NCLEX: Practice test 1

long acting insulins

-detemir, glargine

Thombolytic medications

-end in ase -alteplase

Calcium Channel Blockers

-usually end in pine or have ca in the name (amplodipine, diltiazem, Nimopidine) -Some calcium channel blockers have the added benefit of slowing your heart rate, which can further reduce blood pressure, relieve chest pain (angina) and control an irregular heartbeat.

Nonstress test

-wan to see 2 or more ACCELERATIONS of 15 beats/minute (or more) *with FETAL MOVEMENT* -the incr of 15 beats above baseline should last at least 15 seconds but HR should return to baseline w/in 2 minutes -you want test to be *REACTIVE*

Cr

.5-1

Normal lithium level

0.5-1 -Symptoms of *lithium toxicity begin to appear at blood levels greater than 1.5 mEq/L*. ~~~*concurrent administration of lithium and diuretics such as furosemide incr chance of toxicity* ~~~serum levels of 1.5-2.0 mEq/L: blurred vision, ataxia, tinnitus, persistent nausea and vomiting, severe diarrhea. ~~~serum levels of 2.0-3.5: excessive output of dilute urine, increasing tremors, muscular irritability, psychomotor retardation, mental confusion, giddiness. ~~~serum levels above 3.5: impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmias, myocardial infarction, cardiovascular collapse.

BUN

10-20

FETAL HR ALWAYS

120-160 normal 110-120: little concerned and watching less than 110= panic

Second trimester

14-26 weeks -1 pound a week -no more N/V or urinary frequency because fundus rises up relieving pressure on bladder -quickening= fetal movement -fetal HR (120-160)

The nurse is performing CPR on an adult client with facial and neck trauma. Following the administration of rescue breaths, where is the best location for the nurse to assess for a pulse in this client? 1. Apical area 2. Carotid artery 3. Femoral artery 4. Radial artery

3. Correct: *Pulses that are best palpated are large and close to the trunk of the body.* The femoral artery is large and at the trunk (proximal) of the body.

RBC

4.2-6 million

Ca

9-10.5

Amniotomy

Artificial rupture of membranes for labor

The nurse is caring for a depressed client. The client has a flat affect, apathy, and slowed physical movement. The client has not bathed in several days and there is a malodorous odor noted. Which intervention would be most appropriate at this time? 1. Explain the rules about daily showers. 2. Leave the client alone since there is slowed movement. 3. Tell the client it is time to take a shower. 4. Ask when he or she would like to take a shower.

3. Correct: Depressed clients often have little energy to do or think. Give short, simple commands during this time. 1. Incorrect: Not very therapeutic. This is difficult to comprehend at this time. Give short, clear, simple commands. 2. Incorrect: Do not ignore the problem. You must do what is best for the client and this would not be the best decision. 4. Incorrect: The client will not want to do anything at this time. It will be put off and depressed client's often have difficulty making decisions.

Following surgery, a client refuses to ambulate as prescribed. What action should the nurse take? 1. Notify the primary health care provider of client's refusal to ambulate. 2. Offer the client pain medication. 3. Explain complications associated with bed rest. 4. Perform passive range of motion exercises.

3. Correct: The nurse should educate the client about complications that can be prevented with ambulation, such as constipation, pneumonia, or deep vein thrombosis (DVT). 2. Incorrect: The first action should be for the nurse to educate the client so that he/she can make an informed decision. Offering pain medication would be appropriate if pain is impeding the client's ability to move; however, pain medications may make the client at risk for falls so safety precautions would be priority.

The nurse is evaluating dietary education provided to a client diagnosed with cholecystitis. The nurse determines that further teaching is necessary when the client chooses which meal to consume? 1. Cup of oatmeal, blueberries, soymilk 2. Whole grain pasta, marinara sauce, baked fish, coffee 3. Spaghetti with meat sauce, peas, garlic French bread, tea 4. Lentil soup, vegetable medley, fruit salad, water

3. Correct: This is not a good choose for this client. Meat is high fat. French bread with butter is low fiber and high fat. 1. Incorrect: This is a good meal choose when on a low fat, high fiber diet. Blueberries are high in fiber and all are low fat. 2. Incorrect: This is a good low fat, high fiber meal choose. Whole grain pasta is high in fiber and low in fat. Fish and marinara sauce are low in fat. 4. Incorrect: These are low fat, high fiber items to consume.

A nurse attaches a client to continuous cardiac monitoring due to a potassium level of 2.8 mEq (2.8 mmol). The nurse should monitor for which dysrhythmia? 1. Third degree heart block 2. Atrial fibrillation 3. Premature atrial contractions 4. Premature ventricular contractions

4. Correct: Hypokalemia is reflected by the EKG. The earliest EKG change is often premature ventricular contractions (PVCs) which can deteriorate into ventricular tachycardia or fibrillation (VT/VF) without appropriate potassium replacement.

Miscarriage/abortion

Also called spontaneous abortion; spotting common during pregnancy but the combination of bleeding and cramping is more indicative of a miscarriage s/s will be - bleeding, - cramping, - backache—*measure hCG levels b/c get worried when they DECREASE* o Treatment is - bed rest, - abstinence from sex, - and sedation if miscarriage is pending then start an IV of fluids, may need blood depending on how much was lost, and a D&C (dilation & curettage) to remove any remaining products of conception

Hydatidiform mole (molar pregnancy)

Benign neoplasm that can turn malignant; starts like any other normal pregnancy o Grape-like clusters of vesicles o May/may not have a fetus involved, usually fetus is not involved s/s are the - *uterus enlarges WAY TOO FAST* - absence of fetal heart tones; - bleeding (sometimes will have vesicles); - confirmed with an ultrasound TREATMENT • If it's a small mole will D&C to empty uterus • *Do not get pregnant; follow up/follow up time is very important* ~~~do not want them to become pregnancy again b/c can elevate hCG which also increases with malignancy • If it becomes malignant it is called *choriocarcinoma*; will do a CXR to determine metastasis • Will measure hCG's weekly until normal; rechecked every 2-4 weeks; then every 1-2 months for 6 months to a year

Post partum hemorrhafe

EARLY: more than 500 ml blood lost 24 hours & a 10% drop from admission hematocrit

Antivirals

Have vir in name (Ritonavir)

A nurse drops a bottle of IV fluid, which shatters on the floor in the hallway. What action should the nurse take? 1. Notify housekeeping to clean up the spill. 2. Pick up glass with a broom and dustpan and dispose into a puncture resistant sharps container. 3. Pick up the glass with gloved hands and dispose into a puncture resistant sharps container. 4. Use a wet mop to collect the glass and dispose of it in the garbage can.

Pick up glass with a broom and dustpan and dispose into a puncture resistant sharps container. -The nurse must not be cut by the broken glass. Proper removal of glass includes using a dustpan and broom to collect the glass and disposing of it into a puncture resistant sharps container.

The primary healthcare provider prescribed tolbutamide 250 mg orally twice a day. The pharmacy dispensed tolbutamide 0.5 g scored tablets. How many tablets will the nurse administer? Round your answer using one decimal point.

Step 1: 1000 mg : 1 g = x mg: 0.5 g x = 500 mg Step 2: 500 mg: 1 tab = 250 mg : x tab 500 x = 250 X = 0.5 *RULE: if doesnt say in 24 hours then means for that administration only!*

Ectopic Pregnancy

This is a gestation OUTSIDE the uterus that usually forms in the fallopian tubes; confirmed with an ultrasound, ~~~*the first sign is PAIN* S/S the pt will exhibit the usual s/s of pregnancy then will have pain; -spotting or may be bleeding into the peritoneum; -if a pt has had 1 ectopic pregnancy she is at risk for another TREATMENT *Methotrexate* (rheumatrex/trexall) is given to mom to stop the growth of the embryo to save the tube • If the methotrexate doesn't work then a laparoscopy may be done, a small incision will be made into the tube and the embryo will be removed; the entire tube may have to be removed • A laparotomy is done if the tube has ruptured or if ectopic pregnancy is advanced; if the tube does rupture your pt could hemorrhage and may need a blood transfusion

The six bed Labor and Delivery area is full when the Emergency Department nurse calls for a bed for a woman reporting low back pain, pelvic pressure and increased vaginal discharge at 36 weeks gestation. Which would be the most appropriate action for the charge nurse? 1. Transfer a G4P4 who delivered full-term twins one hour ago to the antepartum/postpartum floor. 2. Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the antepartum/postpartum floor. 3. Transfer an 8 hour postpartum G1P1 on Magnesium Sulfate for eclampsia from the LDR unit to the ante/postpartum unit. 4. Request that the new client be admitted to the antepartum/postpartum floor.

Transfer a G3 P3 who delivered an 8 lb. newborn three hours ago to the antepartum/postpartum floor. -The client and newborn are not in any present distress. Also the delivery occurred 3 hours ago. This client would not be a risk and could be cared for on the antepartum/postpartum floor.

Beta blockers

lol

Phytonadione

promotes formation of clottin factors

Lorazepam

sedative/hypnotic or antianxiety agent.

aPTT

-(patients receiving anticoagulant therapy: 1.5-2.5 times the control value in seconds) 30-40 seconds

Naegeles rule

-1st day of last menstrual period -*add 7 days and 9 months*

metronidazole

-antibiotic -dont confuse w/ proton pump inhibitors b.c ends in 'azole'

Proton pump inhibitors

-end in zole -main action is a pronounced and long-lasting reduction of gastric acid production *DONT confuse with METRONIDAZOLE which is an ANTIBIOTIC*

MEDS USED TO HALT POSTPARTUM HEMORRHAGE

1. oxytocin 2. methylgonovine maleate 3. carboprost tromethamine

Which foods should the nurse teach a client to avoid when prescribed a diet limiting purine rich foods? 1. Peanut butter 2. Potatoes 3. Apples 4. Venison 5. Scallops

4., & 5. Correct: Meats such as liver, bacon, veal, and venison are high in purine and should be avoided. Seafood such as sardines, mussels, codfish, scallops, trout, and haddock are high in purine and should be avoided.

Hegars sign

softening of lower uterine segment -2nd/3rd month

MED ENDINGS ace inhibitors

-pril -block angiotensin converting enzyme (angiotensin-renin system) and in turn block aldosterone (lowers BP)

Goodells sign

-softening of cervix -2nd month

Braxton hicks contractions

-throughout whole pregnancy which is good just blood through placenta

The nurse is preparing to administer iron dextran IM. Which injection site would be best for administration? 1. Ventrogluteal site 2. Vastus lateralis site 3. Rectus Femoris site 4. Deltoid site

1. Correct: This site would be used for Z track IM injections. Iron preparations are administered by the Z track technique, preferably in a large, deep muscle such as the ventrogluteal muscle.

Which assignments would be most appropriate for the RN to delegate to an LPN/VN? 1. Six year old with new onset diabetes. 2. Ten year old with pneumonia admitted two days ago. 3. Three month old admitted with severe dehydration. 4. Four year old admitted for developmental studies. 5. Twelve year old with post op wound infection taking oral antibiotics.

2.,4. & 5. Correct: The best assignments for the LPN/VN would be the child with pneumonia admitted two days ago and the child admitted for developmental studies. The twelve year old with post op wound infection taking oral antibiotics is also stable.

anticholinergic agent

-blocks the neurotransmitter acetylcholine in the central and the peripheral nervous system -antispasmodic INDICATIONS: ~Overactive bladder. ~Movement problems in Parkinson's disease. ~Diarrhea. ~Motion sickness. ~Nausea and/or vomiting. ~Muscle spasms. ~Chronic obstructive pulmonary disease (COPD) ~Asthma.

Chadwicks sign

-bluish color of vaginal mucosa/cervix -4 weeks

What risk factors should the nurse include when conducting a class about type 2 diabetes mellitus? 1. Fat distribution greater in abdomen than in hips. 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. 5. Polycystic ovary syndrome.

*1. Fat distribution greater in abdomen than in hips.* 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. *5. Polycystic ovary syndrome.* 1., & 5. Correct: If the body stores fat primarily in the abdomen, risk of type 2 diabetes is greater than if body stores fat elsewhere, such as hips and thighs. Women with polycystic ovary syndrome have increased risk of diabetes. 4. Incorrect: Blacks, Hispanics, American Indians, and Asian Americans are more likely to develop type 2 diabetes than Caucasians are.

A nurse is teaching a group of small farm owners how to prevent pesticide exposure for field workers. What points should the nurse include? 1. Importance of hand washing before eating. 2. Wearing protective clothing while working in the field and at home. 3. Removing clothing and shoes worn in the field before entering the home. 4. Washing fruit and vegetables prior to eating. 5. Boiling all vegetables for a minimum of 5 minutes prior to eating.

*1. Importance of hand washing before eating.* 2. Wearing protective clothing while working in the field and at home. *3. Removing clothing and shoes worn in the field before entering the home. 4. Washing fruit and vegetables prior to eating.* 5. Boiling all vegetables for a minimum of 5 minutes prior to eating. 1., 3. & 4. Correct: The standard precautions of hand hygiene is recommended prior to eating. This will reduce the transmission of pathogens and possible pesticides. The pesticides may be present on their clothing, so the clothing and shoes should be removed. Fruits and vegetables should be washed to remove pathogens and pesticides. All points are important to include when teaching prevention of pesticide exposure. 2. Incorrect: Yes, wear protective clothing while working in the field, but it is not necessary to wear protective clothing at home. 5. Incorrect: No, it is not necessary to boil or cook vegetables to remove chemicals from fresh produce. Washing thoroughly with water is adequate.

Which action by a nurse indicates to the charge nurse that the sterile field has been contaminated? 1. The sterile field is above the level of the waist. 2. Sterile gauze dressing within the one inch border of sterile field. 3. Remains facing the sterile field throughout procedure. 4. Inspects sterile wrapped instruments for tears.

*2. Correct: No sterile object should be within the one inch border of the sterile field as the object is no longer considered sterile.* -Bacteria tend to settle below the level of the waist, so there is less contamination when the field is above the waist and away from the nurse. This action is correct -The sterile wrapped instruments and trays should be purposely inspected for small tears that would compromise sterility before opening and placing the instruments on the field. This action is correct

Third trimester (27-40 weeks)

-1 pound a week -fetal position/presentation determined by LEOPOLE MANEUVERS (have pt void 1st and do btw contractions) -done to determine position (fetal dopplar best taken where fetal back is)

Viability

-24 weeks -fetus not viable at 20 weeks wont survive

Post cataract removal a client reports nausea and severe pain in the operative eye. Which nursing intervention takes priority? 1. Administer morphine and ondansetron. 2. Reposition client to non-operative side. 3. Massage the canthus to unblock the lacrimal duct. 4. Notify the primary healthcare provider.

-Severe pain with nausea indicates an increase in intraocular pressure and needs to be reported at once. Eye damage can result if not resolved quickly. The primary healthcare provider may prescribe medications or take the client back to surgery.

Amniocentesis

-amniotic fluid test -medical procedure used in prenatal diagnosis of chromosomal abnormalities and fetal infections, and also for sex determination -small amount of amniotic fluid, which contains fetal tissues, is sampled from the amniotic sac surrounding a developing fetus, and then the fetal DNA is examined for genetic abnormalities. -Amniocentesis is performed when a woman is between 14 and 16 weeks gestation

Atropine

-anticholinergic agent; not used to trt pseudoparkinism -commonly used to treat arrhythmias and preoperatively to decrease secretions

Guillane Barre

-condition in which the immune system attacks the nerves. -Symptoms start as weakness and tingling in the feet and legs that spread to the upper body. Paralysis can occur. Special blood treatments (plasma exchange and immunoglobulin therapy) can relieve symptoms. Physical therapy is needed. -difficulty swallowing, facial muscle weakness, shortness of breath, slow reflexes, uncomfortable tingling and burning, urinary retention, difficulty raising the foot, or impaired voice -may need mechanical ventilation or intubation

What should the nurse include when providing education to a client receiving tetracycline? 1. Wear long sleeves when going outside. 2. Take tetracycline on a full stomach. 3. Wait at least two hours after taking tetracycline prior to taking iron supplements. 4. Tetracycline can decrease the effectiveness of birth control pills. 5. Do not take this medicine after the expiration date on the label has passed.

-cycline antibiotic -1., 3., 4., & 5. Correct: Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Tetracycline *can make your skin more sensitive to sunlight* and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun. Take tetracycline on an *empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective.* Tetracycline can make birth control pills less effective. Use a second method of birth control while you are taking this medicine to keep from getting pregnant. Throw away any unused tetracycline when it expires or when it is no longer needed. Do not take this medicine after the expiration date on the label has passed. Expired tetracycline can cause a dangerous syndrome resulting in damage to the kidneys. 2. Incorrect: Take tetracycline on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective.

Pagets Disease

-disease that disrupts the replacement of old bone tissue with new bone tissue. -most commonly occurs in the pelvis, skull, spine, and legs -Treatment involves medications that reduce the breakdown of bone.

Contraction stress test (oxytocin challenge test)

-done in *third trimester* when NST non reactive -done on high risk pregnancies (preeclampsia, maternal diabetes, any condition where placental insufficiency suspected) -done to determine if fetus can handle stress of uterine contraction since they decr blood flow to uterus/placenta -when decr below baseline its a deceleration, DONT WANT TO SEE LATE DECELERATIONS b/c means uteroplacental insufficiency -*you want test to be NEGATIVE*

Biophysical profile

-done in last trimester, but can be done 32-34 weeks in high risk pregnancy -high risk may have BPP every week or twice a week in 3rd trimester -NST is part of BPP and measurements are done by ultrasound, each parameter is 2 points 1. *HEART RATE*: non stress test 2. *MUSCLE TONE*: need 1 fetal flexion/extension in 30 mins 3. *MOVEMENT*: fetus move at least 3x in 30 mins 4. *BREATHING*: does fetus have breathing movements least once in 30 mins 5. *AMNIOTIC FLUID*: enough around fetus? -observation time= 30 mins -RESULTS: 8-10= good 6 worrisome <4 ominous

ULTRASOUNDS preg considerations

-drink water to distend bladder (NO VOID) -you want bladder to push uterus to abdominal surface -UNLESSSS its an ultrasound prior to procedure like amniocentesis, THEN VOID

Positive signs of pregnancy

-fetal heartbeat by dopplar (10-12 weeks) -fetoscope (17-20 weeks) -fetal movement (what CLINICIAN feels not what pt reports) -ultrasound

Epidural anesthesia

-given stage 1 at 3-4 cm dilation -major complication is hypotension so watch BP -IV bolus with fluids 1st of 1000 ml NS or LR to fight hypotension

The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given? 1. "The action of the medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you do not break a bone." 4. "Glycopyrrolate will decrease stomach secretions."

-glycopyrrolate is an ANTICHOLINERGIC 4. Correct: Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease the risk of aspiration. 2. Incorrect: Glycopyrrolate blocks the secretions in the mouth, throat, airway and stomach. The medication does not prevent the client having a seizure. The ECT will induce a seizure, which is the desire.

Pts having vaginal birth after csection

-high risk for uterine rupture -scar from c section prone to open under stress -highest risk are those getting oxytocin

SIGNS OF LABOR

-lightening: 2 weeks before term (presenting part of fetus {usually head} descend into pelvis) -pt feels less congested, breathe easier, but urinary frequency problem again b/c pressure back on bladder -*ENGAGEMENT*: fetal largest part in pelvic inlet -*FETAL STATION*: measure in cm and measures relationship of presenting part of fetus to moms ischial spine -bloody show (if lots think hemorrhage) -sudden energy burst (nesting) -diarrhea -rupture of membranes

Maternity pigmentation changes

-linea nigra= dark line down center of abdomen -abdominal striae= stretch marks -facial chloasma= preg. mask) -darkening of areola

rapid acting insulins

-lispro, aspart, glulisine

Rh0 (D) immunoglobulin (rhogam)

-must be given before antibodies have formed! -it destroys fetal cells that got in mothers blood and has to be done BEFORE antibodies are formed ~~~Once antibodies form, the woman has them for life so it MUST be given BEFORE these antibodies can form -given 72 hrs after birth or if there was any chance of bleeding such as trauma, procedure, abortion, etc. RhoGAM is given

Reporting faulty equipment is an act to promote...

-nonmaleficence or to do no harm. This is the core of nursing ethics.

mastitis

-painful infection of breast tissue -To avoid plugged milk ducts and mastitis— alternate breast with each feeding; ex. 8am offer right breast first, 10am offer left breast first

Fetal bradycardia put on what side?

-put on leftside to enhance uterine perfusion

Parity

-reaches 20weeks

Emergency delivery

-tell pt to pant/blow to decr urge to push wash hands elevate HOB minimize touching of vaginal area as head crowns, tear amniotic sac if not already rutured -put hands on fetal head to prevent coming out too fast -when head out feel for cord at neck -keep baby head down & at level of uterus -dry baby -place on moms abdomen and cover baby -wait for placenta to deliver/seperate then inspect for intactness -tie cord off w/ piece of string ect (place one knot about 4 in from babys navel and second knot about 8 in from babys navelp

Alendronate

-treat or prevent osteoporosis. It can also treat Paget's disease of the bone. -Alendronate is also used to treat Paget's disease of bone (a condition in which the bones are soft and weak and may be deformed, painful, or easily broken) & osteoporosis -class of medications called bisphosphonates. It works by preventing bone breakdown and increasing bone density

Normal digoxin level

.8-2 -A DRUG THAT STRENGTHENS THE CONTRACTION OF THE HEART MUSCLE, SLOWS THE HEART RATE AND HELPS ELIMINATE FLUID FROM BODY TISSUES. IT'S OFTEN USED TO TREAT CONGESTIVE HEART FAILURE AND IS ALSO USED TO TREAT CERTAIN ARRHYTHMIAS -Here are some of the signs and symptoms of digitalis toxicity: includes: ~~~CONFUSION ~~~NAUSEA, VOMITING, ~~~DIARRHEA ~~~BLURRED VISION ~~~HALOS OR RINGS OF LIGHT AROUND OBJECTS

The nurse is caring for a client following spinal surgery. The client is placed on methylprednisolone. What additional drug therapy would the nurse expect to be prescribed with methylprednisolone? 1. Pantoprazole 2. Phenytoin 3. Imipramine HCI 4. Aminocaproic acid

1. Correct: A potential side effect of methylprednisolone is a peptic ulcer. The primary healthcare provider will prescribe a proton pump inhibitor or H2 blocker to prevent this side effect. 2. Incorrect: Phenytoin is an anticonvulsant. Seizures are not a side effect of methylprednisolone. 3. Incorrect: Imipramine HCI is an antidepressant which is not routinely given with methylprednisolone (Although mood changes can occur with steroid administration, anti-depressants are not routinely given). 4. Incorrect: Aminocaproic acid is given when clients are bleeding. Bleeding is not a side effect of methylprednisolone.

A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most important nursing measure to include in the nursing care plan for this client? 1. Observation and support of ventilation 2. Insertion of indwelling urinary catheter 3. Nasogastric suctioning 4. Frequent assessments of level of consciousness

1. Correct: Guillain-Barre syndrome is an acquired inflammatory disease that results in demyelinization of the peripheral nerves. It is usually ascending in nature and can lead to respiratory paresis or paralysis.

A 72 year old client admitted with a diagnosis of bleeding ulcers has been prescribed ranitidine 50 mg IVPB every 8 hours and omeprazole 10 mg po every morning. Based on this data what intervention should the nurse take first?​ Exhibit -0900 Client alert and oriented. Denies abdominal pain, discomfort, or nausea and vomiting. Active bowel sounds in all quadrants. Abdomen soft, non-tender to palpation. Ranitidine 50 mg IVPB hung to IV line of NS at 100 mL per hour. No redness or edema noted at IV site. -0930 Client confused to place and time. Oxygen sat 95%. Lungs clear bilaterally. Denies pain. BP 118/78, HR 84/min, RR - 20/min, Temp. - 97.8 F (36.55 C). 1. Stop the infusion of ranitidine. 2. Send the client for a CT scan of the head. 3. Provide oxygen at 2L/NC. 4. Notify the primary healthcare provider.

1. Correct: Ranitidine can cause confusion in the elderly as well as agitation. Stop the infusion, then notify the primary healthcare provider. 2. Incorrect: Confusion is a side effect of ranitidine, so the medication should be stopped and then the healthcare provider notified. 3. Incorrect: The oxygen saturation is not low at 95%. Providing oxygen will not correct the confusion. 4. Incorrect: The primary healthcare provider should be notified after stopping the ranitidine.

Which task should the nurse perform first? 1. Suctioning the tracheostomy. 2. Changing a colostomy bag that is leaking. 3. Performing an admission assessment on a client. 4. Administering pain medication to a postoperative client.

1. Correct: The tracheostomy tube must be suctioned to keep the client's airway open. Suctioning the tracheostomy should take priority. Remember, airway first.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which clients should the charge nurse assign to the medical-surgical nurse? 1. Total abdominal hysterectomy 2. Breast reduction 3. Vaginal delivery with fetal demise 4. 32 week gestation with lymphoma 5. Post-partal with HELLP syndrome

1., & 2. Correct: Though the clients are females, their postoperative care has similarities to the standard postoperative clients. 4. Incorrect: This client needs specialized care. The client is at 32 weeks gestation. A nurse with obstetrical experience, should be assigned to this client. 5. Incorrect: No, the monitoring is too specific for the medical-surgical nurse. Hemolysis Elevated Liver enzymes Low Platelet count (HELLP) syndrome is a form of preeclampsia with severe liver damage. The medical-surgical nurse should not be assigned to this client.

The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client? You answered this question Incorrectly * 1. Document the client's statement in the client's own words. 2. Provide information on advance directives to the client. 3. Inform the client that personnel are available to assist with completing an advance directive.* 4. Avoid inquiring about a client's advance directive as this could cause the client anxiety and concern. 5. Ask the daughter if she agrees with her mother's decision.

1., 2. & 3. Correct: The nurse should document the client's statement in the client's own words. The nurse should provide the client with information on advance directives and assurance that there are hospital personnel to assist with completing the advance directive.

What should a community health nurse include when planning a presentation on prevention and early detection of colon cancer? 1. Maintain a diet high in fruits, vegetables, and whole grains. 2. Exercise regularly. 3. Regular screening should begin at age 30. 4. Yearly guaiac-based fecal occult blood test. 5. Flexible esophagogastroduodenoscopy every 5 years.

1., 2., & 4. Correct: A diet high in vegetables, fruits, and whole grains has been linked with a decreased risk of colorectal cancer; whereas, a diet high in red meats, processed meats, and cooking meats at very high temperature (frying, broiling or grilling) creates chemicals that may increase the risk for colorectal cancer. There is a greater risk of developing colorectal cancer in individuals who live a sedentary life style. The guaiac-based fecal occult blood test detects blood in the stool through a chemical reaction. This test is done yearly. 5. Incorrect: Flexible sigmoidoscopy looks at the rectum and colon to detect polyps and colon cancer. For people who have none of the risks described earlier, digital rectal examination and testing of the stool for hidden blood are recommended annually beginning at age 40. Flexible sigmoidoscopy is recommended every 5 years at age 50 or older. A double contrast barium enema every 5 to 10 years and colonoscopy every 10 years are acceptable alternatives.

What discharge instructions should the nurse provide to the client post abdominal hysterectomy? 1. Ambulate at least 3-4 times per day. 2. Notify the primary healthcare provider if there is a yellow discharge from the surgical wound. 3. Swimming is allowed if staples were used to close the skin. 4. Press a pillow over incision when coughing to ease discomfort. 5. Apply moist heat to surgical site the first couple of days for pain relief.

1., 2., & 4. Correct: The client should get up and move to prevent complications such as deep vein thrombosis (DVT), pneumonia, constipation, etc. The healthcare provider should be notified if the surgical wound is bleeding, red and warm to touch or has a thick, yellow, or green drainage. Pressing a pillow over incision when coughing or sneezing will ease discomfort and protect the incision. 3. Incorrect: Do not go swimming or soak in a bathtub or hot tub until the primary healthcare provider says it is ok. You worry about infection. 5. Incorrect: In the first couple of days, an ice pack may help relieve some pain at the site of surgery. Remember NCLEX wants you to think safety first when it comes to the use of heat.

The nurse is caring for a client admitted to the emergency department with a history of asthma. Which assessment findings would the nurse anticipate? 1. Coughing 2. Chest tightness 3. 3 + pitting edema to ankles 4. Kussmaul respirations 5. Increased respiratory rate

1., 2., & 5. Correct: The client with asthma has a pattern of dyspnea (shortness of breath), chest tightness, coughing, wheezing, and increased respiratory rate. 3. Incorrect: There should be no dependent edema with asthma. 4. Incorrect: *This respiration classification relates to metabolic acidosis and is seen in DKA.*

The nurse educator is teaching a group of nursing students about client advocacy. What should the educator tell the students are the consequences of failure to act as a client advocate? 1. Life-threatening complications for the client. 2. Legal action against the nurse and/or healthcare facility. 3. Suspension or loss of license to practice nursing. 4. Suspension or loss of license to practice medicine. 5. Loss of client autonomy and right to make decisions.

1., 2., 3. & 5. Correct: The role of client advocate is a nurse's responsibility. Failure to act as a client advocate could result in a range of complications for the client, including: -life-threatening or life-ending complications. -Failure to act as client advocate exposes the nurse to liability, potential legal action against the nurse and/or healthcare facility -potential suspension or loss of license to practice nursing. -The client advocate protects client autonomy and right to make decisions.

Which prescriptions are appropriate for the nursery nurse to initiate on a newborn prior to discharge home? 1. Hepatitis B vaccine 2. Erythromycin Ointment 3. Vitamin K 4. Lanolin 5. PKU Screening

1., 2., 3. & 5. Correct: This vaccine is recommended at birth to decrease the incidence of hepatits B virus. Mandatory prophylactic agent is applied in newborn's eyes as precaution against ophthalmia neonatorium. Vitamin K (Aquamephyton) routine injection to prevent hemorrhagic disease of newborn. *PKU-Screening for phenylketonuria is not reliable until the newborn has ingested an ample amount of the amino acid, phenylalanine, a constituent of both human and cow's milk. Nurse must document initial ingestion of milk and perform test at least 24 hours after that time. This test is thus done just prior to discharge.*

A client diagnosed with mania and hypertension is hospitalized due to confusion and polyuria. Based on current data, what interventions should the nurse implement? Exhibit Home meds: Lithium carbonate 1000 mg po daily Aripiprazole 10 mg po daily Furosemide 10 mg po daily.Ataxia and mild hand tremors noted. Assessment: BP 120/74, Respirations 18, Heart rate 92. Sodium - 140 mEq /L (130 mmol/L) Potassium - 4.5 mEq/L (4.5 mmol/L) Glucose - 122 mg/dl (6.77 mmol/L) Lithium level - 2.1 mEq/L 1. Hold the lithium carbonate dose. 2. Notify primary healthcare provider of lithium level. 3. Connect client to heart monitor. 4. Administer sodium polystyrene for hyperkalemia. 5. Pad the siderails of the client's bed.

1., 2., 3., & 5. Correct: Symptoms of *lithium toxicity begin to appear at blood levels greater than 1.5 mEq/L*. Additionally, *concurrent administration of lithium and diuretics such as furosemide increase the chance of toxicity*. At serum levels of 1.5-2.0 mEq/L: blurred vision, ataxia, tinnitus, persistent nausea and vomiting, severe diarrhea. At serum levels of 2.0-3.5: excessive output of dilute urine, increasing tremors, muscular irritability, psychomotor retardation, mental confusion, giddiness. At serum levels above 3.5: impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmias, myocardial infarction, cardiovascular collapse. Arrhythmias and seizures can occur with toxicity. So the lithium dose should be held, and the healthcare provider notified. The client is at risk for arrhythmias, so connect to a heart monitor. The client is also at risk for seizures, so pad the side rails. 4. Incorrect: The potassium level is normal, so there is no need to treat hyperkalemia.

A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who will need assistive devices upon discharge. Which devices should the case manager include for this client? 1. Dinner plate food guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip eating utensils 6. Button closures on clothes

1., 2., 3., 4., & 5. Correct: The goal is to promote self-care by the client as much as possible. The case manager should evaluate the need for assistive devices to help with eating, bathing, dressing, and ambulating. The dinner plate food guard will prevent food from being pushed off the plate. The transfer belt will provide safety for the client to get into a chair or back in bed. A raised toilet seat makes it easier for the client to sit on the toilet without falling. The long-handled shoe horn allows the client to put on shoes without assistance. Wide grip utensils accommodate a weak grip. 6. Incorrect: It is hard for someone with hemiplegia to use buttons. Velcro fasteners are best.

What should the nurse document after a client has died? 1. Time of death 2. Who pronounced the death 3. Disposition of personal articles 4. Destination of body 5. Primary healthcare provider's prescriptions 6. Time body left facility

1., 2., 3., 4., & 6. Correct: All of these should be documented. Also document consideration of and preparation for organ donation; family notified and decisions made; location of identification tags. 5. Incorrect: The primary healthcare provider's prescriptions do not need to be documented after a client dies.

Which assessment findings would be of concern to the nurse who is caring for a client who has an arterial line to the radial artery? 1. Capillary refill: Left hand-2 seconds; Right hand- 4 seconds. 2. Blue tinged color to finger tips of right hand. 3. Warm skin to right and left hand. 4. Left radial pulse-88/min; Right radial pulse-82/min 5. Blanching to right hand.

1., 2., 4., & 5. Correct: These are all signs of poor circulation to the right hand. The arterial line could be occluding circulation and needs to be removed. 3. Incorrect: This is a good sign. We would worry with cool skin/extremity.

A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis. What interventions should the nurse initiate? 1. Wear an N95 respirator when caring for client. 2. Restrict fluid intake to 500 mL per day. 3. Position client in semi-Fowler's position. 4. Place client in a negative pressure airflow room. 5. Do not allow visitors for 48 hours.

1., 3. & 4. Correct: The nurse should suspect that the client is suffering from tuberculosis. Early pulmonary TB is asymptomatic. When the bacterial load increases, nonspecific symptoms of fatigue, weight loss, afternoon fevers, and night sweats may set in. As disease advances, cough, sputum production, and hemoptysis may appear. This client has the classic symptoms of TB and should be placed on airborne precautions. N95 respirator ensures that the nurse does not inhale the TB organism. Placing in a semi-Fowler's position reduces the work of breathing. 2. Incorrect: Unless contraindicated, 3-4 liters of fluid is needed per day to liquefy secretions. 5. Incorrect: Visitors are allowed if standard and airborne precautions are followed.

The nurse notes that a client has impaired swallowing as a result of a cerebrovascular accident (CVA). Which interventions are appropriate for the nurse to include in the plan of care? 1. Sit the client up at a 90° angle during meals. 2. Assist the client to hyperextend the head when preparing to swallow. 3. Encourage the client to sit up for 30 minutes after eating. 4. Educate a family member on the Heimlich maneuver. 5. Start the client on a thin liquid diet.

1., 3. & 4. Correct: This is the optimal position for chewing and swallowing without aspirating. Sitting up 30 minutes after completing a meal will prevent regurgitation of food. *In case of choking, family members should know how to perform emergency measures such as the Heimlich maneuver.* 2. Incorrect: The client should position the head in forward flexion in preparation for swallowing, called the "chin tuck". Hyperextension would cause aspiration. 5. Incorrect: *The client should be started on thick liquid or pureed diet.* Thickened or pureed foods are easier to swallow than thin liquids and prevent aspiration.

Which signs and symptoms, if noted by the nurse, would indicate that the client with hyperthyroidism is experiencing thyroid crisis? 1. Hyperkinesis 2. Bradycardia 3. Hypertension 4. Restlessness 5. Confusion

1., 3., 4., & 5. Correct: These are symptoms of thyroid crisis and should be reported immediately.

A primary healthcare provider prescribed KCL 40 mEq in 100 mL NS to infuse over 30 minutes. What action should the nurse take? 1. Administer the KCL through the lowest IV line port. 2. Clarify the prescription with the primary healthcare provider. 3. Mix KCL 40 mEq into the present infusing bag of NS when it reaches 100 mL. 4. Set the infusion pump to 100 mL / hour.

2. Correct: *Potassium chloride should be diluted and administered to infuse no faster than 40 mEq per hour. So this prescription would infuse too quickly and may lead to life threatening arrhythmias.

Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching of proper diet was understood? 1. Pancakes with whipped butter, syrup, bacon, apple juice 2. Scrambled eggs, sliced turkey, biscuit, whole milk 3. Grits, fresh fruit, toast, coffee 4. Bagel with jelly, hash browns, tea

2. Correct: Client needs low sodium and increased proteins.

A primary healthcare provider informs the nurse to prepare for an amniotomy on a client who's labor has not progressed. What should the nurse assess for prior to the primary healthcare provider performing this procedure? 1. Fetal attitude 2. Fetal engagement 3. Fetal lie 4. Fetal position

2. Correct: Fetal engagement is important prior to rupturing the membranes so that the umbilical cord cannot prolapse. Fetal engagement is when the fetus is at station 0 (level of mom's ischial spines). If the fetus is not well engaged when the membranes are ruptured, then prolapsed cord could result. 4. Incorrect: Fetal position tells us the presenting part of the fetus to mom's pelvis.

A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client? 1. "Do you take metronidazole on an empty stomach?" 2. "Are you using any products that contain alcohol?" 3. "How long have you had these symptoms?" 4. "What other medications are you currently taking?"

2. Correct: Flushing, nausea and vomiting, palpitations, tachycardia, psychosis are signs of disulfiram-type reaction seen when using products containing alcohol (cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking metronidazole. 1. Incorrect: Although it is preferable to take metronidazole on an empty stomach, this is not the most important question to ask at this time. 3. Incorrect: How long the client has had these symptoms is not as important as whether the client is using any alcohol containing products. 4. Incorrect: Although the nurse needs to know what other medications the client is taking, it is not as important as knowing if the client is using any alcohol containing products.

Which electrolyte imbalance would be the nurse's priority concern in the burn client? 1. Hypernatremia 2. Hyperkalemia 3. Hypoalbuminemia 4. Hypermagnesemia

2. Correct: Good job. When the cells lyse they release potassium, and then the serum potassium goes up. And if the kidneys stop, we are in real trouble. 1. Incorrect: Well this one does occur when the client becomes very dehydrated, but it's not as dangerous as the potassium one. 3. Incorrect: Low albumin can cause problems keeping fluid in the vascular space, but albumin is not an electrolyte. 4. Incorrect: No, the magnesium doesn't go up unless the kidneys shut down.

A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What should the nurse suggest to reduce this side effect? 1. Stop taking the medication and call the primary healthcare provider. 2. Drink plenty of water with the medication. 3. Take the medication before bedtime. 4. Take antacids when taking the medication.

2. Correct: Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet. 1. Incorrect: Slight heartburn does not warrant primary healthcare provider report. Extreme pain or difficulty swallowing should be reported, as should heartburn that increases despite suggestions listed above. 3. Incorrect: The client should take in the morning, thus preventing prolonged contact with the esophagus. 4. Incorrect: The absorption of the medication is decreased when it is taken with calcium, iron, and magnesium, or antacids containing calcium, aluminum, or magnesium. Thirty minutes should elapse before taking the antacid following administration of the alendronate.

-The oncoming nurse has just received report and is preparing to make initial rounds. Which postpartum client should the nurse see first? 1. A primipara 6 hours postpartum saturating one peripad every two hours 2. A multigravida 1 hour postpartum and reporting intense perineal pain 3. A primigravida 12 hours postpartum with the uterine fundus at the umbilicus 4. A multigravida 72 hours postpartum with a brownish pink lochia discharge.

2. Correct: Intense perineal pain is a symptom of a perineal hematoma which is a medical emergency.

The oncoming nurse has just received report and is preparing to make initial rounds. Which postpartum client should the nurse see first? 1. A primipara 6 hours postpartum saturating one peripad every two hours 2. A multigravida 1 hour postpartum and reporting intense perineal pain 3. A primigravida 12 hours postpartum with the uterine fundus at the umbilicus 4. A multigravida 72 hours postpartum with a brownish pink lochia discharge.

2. Correct: Intense perineal pain is a symptom of a perineal hematoma which is a medical emergency. 1. Incorrect: Expected findings for the postpartum period are described here. This is a normal peripad saturation and does not indicate a problem. 3. Incorrect: Expected findings for the postpartum period are described here. This is the proper position of the fundus 12 hours postpartum. 4. Incorrect: Expected findings for the postpartum period are described here also. A client postpartal 72 hours should have a brownish pink lochia discharge.

Which nursing intervention should receive priority after a client has returned from having had eye surgery? 1. Administer pain medication around the clock. 2. Maintain head of bed at 35°. 3. Apply warm compresses. 4. Instruct on importance of turning, coughing, and deep breathing.

2. Correct: Maintaining head of bed in an elevated position will help to decrease intraocular pressure. Do not lie the client supine as this will increase intraocular pressure. If the intraocular pressure increases too much, damage to the eye structures, including the retina and optic nerve, with resulting loss of vision, may result. 3. Incorrect: Warm and hot compresses could possibly increase intraocular pressure and cause damage to the eye structures. 4. Incorrect: Coughing will increase intraocular pressure and could result in damage to the surgical site and/or the structure within the eye. Loss of vision could result if pressure becomes too great. Coughing is a type of valsalva movement which results in an increase in the intraocular pressure.

A client is scheduled for plateletpheresis. When taking the client's history, which information is most significant? 1. Allergies to shellfish 2. Date last donated 3. Time of last oral intake 4. Blood type aka platelet donation

2. Correct: Platelet donors can have plateletpheresis as often as every 14 days.

A client, who is having difficulty falling asleep, asks the nurse for a sleeping aid. What is the first action the nurse should provide to the client? 1. Assist client to take a cool bath. 2. Provide a back massage. 3. Administer prescribed triazolam. 4. Give client a crossword puzzle to work.

2. Correct: Research indicates that back massage can enhance client comfort, relaxation, and sleep. This is the least invasive option and should be done first. 1. Incorrect: A cool bath would wake a client, whereas, a warm bath would increase relaxation. 3. Incorrect: Triazolam is a short acting benzodiazepine. Do not go to the sleeping pill first. 4. Incorrect: Distraction is a good strategy for drawing a client's attention away from pain but may increase thinking, thus keeping the client awake.

The client in the manic phase of bipolar disorder begins climbing onto a table in the dayroom and shouts, "I can fly! I can fly! Watch me fly!" What should be the initial intervention by the nurse? 1. Leave the client alone and remove clients from the dayroom. 2. Call for personnel to escort the client out of the day room. 3. Restrain the client, and notify the primary healthcare provider. 4. Tell the client that there is no way that a person can fly.

2. Correct: The first priority is the safety of the client. If the client jumps off the table, this action may cause an injury to the client. The nurse may need extra help in case the client becomes violent. 3. Incorrect: The primary healthcare provider does not need to be notified at this time. Restraints should be used as a last resort.

A client received 2nd and 3rd degree burns on both arms and the anterior trunk when pouring gas on a burning trash pile. With the percentage of burns indicated, what should the nurse anticipate? 1. Movement of fluid out of the cells into the vascular space. 2. Increased capillary permeability and 3rd spacing of fluids. 3. Rapid fluid shift out of the vascular bed 48 hours after the burn. 4. Severe fluid volume excess in the first 24 hours after the burn.

2. Correct: Using the Rule of Nines, the client would have burned approximately 36% of the body. *For burns greater than 20-25% of the total body surface area, the nurse should recognize that significant vascular damage occurs which causes increased permeability. The fluid leaks out of the vascular space and out into the tissues (3rd spacing). The client can go into a severe fluid volume deficit and shock.* -The majority of fluid shifts out of the vascular bed occur in the first 24 hours. The diuresis phase begins about 48 hours after the burn injury when fluid is returning to the vascular bed.

An emergency department (ED) nurse working triage has assessed four clients. Which client should receive the highest priority? 1. Alert client who fell on the side walk. Skin warm and dry to the touch, with a three inch laceration on the right knee continuously oozing dark red liquid. 2. Elderly client who moans when the nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds. 3. A client who "passed out" but regained consciousness when feet were elevated. Awake and confused, with warm and dry skin. 4. An alert, responsive client who reports severe abdominal and shoulder pain that began two hours after eating at a local fast food restaurant. Skin is warm and dry

2. Elderly client who moans when the nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds. -This client is responding to verbal stimuli by moaning and has an open airway; but any client with an altered level of consciousness is at risk for airway obstruction. The skin assessment indicates a circulation problem.

What should the nurse include when providing teaching to a female client prescribed doxycycline for the treatment of acne? 1. Take this medication with food to maximize absorption. 2. Use a non-hormone method of birth control while taking this medication. 3. Wear protective clothing when outside. 4. Drink plenty of fluids while taking this medication. 5. Iron and calcium supplements can be taken with this medication.

2., 3., & 4. Correct: Doxycycline is a tetracycline antibiotic. Doxycycline can make birth control pills less effective. A non-hormone method of birth control (such as a condom, diaphragm, spermicide) should be used to prevent pregnancy while using doxycycline. Avoid exposure to sunlight or tanning beds. Doxycycline can make you sunburn more easily. Wear protective clothing and use sunscreen (SPF 30 or higher) when outdoors. Take doxycycline with a full glass of water. Drink plenty of liquids while taking this medicine. 1. Incorrect: Take on an empty stomach to maximize absorption, although may not be tolerated unless administered with food. 5. Incorrect: Do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking doxycycline. Absorption will be altered. For instance, iron can bind to doxycycline in the gastrointestinal tract, which may prevent their absorption into the bloodstream and possibly reduce their effectiveness. To avoid or minimize the interaction, iron containing medications and doxycycline should preferably be taken at least three hours apart in most cases.

The charge nurse on the pediatric unit is reviewing the protocol for blood administration with a staff nurse. Which actions by the staff nurse indicate understanding of blood administration? 1. The blood infusion time was within 6 hours. 2. A filter was used when administering the blood. 3. A second nurse checked the blood compatibility. 4. A set of vital signs was taken 5 minutes after the blood infusion started. 5. One form of client identification were obtained prior to infusion.

2., 3., & 4. Correct: Filters are used when infusing blood. Two nurses must check the blood product label and blood group. Vital signs are checked frequently during a blood transfusion. For example: A baseline set of vital signs are taken, then again 5 minutes after the initiation of the transfusion, then 15 minutes after transfusion started and every 15 minutes for one hour, then every 30 minutes for one hour, then hourly until infusion is complete. *1. Incorrect: Blood should hang for no longer than 4 hours because it increases the chances of a reaction. 5. Incorrect: At least two methods of proper identification should be obtained, such as asking client his/her name and checking ID band.*

What should the nurse do first when caring for a client who is being admitted with a diagnosis of meningococcal meningitis? 1. Assess neuro status. 2. Obtain health history. 3. Institute droplet precautions. 4. Orient client to the room and procedures.

3. Correct: Although all the options are appropriate, the priority is to place the client on droplet precaution to prevent the spread of meningococcal meningitis. 1. Incorrect: Placing client in isolation should be done first (actually prior to arriving to room) since the client has a diagnosis of meningococcal meningitis. Assessment of the neuro status can be done next.

A home health nurse has taught a client about home dressing changes using a clean technique. Which statement made by a client indicates to the nurse that the client understands this technique? 1. "The wound should be cleaned using a washcloth, soap, and water." 2. "Povidone-iodine should be applied to the wound with each dressing change." 3. "It is important that I wash my hands using soap and water before removing my dressing." 4. "I will use sterile gloves to clean my wound and change the dressings."

3. Correct: Clean technique requires washing hands with soap and water prior to removing the dressing. 1. Incorrect: The wound should be cleaned with 4x4's and sterile water. Soap can be very drying to the wound. A washcloth may not be clean as it has been sitting in a cabinet. 4. Incorrect: Sterile gloves are not needed when using clean technique. Clean gloves may be used.

The nurse is caring for a client diagnosed with type 2 diabetes who was brought to the emergency department in an unresponsive state. A diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is made. The nurse prepares for the administration of which initial therapy? 1. Oxygen by nasal cannula 2. Long-acting IV insulin 3. Normal saline 4. IV dextran

3. Correct: Clients in HHNS diurese due to a high glucose load in the vascular space. The client becomes severely volume depleted and is at risk for developing shock. Therapy is focused on combating shock. 2. Incorrect: The client will be given short-acting insulin. 4. Incorrect: Dextran is contraindicated as this will increase blood sugar even more.

The nurse is working with the parents of a preschooler to help promote healthy sleep patterns of approximately 8-12 hours per night. Which intervention should assist the parents to achieve adequate sleep for their preschooler? 1. Offer a time of exercise prior to bedtime. 2. Follow a bedtime routine at least three or four nights per week. 3. Spend about 30 minutes with the preschooler prior to bedtime for stories, prayers, etc. 4. Do not encourage your preschooler to take a toy to bed.

3. Correct: Rituals help the preschooler to feel secure. Quiet time to read, tell stories, and say prayers prepares the child for sleep. 2. Incorrect: The routine should be maintained each night if at all possible. Only through routine does the child feel secure in preparation for bedtime. 4. Incorrect: A special toy helps the child to feel secure and adds to the nighttime routine.

The nurse is assessing pain after surgery in a 3 year old client with a known developmental delay. Which pain scale should the nurse use to assess this client's pain level? 1. CRIES scale 2. Numeric scale 3. FLACC scale 4. FACES scale

3. Correct: The FLACC scale can be used for pediatric clients from age 2 months to 7 years and is appropriate when clients cannot communicate their pain. 1. Incorrect: The CRIES scale is used with neonates and infants. 2. Incorrect: Not age-appropriate; used for children ages 5 and up. 4. Incorrect: Not age-appropriate. The FACES scale is indicated for children ages 3 years and up. When using the FACES scale, the child must be able to understand the difference between pain and being sad. Because this child is only 3 years old (the bottom age for use of the FACES scale), and because the client has a developmental delay, the FLACC scale is a better choice as it is based on nursing observations.

A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops slurred speech, shuffling gait and drooling. Which prescribed PRN medication would the nurse administer? 1. Lorazepam 2. Atropine 3. Benztropine 4. Chlorpromazine

3. Correct: These signs and symptoms are reflective of pseudoparkinsonism, a form of extrapyramidal side effects which are side effects of the haloperidol. An anticholinergic agent maybe used for treatment. This is an anticholinergic agent that may be used for extrapyramidal side effects. 1. Incorrect: This is a sedative/hypnotic or antianxiety agent. It is not used for treatment of extrapyramidal side effects. 2. Incorrect: This is an anticholinergic agent, but not one commonly used to treat pseudoparkinsonism, a form of extrapyramidal side effects. It is commonly used to treat arrhythmias and preoperatively to decrease secretions. 4. Incorrect: This is another antipsychotic medication.

The nurse is caring for a client who has taken an acetaminophen overdose. Which symptom is the client most likely to exhibit? 1. Expectorating pink frothy sputum 2. Sudden onset of mid-sternal chest pain 3. Jaundiced conjunctiva 4. Diaphoresis and fever

3. Correct: This is a sign of liver damage, which is caused by an overdose of acetaminophen. 1. Incorrect: This is a symptom of pulmonary edema, not liver damage. 2. Incorrect: This is a symptom of myocardial ischemia, not liver damage. 4. Incorrect: Acetaminophen would decrease fever, and fever could cause diaphoresis so neither of these are expected with acetaminophen overdose.

The nurse is providing post-operative care to the craniotomy client. Hourly urinary output increases from 100 mL last hour to 500 mL this hour. What action by the nurse takes priority? 1. Elevate HOB 90 degrees 2. Auscultate apical pulse 3. Obtain a blood pressure 4. Assess Glasgow Coma Score

3. Correct: This is the best answer because we are "worried" this client is going into SHOCK due to diabetes insipidus. So, you better be checking a BP. This is a time where checking the BP is appropriate. If we "assume the worst" I better check a blood pressure. It could have dropped out the bottom. *1. Incorrect: This client is losing too much fluid. We worry about shock. Lower the HOB.*

A client is hospitalized because of severe malnutrition related to anorexia nervosa. What is the most important goal for this client? 1. Verbalize understanding that eating behaviors are maladaptive. 2. Verbalize the importance of adequate nutrition. 3. Achieve at least 80% of expected body weight. 4. Acknowledge misperception of body image as fat.

3. Correct: Until appropriate weight is gained, the client continues to be at risk for major health complications including hypotension, cardiac arrhythmias, poor muscle tone, increased risk for infection, abnormal liver function, and damaged kidneys. 1., 2. & 4. Incorrect: These are all appropriate goals; however, the most important one is that the client gain adequate weight.

The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice for the nurse to place the client in until full consciousness is regained? 1. Supine 2. Fowler's 3. Lateral 4. High Fowler's

3. Correct: When someone is very sedated and not fully conscious, we want them on their side so the airway remains open and the secretions can drain. 1. Incorrect: No, the jaw will fall back, the tongue will block the airway, and the client will have airway obstruction, either partial or maybe even life-threatening. 2. Incorrect: No, if you sit a client up who is not fully conscious, the client's head tips forward and blocks the airway. 4. Incorrect: Again, head may fall forward and block airway

A clinic nurse is educating a client diagnosed with Bell's Palsy. What is the most important educational point the nurse must emphasize to the client? 1. Physical therapy will be needed to maintain muscle tone of the face. 2. Massaging the face several times daily using a gentle upward motion. 3. Proper methods of closing eyelids and eye patching. 4. Non-steroidal anti-inflammatory medications are used to alleviate painful muscles.

3. Proper methods of closing eyelids and eye patching. 3. Correct: Even though all are educational points that need to be provided to the client, this is the most important educational point to make. Keratitis, or the inflammation of the cornea, is one of the most dangerous complications for a client with Bell's palsy. As a precautionary measure, the nurse must ensure that the cornea is protected even if the eyelids will not close. 1. Incorrect: Physical therapy will be needed, however care to prevent eye injury takes priority. 2. Incorrect: This can be done once the client's facial sensitivity to touch decreases and the client can tolerate touching the face. Preventing eye injury takes priority. 4. Incorrect: This is true, but again, protecting the eye is the most important point to convey to the client.

A client with a history of congestive heart failure has an implantable cardioverter defibrillator (ICD) surgically implanted. What teaching points should the nurse provide the client prior to discharge? 1. Avoid hot baths and showers. 2. Increase intake of leafy green vegetable products. 3. Avoid magnets directly over the site. 4. Notify primary healthcare provider whenever a shock is delivered by the ICD. 5. Driving is not recommended for 1 year after placement of an ICD.

3., & 4. Correct: Magnets can deactivate the defibrillator. Other transmitter devices should also be avoided. Most arrhythmias need only one shock, but the healthcare provider should be notified when a shock is delivered so that monitoring can increase. 1. Incorrect: Hot baths or showers are not contraindicated with ICDs. 2. Incorrect: Increase of *leafy green vegetable products* would have no relation to the ICD *but should be avoided if the client is on warfarin.* 5. Incorrect: The *client cannot drive for 6 months after implantation of an ICD and cannot drive for 6 months after any shock therapy from the ICD. *

A hysterical college student arrives in the emergency department in bloody soiled clothing. The nursing assessment reveals facial bruising and multiple contusions consistent with the client's report of being raped. Which initial nursing intervention takes priority at this time? 1. Notify police of the alleged rape. 2. Allow the client privacy to wash self. 3. Remove clothing and bag for evidence. 4. Encourage client to express fears and anxiety.

4. Correct: Although there are specific protocols that must be followed when dealing with rape clients, it is important to remember that this client had all control taken away during the attack. The emotional effects of rape are as traumatizing as the physical injuries. Allowing the client to first express emotions, such as fear or anxiety, returns a small amount of control to a situation in which the client has little or none. 1. Incorrect: The police will indeed be notified of the situation by the hospital personnel, but the nurse's initial priority is to focus on the client's needs, both physical and emotional. 2. Incorrect: The client will not be permitted to clean self until all evidence has been collected per protocol. However, initial contact between nurse and client should focus on more than just the physical aspects of the situation. 3. Incorrect: Collection of all evidence for the police is a crucial part of treating rape clients and will be completed according to protocols. But it is more important to remember that this client has already been violated during the attack. Removing clothing before addressing emotional needs may further exacerbate that sense of violation.

The nurse is caring for a client who has been diagnosed with dissociative identity disorder. What is the most appropriate short term goal? 1. Recovery of memory deficits. 2. Demonstration of the ability to perceive stimuli correctly. 3. Elimination of causative phobia. 4. Verbal recognition of the existence of multiple personalities.

4. Correct: In order for therapy to be successful, the client must first acknowledge that there are multiple personalities within the client's personality. 1. Incorrect: This is related to a client with dissociative amnesia. 2. Incorrect: This is related to a client with disturbed sensory perception. 3. Incorrect: This outcome would not be related to this client.

A client with gestational diabetes delivers an infant with macrosomia. What is the most vital component of the infant's assessment for the nurse to perform? 1. Evaluation of the infant for cephalhematoma. 2. Determining if the infant sustained a clavicle fracture. 3. Observing for arm movement to evaluate for facial palsy. 4. Frequent blood glucose monitoring to ensure stable values.

4. Correct: Infants of diabetic mothers are at risk for hypoglycemia following birth. Hypoglycemia can trigger seizures and cognitive deficits. 1. Incorrect: Assessing for cephalhematoma is important in macrosomia infants, but not as vital as ensuring stable glucose levels. 2. Incorrect: Assessing for clavicle fracture is important in macrosomia infants, but not as vital as ensuring stable glucose levels. 3. Incorrect: Assessing for facial palsy is important in macrosomia infants, but not as vital as ensuring stable glucose levels.

The nurse is teaching a diabetic client who has been prescribed Lispro insulin about avoiding hypoglycemia. What administration teaching is priority? 1. Take insulin 30 minutes before bedtime 2. Take insulin twice daily in AM and PM 3. Take insulin one hour before meals 4. Take insulin with meals

4. Correct: Lispro is a rapid-acting insulin that should only be taken with food or within 15 minutes of a meal. 1. Incorrect: Lispro is a rapid-acting insulin and should not be taken without food. 2. Incorrect: Lispro is a rapid-acting insulin and should not be taken without food. 3. Incorrect: Lispro is a rapid-acting insulin and should not be taken without food. Giving an hour before eating is too early and would put the client at risk for hypoglycemia.

The nurse is caring for a Native American client who has returned to the surgical floor following abdominal surgery. The nurse is concerned about the level of discomfort that the client is experiencing. Which comment is the nurse likely to hear upon assessment? 1. "The pain is getting worse. I can't stand it." 2. "I need something for pain as soon as possible." 3. "I hope that the pain will go away soon." 4. "I am doing okay. The pain is not bad."

4. Correct: The Native American client is likely to be quiet and less expressive of pain. Native Americans tend to tolerate high levels of pain.

A client with heart failure and pulmonary edema is given furosemide intravenously. Which assessment indicates that the furosemide has achieved the desired effect? 1. Weight has decreased 2 pounds. 2. Systolic blood pressure has decreased. 3. Urinary output has increased. 4. Lungs have fewer rales on auscultation.

4. Correct: The goal for diuretic therapy in this client is to prevent/relieve fluid accumulation in the lungs. This answer addresses the most life-threatening sequelae with HF. The number one thing to worry about in clients with HF is pulmonary edema, because this is what can kill the client. 1. Incorrect: Weight loss is a good assessment of fluid loss or gain, especially acute weight changes. The stem of the question, however, asks which is the desired effect? The desired effect is to decrease fluid in the lungs and weight loss alone does not ensure that the lungs are clearing. 2. Incorrect: Lowered blood pressure is an expected finding, but treatment of pulmonary edema is the primary goal. 3. Incorrect: Increased urinary output is an expected finding, but treatment of pulmonary edema is the primary goal.

Upon receiving a diagnosis of Stage 4 lung cancer, an elderly client expresses regret for having chosen to smoke. Which response by the nurse would best help the client cope at this time? You answered this question Correctly 1. "You are lucky to have lived a very long life." 2. "We have younger clients in worse shape than you." 3. "The doctor will make sure to treat any pain." 4. "You are regretting your decision to smoke."

4. Correct: The nurse responds with an open-ended statement that reflects back what the client has stated. This allows the client to continue expressing concerns and feelings about the diagnosis or past choices. At this time, encouraging the client to verbalize is the best choice to help with coping.

The nurse is caring for a client with possible hepatic failure. The nurse asks the client to sign a permit for a procedure. The nurse recalls the client's admission signature as legible, but, now observes a jerky, illegible signature. How should the nurse document this handwriting change? 1. Fetor 2. Ataxia 3. Apraxia 4. Asterixis

4. Correct: Yes, the liver flap, which is an abnormal muscle tremor, is usually found in clients with diseases of the liver. This is an indication that the hepatic failure is worsening and needs to be documented. 1. Incorrect: This is an offensive odor of the client's breath often associated with liver failure. 2. Incorrect: This is uncoordinated movement that is associated with many different neuromuscular disorders. 3. Incorrect: This is a term to describe not using items for their intended purpose and is associated with neurological disorders and damage to the brain.

A client with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidos and a serum glucose level of 789 mg/dl. The physician prescribes 10 units of regular insulin by intravenous (IV) bolus, followed by a continues insulin infusion at a rate of 5 units/hr. The pharmacy sends 500 ml of normal saline solution containing 50 units of regular insulin. After administering the IV bolus of 10 units of regular insulin, the nurse sets the flow rate of the normal saline solution to infuse at how many milliliters per hour to deliver 5 units/hr?

50u/500ml * 5/x = 50 ml

Question 1: You're collecting the 1 minute APGAR on a male newborn. You note the heart rate to be 140 bpm. The baby's cry is strong and regular and the body is pink with slightly blue hands. There is some flexion of arms and legs. While assessing the newborn it moves and cries. What is the newborn's APGAR score?

A: 1 P: 2 G: 2 A: 1 R: 2 Answer: APGAR: 8

pseudoparkinsonism

Adverse effect of drugs that causes symptoms resembling parkinsonism such as tremor, masklike facies, drooling, rigidity, and stiff gait.

The nurse's goal is to reduce the risk of flu and its complications by offering a class at the local high school. Which groups of people should be included in the nurse's teaching plan as needing the flu shot? 1. Babies less than 6 months old 2. Any child older than 6 months 3. Pregnant women 4. Parents of young children 5. People with a chronic illness

All but 1

An obstetrician already has three clients on the Labor unit receiving Oxytocin (Pitocin®) for induction of labor. All of the women are 38 weeks gestation. This labor unit has 6 beds and four nurses are on duty: 3 RN staff members and 1 RN nurse manager. The primary healthcare provider calls from the office to inform the nurse manager that a fourth client is en-route to the labor unit with orders to start an Oxytocin (Pitocin®) induction. Which next action by the nurse manager is priority? 1. Assign yourself to monitor one client receiving Oxytocin (Pitocin®) 2. Request for delay of induction until one client delivers. 3. Call nursing supervisor, requesting float nurse from another floor. 4. Report the primary healthcare provider to the PRO review committee for indiscriminate inductions.

Correct answer? #2: Negotiate for a delay of induction until one client delivers. The priority will always be client safety!

In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last.

First, apply clean gloves. Second, remove soiled dressings. Third, discard soiled dressings and clean gloves in red bag. Fourth, don sterile gloves. Fifth, clean surgical wound with moistened sterile 4x4's. Sixth, clean around Penrose drain using circular pattern inside to outside. Seventh, place dry, sterile 4x4's over surgical wound and Penrose drain. Eighth, apply abdominal dressing pad.

A client who has been on bed rest for several days is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last.

In order to keep a client safe, the nurse should first assess the client's orientation to determine the client's ability to follow instructions. Second, to avoid orthostatic hypotension, the nurse should assist the client to sit on the side of the bed. Third, apply the gait belt to ensure safety while ambulating. Fourth, assist the client to stand for a few seconds. The fifth action is to ambulate in the room. *apply gait belt afterrrr helping to sitting position

Placenta Previa

Most common cause of bleeding in the later months (usually the 7th) o The placenta has implanted wrong; an ultrasound will be done to confirm placental location o The placenta begins to prematurely separate when the cervix begins to dilate and efface so the baby doesn't get oxygen o Normally, the placenta should be attached up high in the uterus but with previa is may be LOW or on the SIDE so placenta will be delivered 1st s/s is *PAINLESS bleeding in the 2nd half of pregnancy (may be spotting or may be profuse)* TREATMENT • Complete previa usually requires hospitalization (from as early as 32 weeks until birth) to prevent blood loss and fetal hypoxia if pt goes in to labor • If there's not much bleeding then pt will be put on bed rest and watched • Rule out other sources of bleeding • Pad counts • Monitor baby very closely • Monitor for contractions and call MD b/c it's not going to be a normal delivery • *Will be delivered via C-section; do NOT perform a vaginal/pelvic exam*

The home health nurse is caring for a client with a neurological urinary tract dysfunction. What information should be included when teaching the client how to perform intermittent self catheterization?

Perform as a clean procedure. -Home intermittent catheterization is a clean, not sterile technique when performed in the home environment. *Home intermittent catheterization is preferred over continuous use of an indwelling catheter, as an indwelling catheter increases client risk of urinary tract infection (UTI).*

Which nursing action is likely to improve client satisfaction and demonstrate acts of beneficence? 1. Allowing clients to make their own decisions about care 2. Answering all questions posed by client in an honest manner 3. Reporting faulty equipment to the proper departments 4. Sitting at the bedside and listening to an elderly client

Sitting at the bedside and listening to an elderly client -Sitting and listening demonstrates kindness and compassion that are consistent with the ethical term "beneficence." Beneficence is taking positive action to help others and a desire to do good which is the core principle of client advocacy.

Bells Palsy

Sudden weakness in the muscles on one half of the face. -Bell's palsy usually resolves on its own within six months. Physiotherapy can help prevent muscles from permanently contracting. -Treatment for Bell's palsy usually includes generous use of ocular lubricants, such as non-preserved artificial tears and eye ointments. Many people require the eyelid to be patched or taped shut while sleeping, to keep it moist. -Keratitis, or the inflammation of the cornea, is one of the most dangerous complications for a client with Bell's palsy.

A school nurse educates a group of teachers how to extinguish a fire involving a child whose clothes are on fire. Which statement by the teachers would indicate to the school nurse that the teachers understand what should be done first? 1. "Someone should be assigned to call 911." 2. "Lay child flat and roll in a blanket." 3. "A blanket should be thrown over the child's head and body." 4. "Use a fire extinguisher to put out the flames."

The flames should be extinguished first. The best way to accomplish this it to lay the child flat and roll in a blanket. This is referred to as the drop and roll method, when a blanket is available. 1. Incorrect: 911 should be called but the most important thing to do is to extinguish the flames first.

Family members have been asking triage nurses if loved ones were admitted to the hospital during a national emergency situation with massive casualties. What response should be made by the nurses? 1. Tell the family members that information about clients cannot be provided. 2. Ask for the victims' permission before talking with the family members. 3. Instruct the family to wait for public announcements about victims. 4. Inform them if their family members have been admitted.

The national emergency situation allows waivers for the Health Insurance Portability and Accountability Act (HIPAA) provisions. Due to the emergency situation, the nurse may inform the family members about the status of their loved ones.

Histamine receptor antagonist

end in dine (Cimetidine) -H2-antagonists are used by clinicians in the treatment of acid-related gastrointestinal conditions, including: Peptic ulcer disease (PUD) Gastroesophageal reflux disease (GERD/GORD) Dyspepsia. Prevention of stress ulcer (a specific indication of ranitidine) -*confusion is side effect in elderly, if occurs stop infusion then alert health care provider*

Benzodiazepines

end in pam (diazepam) -Benzodiazepines possess sedative, hypnotic, anxiolytic, anticonvulsant, muscle relaxant, and amnesic actions, which are useful in a variety of indications such as alcohol dependence, seizures, anxiety disorders, panic, agitation, and insomnia.

Antidiuretic hormones

end in pressin

Pt recieving extocin

needs 1 on 1 care COMPLICATIONS= ~uterine rupture: ---Complete Rupture: through uterine wall into peritoneal cavity ---Incomplete Rupture: through uterine wall but stops in peritoneum so peritoneal cavity still intact ~hypertonic labor ~fetal distress -want a contraction rate of 1 every 2-3 mins each lasting 60 secs -oxytocin piggybacked into main IV fluid so if need to turn off oxytocin make sure not to turn off main IV fluid

Antilipidemics

statin