyes. C.Observe for facial drooping. D. Have the client stand erect with eyes closed.

D is correct. A babinski sign is elicited by stroking the lateral aspect of the sole of the foot. B-Asking the client to blink his eyes assesses cranial nerve function and is not part of the Romberg test. C-Observing for facial drooping assesses cranial nerve function and is not part of the Romberg test. D-A positive Romberg sign is indicated when a client loses their balance while attempting to stand erect with their eyes closed.

A nurse is providing teaching to a client who has a new diagnosis of diabetes insipidus. Which of the following client statements indicates an understanding of the teaching? A. "I can drink up to 2 quarts of fluid a day." B. "I will need to use insulin to control my blood glucose levels." C. "I should expect to gain weight during this illness." D. "I might experience confusion or balance problems.

D is correct. A-Excessive thirst is a manifestation of diabetes insipidus. Consumption of 4 to 30 L/day can be expected, and fluid intake should typically not be limited. B-Elevated blood glucose levels are a manifestation of diabetes mellitus. C-Weight loss is a manifestation of diabetes insipidus. D-Confusion and ataxia are findings associated with DI.

A nurse is reviewing the plan of care for a client who has leukemia and has developed thrombocytopenia. Which of the following actions should the nurse take first? A. Instruct the client to take rest periods throughout the day. B. Encourage the client to reposition in bed every 2 hr. C. Check temperature every 4 hr. D. Monitor platelet counts.

D is correct. A-Offer the client rest periods throughout the day to prevent fatigue. However, another action is the priority. B-Encourage the client to reposition in bed every 2 hr to prevent skin breakdown. However, another action is the priority. C-Check the client's temperature every 4 hours to monitor for indicators of infection. However, another action is the priority. D-The greatest risk to the client who has thrombocytopenia is injury due to bleeding. The priority action for the nurse to take is to monitor the client's platelet level to ensure it does not reach critical level. The nurse should institute bleeding precautions.

A nurse is caring for a client who has Parkinson's Disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse? A. Teach the client to walk more quickly while ambulating. B. Complete passive range-of-motion exercises daily. C. Place the client on a low-protein, low-calorie diet. D. Give the client extra time to perform activities.

D is correct. The client who has PD develops a propulsive gait and tends to walk increasingly rapidly. The client should be reminded to stop occasionally when walking to prevent a propulsive gait and decrease the risk for falls. B-Encourage active, not passive, range-of-motion exercises to promote mobility in the client who has PD and is displaying bradykinesia. C-The client who has PD often requires high-calorie, high-protein supplements between meals to maintain an adequate weight. D-Bradykinesia is abnormally slowed movement and is seen in clients who have PD. The client should be given extra time to perform activities and should be encouraged to remain active.

The nurse is caring for a woman who is three hours' postpartum. The nurse takes all except which of the following actions to prevent and monitor for postpartum hemorrhage? a. Massage the uterine fundus. b. Obtain regular vital signs, including heart rate and blood pressure. c. Ensure that the woman avoids bladder distention. d. Encourage the woman to perform her Kegel exercises.

D is correct: Kegel exercises are performed to strengthen the pelvic floor and prevent urinary incontinence, among many other benefits. They are not specifically targeted at preventing postpartum hemorrhage, however. All three of the other options are correct. Massaging the uterine fundus will encourage uterine contractions, which will help prevent excessive bleeding. A boggy fundus is a worrisome sign. The nurse wants to feel a firm uterus, signaling healthy contractions. Monitoring vital signs, especially heart rate and blood pressure, will keep the nurse informed about the woman's hemodynamic stability. The nurse will encourage the patient to empty her bladder regularly, as bladder distention can displace the uterus and interfere with proper uterine contractions.

Prior to administering a client's scheduled dose of enoxaparin sodium, which laboratory finding should the nurse evaluate? A. PT B. INR C. aPTT D. Platelets

D. The nurse should hold the medication and notify the provider if the platelet count fails below 1000,000 mm3. The nurse should also monitor for bleeding.

2. Prioritize Hypothesis The nurse brings the patient and his mother back into the clinic to obtain an assessment and vital signs. Based on the patient's assessment findings, highlight (or identify) the findings that would concern you as the nurse. Vital Signs: Heart Rate: 130 Respirations: 28 Blood Pressure: 90/60 Oxygen: 98% Temperature: 98.5 Physical Assessment: Cardiac: Heart sounds are regular. S1 and S2 noted. Respiratory: Wheezes noted in lower lobes bilaterally on expiration. SOB noted with activity. Cough present-irregular pattern noted by mother. Neurological: Headaches occasionally. Last headache was two months ago. No loss of consciousness. Alert and oriented X4. Eyes: No use of glasses. Pupils are reactive to light bilaterally. Nose: No drainage or irritation. Throat: No discomfort noted. Tonsils are 0 bilaterally. Gastrointestinal: Bowel sounds active in X4 quadrants. LBM this morning. Urinary: Urine is clear and straw-colored. No irritation or pain with urination. General: Skin intact. Small bruises noted on bilateral shins. Minimal scrapes and cuts near shins.

Highlighted topics should include: - Wheezes noted in lower lobes bilaterally on expiration. SOB noted with activity. Cough present-irregular pattern noted by mother. Rationale: Abnormal findings within the assessment are directed toward the patient's respiratory system. Wheezes and shortness of breath indicate abnormal breathing and oxygen-CO2 exchange. A cough, whether consistent or inconsistent, can also be a sign of asthma. As the nurse, you would identify that all of the vital signs listed for the patient are within defined limits (WDL) for an 8-year-old patient. Although these vital signs may differ with activity, they remain normal and stable at the clinic.

1. Recognize Cues: Highlight (or identify) the assessment findings that are outside normal limits for the patient's presenting symptoms. An 8-year-old boy presents to the clinic with his mother. His mother states that she thinks he just has a cough but decided to bring him in to get checked out. She states, "when he breathes, there is a wheezing sound." The patient also states that he has been more tired than usual. The nurse asks about any recent changes in their lives, and the mother responds by stating that her father has recently moved in with them and he smokes cigarettes. The patient states that he loves playing soccer but has recently not felt like himself. The patient is independent, alert and oriented x4, and can carry a conversation well. He takes no medications and has no past medical history. He occasionally gets headaches but usually gets resolved with increased fluid intake. The nurse gets them checked into the clinic for further evaluation.

Question 1 Answers: Highlighted topics should include: - His mother states that she thinks he just has a cough - "When he breathes, there is a wheezing sound." - The patient also states that he has been more tired than usual - Her father has recently moved in with them, and he smokes cigarettes - Recently has not felt like himself Rationale: These statements by the mother and the patient let the nurse know the situation regarding what brought them into the clinic. As a nurse, you would recognize that having a cough with wheezes, shortness of breath, and fatigue with activity all contribute to impaired gas exchange between O2 and CO2 in the lungs. Smoke is also a common trigger for asthma patients, as smoke narrows the airway passages. These signs and symptoms relate to asthma and should be highlighted to indicate abnormal signs and symptoms. Although headaches are common in individuals with asthma, it is stated that his headaches resolve after increased fluid intake. This statement would not be highlighted as it is a very common symptom of dehydration. Bruising, cuts, and scrapes on or near the shin area are very common and appropriate for children this age due to an active and playful lifestyle.

The nurse is discharging the client who had an MI with stent placement and subsequent four-vessel coronary artery bypass graft surgery. The client has a BMI of 30 and a history of hypertension, smokes 1 pack per day (PPD) of cigarettes, and has prescriptions for aspirin, clopidogrel bisulfate, atenolol, and atorvastatin. Which discharge instructions are most appropriate? Select all that apply. 1. "Discontinue the use of your compression stockings when at home." 2. "Use a soft toothbrush and electric razor; you may bleed easily." 3. "Minimize alcohol intake; atorvastatin and alcohol affect the liver." 4. "Maintain your present weight; you need the calorie intake for healing." 5. "Begin smoking cessation once your incision is completely healed." 6. "Discontinue the atenolol when your heart rate is less than 60 bpm."

The correct answers are 2 (soft toothbrush) and 3 (avoiding the combination of alcohol and atorvastatin) Rationale: Focus on the client's risk factors, surgical procedure, and prescribed medications to determine appropriate teaching. Next, eliminate options that increase the potential for complications, such as the TED stockings, overweight, smoking, and medications. The nurse should recognize that clopidogrel (Plavix) and aspirin prevent platelet aggregation and increase the risk for bleeding. The client should be advised to use bleeding precautions to decrease the risk. The other correct intervention is to educate the client to avoid concomitant use of alcohol and statin medications. Alcohol affects the liver, and atorvastatin (Lipitor) is metabolized by the liver, and can increase liver enzymes. Alcohol consumption also increases caloric intake. The nurse should recognize that a BMI of 30 indicates the client is overweight, and a healthy diet with appropriate physical activity may help reduce weight. It does not inhibit the healing process. The client should continue use of compression stockings, because they help decrease edema in the leg from which the saphenous vein was removed. Interventions for smoking cessation should begin immediately, not after healing has occurred. Smoking causes a delay in healing. People who quit smoking after cardiac surgery reduce their risk of death by at least one-third. Finally, atenolol (Tenormin) should not be discontinued without consulting the HCP. Atenolol is used for treating hypertension and decreasing cardiac irritability after an MI and cardiac surgery. For a low HR, the client should consult with the HCP and not discontinue the atenolol.

The client being monitored while receiving tissue plasminogen activator (tPA) following an ischemic stroke opens both eyes simultaneously, mumbles inappropriate words in response to orientation questions, has no ability to move any extremities, and has decerebrate posturing in response to nailbed pressure. Using the Glasgow Coma Scale (GCS), below, calculate the GCS score. _________________ (Record as a whole number)

Spontaneous eye opening is a 4, the highest score in this category. The client answers orientation questions, but uses words that are inappropriate. The speech is described as "mumbling", but not incomprehensible, so the verbal response is scored as 3. Finally, decerebrate positioning is extension of the extremities (decorticate is flexion). Pressure to the nail bed is considered a painful stimulus, so the decerebrate posturing is scored a 2. 4+3+2+= 9.

The nurse is caring for the client admitted with dehydration. Which factors should the nurse explore as contributing to the client's dehydration? Select all that apply. 1. Diarrhea 2. Hemorrhage 3. Diabetic ketoacidosis 4. Hypoventilation 5. Decreased urination

The correct responses are 1, diarrhea, 2, hemorrhage, and 3, diabetic ketoacidosis. Rationale: Dehydration occurs when there is insufficient water to replace fluid loss throughout the day. Dehydration can occur from not drinking enough fluids or with abnormal loss of body fluids, including diarrhea. Hemorrhage can result in fluid volume deficit from a large loss of volume. DKA is a risk factor or cause of dehydration because increased blood glucose levels cause diuresis. Hyperventilation and not hypoventilation is a risk factor or cause of dehydration. Decreased urine output is a clinical manifestation of volume deficit, not a cause or contributing factor.

he nurse is to administer chlordiazepoxide HCL 25 mg intramuscularly (IM) to the client. The medication package contains 100 mg of sterile, powdered chlordiazepoxide HCL that must be reconstituted with 2 mL of diluent. After reconstitution, how many mL of medication should the nurse withdraw into the syringe illustrated to administer the correct dose? A. 0.25 B. 0.5 C. 1 D. 1.5

The correct answer is "A". Rationale: Carefully read what the question is asking. Be sure that you choose the option that corresponds to the syringe and not the amount of chlordiazepoxide HCL (Librium) you calculated. Start by calculating how much medication to give: The directions on the package say that the powdered medication is to be reconstituted with 2 mL of the diluent. The vial contains 100 mg of chlordiazepoxide, so the result will be 100 mg chlordiazepoxide in 2 mL. The order is for chlordiazepoxide, 25 mg, IM. Use your preferred method to calculate the dose needed from the dose on hand, and you will end up with 0.5 mL. NOW look at the photo of the syringe, and note that the line A is pointing to the ½ mL or 0.5 mL mark on the syringe.

The nurse is leading a team to develop an evidence-based practice guideline for preventing skin breakdown in the hospitalized client. To fully use the databases available to the nurse, which should be the nurse's first step in the process for developing the guidelines? 1. Critically appraise the resources for their use in clinical decision making. 2. Formulate the issue into a searchable, answerable question. 3. Critically appraise the quantitative and qualitative evidence. 4. Determine the model and strategies for the evidence-based practice.

The correct answer is 2, formulate a searchable, answerable question. Rationale: The key word is "first." Look at each of the options to determine which options are dependent upon another option. The word "searchable" in Option 2 should draw you to this option because other options are dependent on first completing a search. In questions asking for the first step, the more specific option should be the answer. Formulating a well-built question will help determine the resources to access for the best available evidence. Critically appraising the resource is the second step in the process of looking for evidence-based research. Once the research methods have been identified, there should be criteria and a process for evaluating the quantitative and qualitative evidence. This is the third step. Finally, evidence-based practice is the utilization of research knowledge that takes into consideration factors such as best evidence from a thorough search and critical appraisal of the research, context, health care resources, practitioner skills, client status and circumstance, and client references and values. It is the fourth step in the process

The client is actively bleeding from the upper GI tract and vomiting bright red blood. The nurse is to administer blood as prescribed, but the client refuses to receive any blood products because of a conflict with religious beliefs. Which statement should be the basis for the nurse's intervention? 1. The client has a right to be involved in decisions about his or her care and treatment.2. The client has a right to refuse care and treatments regardless of the outcome.3. The client can be assured of his or her right to privacy and confidentiality.4. The client cannot expect the HCP to allow spiritual beliefs to influence care decisions.

The correct answer is 2, the client has a right to refuse care and treatments, regardless of the outcome. Rationale: These are emotionally difficult situations for any nurse to encounter, because they present an ethical dilemma related to the principles of beneficence, autonomy, and respect for the individual's religious beliefs (which is a subset of autonomy). The first statement is correct, as far as it goes, but it does not directly relate to the refusal of treatment. The third and fourth options are similar, in that they are correct, but do not address the entire question. It is important to look at the question, and note that you are asked about the basis for the nurse's action - so you need to understand both the client's rights, and how they relate to refusing care. Only the second option includes both the client's right to refuse care AND consideration of the consequence of that decision.

The nurse on the surgical floor is receiving a hand-off report from the previous shift. Which of the following clients should the nurse see first? 1. A client admitted 3 hours ago with a gunshot wound; 1.5 cm area of dark drainage on the dressing. 2. A client who had a mastectomy 2 days ago; 23 mL of serosanguinous fluid in the wound drain. 3. A client with a collapsed lung due to an accident; no chest drainage noted in the previous 8 hours. 4. A client who had an abdominal-perineal resection 3 days ago; client now reports chills.

The correct answer is 4. A client admitted 3 hours ago with a gunshot wound; 1.5 cm area of dark drainage on the dressing— does not indicate acute bleeding; small amount of blood. A client who had a mastectomy 2 days ago; 23 mL of serosanguinous fluid in the wound drain— expected outcome. A client with a collapsed lung due to an accident; no chest drainage noted in the previous 8 hours— air (not drainage) is expected with a pneumothorax. A client who had an abdominal-perineal resection 3 days ago; client now reports chills— CORRECT: at risk for peritonitis; should be assessed for further symptoms of infection.

The nurse is notifying the physician of the client's change in status, using the SBAR format. What is the correct order of the following nurse's statements? A. "I suggest the client be transferred to the ICU, and I would like you to come evaluate the patient." B. "The client is deteriorating, and I'm afraid the client is going to arrest." C. "I am calling about [client name and location]. Vital signs are BP=100/50, P=120, RR=30, T=100.4 degrees F (38 degrees Celsius)" D. "The client is becoming confused and agitated. The skin is pale, mottled, and diaphoretic. The client is very dyspneic with an oxygen saturation of 85%, despite placing a nonrebreather mask." A, B, C, D B, C, A, D D, B, A, C C, D, B, A

The correct answer is 4.Rationale:Identifying the client, and reporting the vital signs describes the situation and what is happening at the present time. (Statement C). This represents the S of SBAR.The additional information related to the client's confusion, skin condition, respiratory status, and the intervention of the nonrebreather mask describes the background of what happened, leading up to the situation. (Statement D). It is the B of SBAR.The nurse's statement that the client is deteriorating, and the concern for cardiopulmonary arrest, is the nurse's assessment of the problem. (Statement B). It is the A of SBAR.The nurse's statement that the client should be transferred to the ICU is the recommendation for correcting the problem. (Statement A). It is the R of SBAR.

The mother of the 2-year-old telephones the nurse to ask for advice. The child has a temperature of 104°F (40°C) and a sore throat and has been drooling for a few days. The child is now sleepy. Which advice is best? 1. "Take your child to the ED immediately." 2. "Bring your child to the clinic to be seen now." 3. "Give acetaminophen for the temperature and allow your child to sleep." 4. "Use a spoon to look inside your child's mouth and throat and tell me what you see."

The correct answer is A, "Take your child to the ED immediately". Rationale: Being a telephone triage nurse is REALLY hard because you have to remember signs and symptoms that signal a potential emergency, and which ones may be safely managed in a less intense manner. Response1, an elevated temperature, sore throat, and drooling are symptoms of epiglottitis. The sleepiness could be from the effects of the elevated temperature or from respiratory depression. The child should be seen in an ED immediately because respiratory failure may develop. Because respiratory failure is a real concern, taking the child to the clinic (option 2) could delay emergency treatment if needed. Acetaminophen (Tylenol), which is option 3, may reduce temperature, but allowing the child to sleep without being assessed could be life-threatening. Because there is a possibility of a swollen and inflamed epiglottis, stimulating the gag reflex, by accidentally touching the posterior pharynx,can cause complete obstruction of the glottis and respiratory failure. It should never be performed when epiglottitis is suspected. Test-taking Tip: A decreased level of consciousness can occur from impaired oxygenation. Use the ABC's to determine the best advice.

The 8-month-old, who is developing appropriately, is hospitalized. The mother is holding the child, who is crying and trying to hide. Which of Erikson's Developmental Stages should the nurse identify as normal for this child? A. Oral phase B. Initiative versus guilt C. Trust versus mistrust D. Punishment versus obedience orientation

The correct answer is C, trust vs mistrust Rationale: Remember that Erikson's developmental theory includes achievement of a task versus nonachievement of a task; thus eliminate Option 1, which does not include the term versus, and is part of Freud's developmental theory. (Fun but irrelevant fact: the first stage of development in Freud's theory is polymorphous perverse, so named because the infant takes sexual pleasure from any stimulus. It is "perverse" because the only approved source of sexual pleasure is stimulation of the genitals. Freud had lots of interesting ideas.). Of the remaining options, think about the child's reaction of hiding. Initiative versus guilt is a developmental task in the preschool stage. Punishment-versus-obedience orientation is not a developmental stage. According to Erikson's developmental stages, trust versus mistrust is appropriate for a child under a year old. The child learns to love and be loved.

A nursing team consists of an RN, an LPN/LVN, and an unlicensed assistive personnel (UAP). The nurse should assign which of the following clients to the LPN/LVN? 1. A client with a diabetic ulcer that requires a dressing change. 2. A client diagnosed with cancer who is reporting bone pain. 3. A client with terminal cancer being transferred to hospice home care. 4. A client with a fracture

The correct answer is number 1. A client with a diabetic ulcer that requires a dressing change— CORRECT: stable client with an expected outcome. A client with cancer who is reporting bone pain— requires assessment; RN is the appropriate caregiver. A client with terminal cancer being transferred to hospice home care— requires nursing judgment; RN is the appropriate caregiver. A client with a fracture of the right leg who asks to use the urinal— standard, unchanging procedure; assign to the UAP.

The nurse hears a thud and, upon entering a room finds the client on the floor beside a wheelchair. Which notations are most appropriate for the nurse to make in the client's EMR regarding the incident? Select all that apply.The client stated, "I was trying to reach for my water and fell from the wheelchair." The client refused to lock the wheelchair when told to do so. A loud noise was heard from the client's room, and the client was found on the floor. The client stated, "Nothing hurts. I don't think I have any injuries." An incident report has been completed and filed; a copy is in the client's chart.

The correct answers are 1 (documenting the client's statement), 3 (recording that a loud noise was heard, and the client was found on the floor), and 4 (The client's statement that nothing hurts). Rationale: When documenting a fall, only factual and objective information should be included. It is important to include client statements of the incident as well as assessment findings. An incident report form is for agency use only, and the form or the reference to it is never included in a medical record. The documentation should be factual and objective. Quoting the client's statements of how the fall happened is appropriate. Do not document in such a way that looks like the nurse is blaming the client. If prior to the fall the nurse had repeatedly instructed the client to leave the wheelchair locked, and the nurse found the wheelchair in the unlocked position, a notation as to the observations and interventions would be appropriate. But the notation must be in a nonaccusatory manner and not as a result of the incident. Factual statements based on what the nurse observed or assessed, and the client's statements may be placed in the medical record. An incident report should be completed. However, stating it has been completed is never documented in the medical record because it then becomes discoverable evidence if litigation ensues. This may demonstrate the difference between what is ethical (writing down everything the nurse knows about a situation) and what it legal (protecting the institution in case of legal action).

The older adult client is hospitalized with chest pain. Which interventions should the nurse implement when the client states his religious beliefs prevent him from taking any medications except an unknown supplement for bowel regulation? Select all that apply. 1. Document in the client's medical record that the client takes an unknown supplement for bowel regulation. 2. Determine the name of the individual who advised the client about the supplement. 3. Instruct the client that medications not prescribed by the HCP are dangerous and may cause chest pain. 4. Ask the client's family to bring in the supplement, and document the request in the client's medical record. 5. Ask the client the last time the supplement was taken and the amount that was taken.

The correct answers are: 1 (document that an unknown supplement is being taken by the client; 4 (ask a family member to bring in the supplement); and 5 (Ask about the time last taken and the amount of the supplement) Rationale: You should focus on selecting options that will improve the treatment of the client. Eliminate option 3 because not all medications need to be prescribed by the HCP. Remember the client's rights to use of alternative therapies. The nurse should document that an unknown supplement is being taken by the client to ensure that there is follow-up to identify the supplement and in case there is an association between the supplement and the client's chest pain. Do not assume that anyone advised the client to take the supplement, and asking the name of the person may cause the client to fear legal intervention. Telling the client the supplement may have caused the chest pain will likely block meaningful communication with the client; and since the nurse doesn't know anything about the supplement at this time, and it may have anything to do with the chest pain. By asking the family member to bring in the supplement permits identification of the supplement and its physiological actions. Asking about the time last taken and the amount of the supplement is important because it may affect planned treatment and interact with medications.

The nurse admits the client who has cool, pale extremities, HR 110 bpm, BP 100/55 mm Hg, RR 34, restlessness, diaphoresis, and a low urine output. Prioritize the nurse's actions by placing the interventions in the order they should be performed. 1. Administer intravenous fluids. 2. Apply oxygen per nasal cannula. 3. Provide warm blankets. 4. Initiate cardiac monitoring.

The correct order is 2 (oxygen), 4 (cardiac monitoring), 3 (warm blankets), and 1 (IV fluids) Rationale: Use the ABC's and the nursing process to establish priority. Next, consider the actions that could be performed more quickly than the remaining ones. Oxygen is priority because it will help decrease the workload of the heart, and breathing comes before circulation. Initiate cardiac monitoring next. The symptoms suggest a possible cardiovascular problem, and more information is needed to initiate appropriate interventions. Provide warm blankets next to increase client comfort and avoid hypothermia. Shivering increases oxygen demand, and warm blankets can be applied quickly. They also can promote peripheral vasodilation and make IV catheter insertion easier. Finally, administer IV fluids after placement of an IV access device. Fluids will increase intravascular volume, the client's BP, and urine output.

The nurse is assigned four clients at a substance abuse crisis clinic. Place the clients in the order of priority for care by the nurse. 1. The client with cannabis use who has a pulse of 145, dry mouth, and states having an increased appetite. 2. The client with opioid abuse who has pinpoint pupils, BP of 84/46, and temperature of 103.6°F (39.8°C). 3. The client with a flushed face, unsteady gait, and incoordination from alcohol intoxication. 4. The client with opioid abuse who has dilated pupils, diaphoresis, RR of 44, BP of 205/100, and now is having radiating chest pain.

The correct order is 4 (client with dilated pupils, diaphoresis, tachypnea, and elevated BP), 2 (client with pinpoint pupils, hypotension, and hyperthermia), 3 (client with flushed face, unsteady gait, and alcohol intoxication), and 1 (client with cannabis use and pulse of 145) Rationale: Use the ABC's to establish priority. Clients with life-threatening problems should be attended to first. That means the client with opioid abuse and RR of 44, BP of 205/100, and chest pain is priority. The client needs life saving intervention. The next priority client is the one with opioid abuse with pinpoint pupils, BP of 84/46, and temperature of 103.6°F (39.8°C). The client has inadequate perfusion with the low BP, and the high temperature could indicate sepsis. The third priority client is the one with a flushed face, unsteady gait, and incoordination from alcohol intoxication. The client is walking, although with an unsteady gait and is not in any imminent danger. The lowest priority client is the one with cannabis use, a pulse of 145, dry mouth, and the munchies is not experiencing any unexpected effects. This client is reasonably stable, and can be seen after the other clients.

The correct response is 4, fluid volume deficit. Rationale: Focus on the client's symptoms to establish the priority problem. The priority problem is fluid volume deficit. Signs of dehydration and hypovolemia are evident (weakness, syncope, poor skin turgor, dry and dull mucous membranes, hypotension). All of the responses relate to symptoms of fluid volume deficit, rather than to the problem itself. Although the nurse should moisturize the client's dry, dull mucous membranes, this is indicative of the dehydration, and the root problem takes priority over symptom management. Falling is a concern, especially after feeling weak and faint, but again, it is not as important as the root cause. Finally, there are no symptoms of decreased cardiac output. The client's MAP is 67, suggesting adequate cardiac output for tissue perfusion ([systolic BP + 2 diastolic BP] ÷ 3).

The nurse is scheduling immunizations for normally healthy children between ages 1 and 5 years who have been on schedule with previous immunizations. Which immunizations should the nurse plan to administer? Select all that apply. A. Inactivated poliovirus B. Diphtheria, tetanus, pertussis (DTaP) C. Measles, mumps, rubella (MMR) D. Hepatitis B (HepB) E. Human papillomavirus HPV4 series

The correct responses are 1 (IPV), 2 (DTaP), and 3 (MMR). Rationale: If uncertain, recognize that there is a 5-year span of time in the question. The correct responses include inactivated poliovirus, and dose three is given between ages 6 and 18 months; dose four is between ages 4 and 6 years. The next correct response is the diphtheria, tetanus, and acellular pertussis. The fourth DTaP dose is given between 15 and 18 months; and dose five is administered between ages 4 and 6 years. At age 11 or 12, the formulation changes to Tdap, with relatively smaller proportions of diphtheria and pertussis. The final correct response is MMR. Dose one is given between ages 12 and 15 months; and dose two between ages 2 and 6 years. The INcorrect responses are hepatitis B, as this vaccine is given to all infants in the United States at birth; a second dose at 1 to 2 months and a third dose at 6 or 18 months, and human papillomavirus, HPV4, which is administered to males and females in the United States in a three-dose series between the ages of 11 and 12 years.

The client who is dying is talking to her deceased spouse, "I see you at the end of the tunnel in the garden". The family thinks the client is hallucinating and expresses concern to the nurse. What nursing actions are appropriate? Select all that apply. 1. Gently touch the client to reorient the client to time, place, and person. 2. Affirm to the client and family that this is a part of a transition from this life. 3. Encourage the family to talk with and reassure the client who is dying. 4. Allow privacy for the family to express their feelings and say their goodbyes. 5. Treat the client's hallucinations by medicating the client with haloperidol (Haldol), if prescribed.

The correct responses are 2 , 3, and 4 (affirming that this is a part of the transition from this life, encouraging the family to talk with the client who is dying, and allowing privacy for the family and client to say goodbyes). Rationale: Reorienting the client (option 1) is not likely to be helpful, and may be harmful, as visions like this are a common event in the dying process. Haloperidol is useful in some situations with agitated clients, including delirium, psychosis, and aggression. None of these are present in this situation.

The nurse is establishing a therapeutic nurse-client relationship. In what order will the nurse progress through initiating and ending the therapeutic relationship? 1. Termination phase 2. Working phase 3. Preinteraction phase 4. Conclusion of relationship 5. Orientation phase

The correct sequence is 3, 5, 2, 1, 4 Rationale: The preinteraction phase is the first phase, before the nurse meets the client. In this phase, the nurse gathers information about the client. The orientation phase is next. Introductions are made during an initial meeting, the relationship is defined, and the purpose of the visit is established. The working phase occurs next, which is the active part of the relationship in which techniques of therapeutic communication are used to discuss the issues of importance. Next is the termination phase. After the working phase is completed, the termination phase begins, and the relationship is reviewed and summarized. The conclusion of relationship is the final phase in which the relationship with the client comes to an end.

The nurse is calculating the fluid balance for the client with DI. The client's I&O for 8 hours is as follows: Intake: PO: 2000 mL water, 350 mL juice, ½ cup gelatin (110 mL), 360 mL milk, and IV fluid of D5W at 125 mL/hour.Output: 5000 mL urine What amount should the nurse document for the 8-hour fluid balance? Negative (-) __________ mL (Record your answer as a whole number.)

The fluid balance is a negative 1180 ml. Rationale: Intake includes total IV fluid for 8 hours as well as fluid and foods that become liquid at room temperature. First determine the IV fluid intake. 125 mL/hr × 8 hrs = 1000 mL. Next, add this total to the other fluid intake. 1000 mL + 2000 mL + 350 mL + 110 mL + 360 mL = 3820 mL. Then subtract the intake from the output: 5000 mL - 3820 mL = 1180 mL. Because the client's output is greater than the intake, the nurse would record the 1180 as a negative fluid balance.

The nurse asks the unlicensed assistive personnel (UAP) to change the soiled bed linens of the client with acute diarrhea of unknown origin. What interventions should the nurse direct the UAP to implement? Select all that apply. Wear a mask when changing the soiled linens. Wear gloves and gown while in the room. Use alcohol-based hand wash before and after care. Request that the physician order a stool culture. Post an enteric precaution sign outside the room.

The nurse should advise the UAP to wear gown and gloves in the room (2) and post an enteric precautions sign (5). Rationale: Gown and gloves are appropriate, because diarrheal stool may be infectious. The enteric precautions sign will notify other staff members and visitors that an infectious agent may be present, and will help prevent transmission. If the stool culture results are negative, the sign can be removed. Masks are not indicated because intestinal bacteria are not airborne. Hand washing is essential, but the bacterium most commonly found in diarrheal disease is clostridium difficile (c. diff.) and these spores are not killed by alcohol-based preparations. Soap and water is needed. Finally, a stool culture is definitely indicated, but a UAP cannot request an order. The nurse must do so.

Signs, symoptoms, lab values of increased risk for respiratory failure

The signs, symptoms and lab values that may show an ↑ risk for respiratory failure include: gradual ↑in PaCo2, use of accessory respiratory muscles, ↓PaO2, appearance of distress. A fever may indicate an infection which can put a patient at an ↑ risk for respiratory failure. pH of 7.4 is normal.

NCLEX PRACTICE QUESTIONS

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