NCLEX Review 5
Autonomy
and patient self-determination are upheld when the nurse accepts the client as a unique person who has the innate right to have their own opinions, perspectives, values, and beliefs. Nurses encourage patients to make their own decision without any judgements or coercion from the nurse. The patient has the right to reject or accept all treatments
Ganglion cysts
are common, benign tumors over a tendon sheath or joint capsule. They are typically non- tender unless the tumor puts pressure on a nerve. When on the wrist, they become more noticeable with flexion. A ganglion cyst generally resolves on its own and does not require treatment, but can be drained/ removed if causing discomfort
Slander
false verbal statements that are made to erode an individual's character
Assault
any willful spoken threat to inflict physical injury on another person.
You are completing a health history of a 4-year-old male at the primary care office. When checking with his mother about milestones in fine motor development. You would expect that the 4-year-old is able to do which of the following?
A. Complete a puzzle with 5 or more pieces B. Copy a triangle onto a piece of paper C. Dress himself D. Use a fork to eat dinner
The nurse is caring for a patient who is six hours post-operative from a laparoscopic appendectomy. Which of the following findings would be essential for the nurse to follow-up?
A heart rate of 112 beats-per-minute Explain: Immediately following abdominal surgery, shock (distributive, hypovolemia) is a concern to the nurse. A heart rate of 112 would indicate tachycardia, which is one of the earliest manifestations of shock, and the nurse needs to assess the client further.
The nurse is assigned to care for a client with a sodium level of 122 mEq/L. Which assessment findings does the nurse anticipate based on this lab result?
A. Confusion B. Abdominal cramps C. Nausea and vomiting D. Hyperactive bowel sounds E. Muscle spasm
Critical thinking model
A. Contextual awareness :involves being alert to what's happening in the whole situation, including values, cultural issues, interpersonal relationships, and environmental influences
Which of the following statements about calcium are true?
A. 50-70% of serum calcium is ionized in the serum B. Albumin and calcium levels can be directly correlated
The charge nurse is performing safety rounds on clients in the nursing unit. Which observation requires follow-up? A client with
A belt restraint was applied and secured over the chest Explain: This observation requires follow-up because a belt restraint should be applied to the client's waist - not the chest. It is inappropriate to have a belt restraint secured over the client's abdomen or chest.
The nurse is caring for a client who has developed Malignant Hyperthermia. Which of the following actions should the nurse take?
A. Apply a cooling blanket B. Insert indwelling urinary catheter C. Administer prescribed Dantrolene
You are providing education to a mother who gave birth three weeks ago. She has developed mastitis. Which of the following educational points are appropriate?
A. Continue to breastfeed your child normally B. Wear a supportive bra without an underwire C. If unable to breastfeed, express milk every 4 hours It is essential to educate mothers with mastitis that they should continue to breastfeed. The infection will not be passed to their child and they do not need to worry about any adverse effects for their infants. By continuing to breastfeed, the clogged milk ducts should become unclogged and mastitis should improve (Choice A). Wearing a supportive bra but one without an underwire is appropriate educational advice for a mother with mastitis. The support will help with the pain and tenderness in the breasts, but an underwire could cause clogged milk ducts, so it should be avoided (Choice D).
HyperKalemia
A. Diabetic ketoacidosis B. Chronic renal failure C. Addison's disease
The nurse is caring for a cancer patient who is receiving chemotherapy. The patient is experiencing weight loss as a result of intermittent nausea. The nurse should implement which of the following nursing interventions to help with the patient's nausea?
A. Serve small meals every 2-3 hours B. Provide meals that are best eaten at room temperature C. Encourage the patient to brush their teeth in the afternoon rather than in the morning
Which of the following educational points would be helpful for optimizing feedings in an infant with heart failure?
A. Small frequent feedings B. Feed for a maximum of 30 minutes C. Increased calorie formula It is appropriate advice to feed an infant with heart failure for only 30 minutes at a time. After 30 minutes of feeding, the infant is using too much energy to gain calories and grow due to the feeding. Conserving energy is very important for infants experiencing heart failure.
Which of the following may be causes for disciplinary action taken by the Board of Nursing?
A. Testing positive on a routine drug test B. Refusal to provide care to a client based on personal beliefs C. Committing a breach of patient confidentiality
You are on the team in the delivery room caring for a newly born infant. After completing the initial assessment of the infant, you know that positive-pressure ventilation is indicated if which of the following is evident?
A. The infant is apneic B. The infant's heart rate is <100 beats per minute C. The infant is gasping
The nurse manager is completing an annual performance apprasial/evaluation on a staff nurse. Which elements should the nurse manager include when completing the evaluation? Select all that apply.
A. The nurses' bar-code medication administration scan rate B. The number of times the nurse has been absent or tardy C. The nurse achieving a national certification
The nurse is caring for a client who is receiving prescribed cilostazol. Which of the following client findings would indicate a therapeutic response?
Absence of pain while ambulating Explain: Cilostazol is a phosphodiesterase inhibitor approved to treat peripheral arterial disease. Its action mechanism decreases platelet aggregation and promotes vasodilation, allowing a client to ambulate distances without pain.
The nurse is caring for assigned clients. Which client should be evacuated first during a fire? A client with
Acute glomerulonephritis with an indwelling urinary catheter Explain: When evacuating from an internal disaster, the nurse should first evacuate the most ambulatory client. The client with acute glomerulonephritis only has one device, and the nurse can quickly change the system to a leg bag or instruct the client to keep the bag below their bladder.
The patient has been diagnosed with scleroderma. Which of the following will the nurse expect to be the management?
Administer prescribed corticosteroids Explain: Scleroderma is a medical condition in which connective tissue and skin harden. The surest way to manage this disease is to administer prescribed corticosteroids.
The nurse is caring for a client following a large volume paracentesis. To prevent hypovolemic shock, the nurse anticipates the primary healthcare provider (PHCP) to prescribe an infusion of
Albumin Explain: Albumin is a colloid commonly used to prevent post-procedure hypotension after a large-volume paracentesis. Large-volume paracentesis is when at least five liters or more of ascitic fluid is removed. This large amount of removal may cause a fluid shift creating an intravascular fluid deficit. Albumin would be helpful because of its ability to assist in restoring fluid balance without causing fluid volume overload.
The nurse is caring for a 4-year-old child who is being hospitalized due to complications from an autoimmune disorder, frequent infections, and a low white blood cell count. This child is very nervous about being in the hospital. Which intervention should the nurse implement to address this child's fears?
Allow the parents to stay as much as they'd like Explain: While most preschoolers can manage to be away from their parents for school, illness adds another stressor, making separation increasingly tricky. Parents should be encouraged to stay with their children as much as possible.
The nurse is performing a physical assessment. When assessing a client's eyes for accommodation, which of the following actions would the nurse perform?
Ask the client to gaze at a distant object and then at a test object
Which nursing intervention would be a priority for a patient receiving 3% saline maintenance fluids?
Assess blood pressure Explain: 3% saline is a hypertonic solution, so the nurse should monitor for signs/symptoms of fluid volume overload and pulmonary edema (increased blood pressure, crackles in lungs, shortness of breath). This type of fluid increases extracellular osmolality and volume. High osmotic pressure causes water to shift from inside cells into the extracellular fluid. Hypertonic solutions are used to treat hypovolemia and hyponatremia
A 62-year-old man with right shoulder pain starts noticing that his stool is clay-colored. He's never been a heavy drinker and has no known liver issues. What test should the nurse expect the doctor to order first while waiting for an ultrasound?
Bilirubin level Explain: The physician will want to know the patient's bilirubin level since it will be elevated. Increased bilirubin levels are associated with liver disease because the liver creates bilirubin. When it's not able to filter it out of the blood, it builds up.
The nurse is providing teaching to a student nurse about the immune system. Which of the following is the best example of natural adaptive immunity?
Cell-mediated response Explain: Cell-mediated immunity is the best illustration of natural adaptive immunity. This immunity is spurred by cytokines and T-lymphocytes and doesn't include antibodies.
A 42-year-old female client reports colicky abdominal pain that worsens after eating a high-fat meal. The nurse anticipates that this client has which diagnosis?
Cholecystitis Cholecystitis occurs most commonly in women older than age 40 who haven't gone through menopause. Its manifestations include episodic, colicky pain in the epigastric area that radiates to the back and shoulder. Pain in cholecystitis resembles indigestion or chest pain after eating fatty or fried foods.
A client admitted to the medical ward for convulsions is receiving intravenous magnesium sulfate. Which of the following signs indicate an expected side effect of the drug?
Frequent sleepiness Explain: Clients taking magnesium sulfate are expected to become sleepy during the daytime as well as experience hot flashes and lethargy.
The nurse at a gynecology clinic speaks with a 25-year-old, 32-week pregnant client. The nurse assesses the client and the client's laboratory results. Which of the following findings should most concern the nurse?
Glucose present in the urine Explain: Glucose in the urine may indicate gestational diabetes, as up to half of female clients have glucose in their urine at some time during pregnancy. Glucose in the urine may mean that a pregnant client has gestational diabetes. The nurse should promptly alert the health care provider (HCP) to allow further assessment into the cause of the glucose present in the client's urine.
The nurse is planning care for a client with homonymous hemianopia. The nurse should plan for which intervention in the care plan?
Instruct the client to turn their head from side to side Explain: Homonymous hemianopia (HH) is vision loss on the same side of the visual field in both eyes. It is appropriate for the nurse to teach the client to scan the room. Scanning the room will expand the visual field because the same half of each eye is affected.
Beneficence
Is doing good and the right thing for the patient
Justice
Is fairness. Nurses must be fair when they distribute care. Care must be fairly, justly, and equitably distributed among a group of patients
The nurse is assessing a client with phantom limb pain following an above-the-knee amputation. The nurse anticipates a prescription for
Propranolol
A middle-aged African American is being treated in the emergency department (ED) for an acute sickle cell crisis. Which of the following should the nurse use when positioning the client to facilitate oxygenation and adequate circulation?
Semi-Fowler's with legs extended on the bed
A post-hemorrhoidectomy client is preparing for discharge to home. During the provision of discharge instructions, the nurse should highlight which of the following points?
The proper technique for sitz bath
A newly licensed registered nurse is tasked by a nurse educator to perform a wet-to-dry dressing change on a client with a stage 3 pressure ulcer. Which action would indicate to the nurse educator that the registered nurse is following proper technique?
The registered nurse packs wet gauze into the ulcer without overlapping it onto the skin Explain: The wet dressing should not touch the intact skin as this may cause skin breakdown and potentially introduce additional pathogens into the wound.
Following a recent diagnosis of Parkinson's disease, a client was prescribed carbidopa/levodopa. At the follow-up appointment, which of the following objective assessment findings would indicate the effectiveness of the medication?
The tremors have lessened in frequency
The nurse is assessing a client with possible bipolar I disorder. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which laboratory testing?
Thyroid Stimulating Hormone (TSH) Explain: A TSH is the standard of care before diagnosing a mood disorder such as bipolar disorder or major depressive disorder. While this test does not confirm the presence of a mood disorder, it excludes alterations of the thyroid, which could alternatively explain the client's symptoms.
A nurse educates a client who just had a skin test for hypersensitivity reactions. The nurse should teach the client which of the following?
To return on a specific date to have the test results read
Which psychosocial interventions would be appropriate for a patient in the intensive care unit?
Use clocks and calendars Explain: The use of clocks and calendars in the ICU helps with orientation and reduces the patient's risk of developing delirium.
The nurse is caring for a newborn with erythroblastosis fetalis. The nurse understands that this disease is characterized by
incompatibility between maternal and fetal blood Infants with erythroblastosis fetalis are anemic from the destruction of RBCs. Severely affected infants may develop hydrops fetalis, a severe anemia resulting in heart failure and generalized edema. This hemolysis stems from maternal-fetal blood incompatibility.
Inquiry
involves applying standards of ethical reasoning to your thinking when analyzing a situation and evaluating your actions
Considering alternatives
involves exploring and imagining as many options as you can think of for the situation
Reflecting skeptically and deciding what to do
involves questioning, analyzing, and reflecting on the rationale for your decisions
Pilar cyst
is a fluid-filled cyst that originates in a hair follicle pilar cysts are commonly found on the scalp
Battery
is a physical act that results in harmful or offensive contact with another person without that person's consent
Accountability
is accepting responsibility for one's own actions. Nurses are accountable for their nursing care and other actions. they must accept all of the professional and personal consequences that can occur as a result of their actions.
Veracity
is being completely truthful with patients; nurses must not withhold the whole truth from clients even when it may lead to patient distress
Libel
is committed when written documentation causes damage to an individual's reputation that is malicious in nature
Nonmaleficence
is doing no harm, as stated in the historical Hippocratic Oath. Harm can be intentional or unintentional
Fidelity
is keeping one's promises. The nurse must be faithful and true to their professional promises and responsibilities by providing high- quality, safe care in competent manner
Bouchard node
refers to a hard non-tender bony overgrowth on the proximal interphalangeal joint, commonly seen in osteoarthritis
A 35-week pregnant client comes into the emergency room concerned that she had not felt her baby kick for 3 days now. She also complains to the nurse that she had black stools in the morning. The nurse notices bruising in the client's arm and elbows. The nurse should suspect:
Disseminated intravascular coagulation (DIC) Explain: Disseminated intravascular coagulation (DIC) is a maternal condition in which the clotting cascade is activated, resulting in clots in the microcirculation. The patient states that she has not felt her baby kick or move for three days. This could mean that her fetus has died in utero, and an intrauterine fetal death is a predisposing condition for DIC. Other symptoms like black stools and bruising are indicative of bleeding. The nurse should suspect DIC and initiate appropriate measures.
A home health nurse is providing educational information to a client with iron-deficiency anemia. Which meal selection by the client would indicate to the nurse that the client understood the educational information provided?
Egg salad on wheat bread, carrot sticks, kale salad, raisins Explain: Egg yolks, wheat bread, carrots, kale, and raisins are all iron-rich foods, making this an optimal meal for a client seeking to increase dietary iron intake
The nurse is taking care of a client with multiple fractures in his leg. A plaster cast was applied. In positioning the casted leg, the nurse should:
Elevate the leg on pillows continuously for 24 to 48 hours Explain: The leg should be elevated consistently for 24 - 48 hours to promote venous drainage and minimize swelling.
The process of absorbing drugs before elimination after they have been excreted into bile and delivered to the intestines is called:
Enterohepatic cycling
The parents of a 2-month-old infant brought their child to the outpatient clinic due to fever, telling the nurse that the child had a Diphtheria, Tetanus, and Pertussis (DTaP) vaccination injection one week prior. The parents ask the nurse if the fever is related to the DTaP vaccination. What would be the nurse's most appropriate response?
Fever after the DTaP injection is usually low-grade and appears within the first two days
The nurse is working in the emergency department when an elderly man is rushed in with complaints of dizziness, weakness, headache, and nausea. The patient's shirt is drenched in sweat. His son who accompanied him to the hospital tells the nurse that they were watching his 10-year-old grandson's baseball game when suddenly his dad complained of a severe headache and weakness. The nurse understands that based on the client's presentation and history, he is most likely suffering from:
Heart exhaustion Signs and symptoms of heat exhaustion include headache, dizziness, nausea, and weakness. Due to excessive sweating, hyponatremia can also be present.
The nurse is caring for a client with narcolepsy. Which of the following medications would the nurse anticipate the primary healthcare provider (PHCP) prescribe?
Modafinil Explain: Modafinil is a psychostimulant that is effective in treating narcolepsy. This medication promotes wakefulness and is dosed either once or twice a day.
A nurse is caring for a client recovering from a clonazepam overdose. Which of the following arterial blood gas (ABG) results would be expected?
PH 7.25, CO2 74, HCO3 25 Explain: This ABG result demonstrates uncompensated respiratory acidosis. Clonazepam is a benzodiazepine which depresses the central nervous system (CNS). The depression of the CNS can subsequently lower the respiratory rate and cause respiratory depression. When the client's respiratory rate decreases too much, the body retains CO2 (which, as an acid, lowers the pH, causing acidosis). The elevated CO2 level and subsequently low pH is what the nurse would anticipate following a clonazepam overdose.
The nurse is performing health education to a 21-year-old male who just had a fiberglass cast fitted on his right forearm for an ulnar fracture. They are talking about the early signs of compartment syndrome. The nurse notes that the patient has a full understanding of the topic when he states which of the following signs and symptoms:
Pain with passive motion and loss of sensation
The nurse is developing the care plan for an 86-year-old patient with a diagnosis of cor pulmonale. Which nursing intervention would be most important to include in regards to monitoring this patient's peripheral edema?
Record calf circumference daily Explain: Cor pulmonale describes right ventricular enlargement due to pulmonary hypertension. The accumulation of fluid in the interstitial spaces results in dependent edema, jugular vein distension, shortness of breath, and weight gain. Measuring and recording the circumference of the extremity at the same location daily is the best way to monitor for changes in the patient's peripheral edema
You are the nurse in a pediatrician's office. An 8-year-old boy with a history of asthma is brought to the office with complaints of a drippy nose, congestion, and runny eyes. The NP sees the patient and makes the diagnosis of allergic rhinitis. The NP prescribes an intranasal corticosteroid and an intranasal antihistamine. The outcome from allergic rhinitis that would put this child at highest risk is:
An asthma attack Explain: An asthma attack would put this child at the highest risk. Studies show that uncontrolled allergic rhinitis can make asthma much more challenging to manage. Since this child has a history of asthma, he should be treated aggressively to manage allergic rhinitis.
A 7-year-old child in the pediatric ward does not want to ambulate after surgery. Which action by the nurse is most appropriate?
Ask the child when he wants to ambulate; whether at 9AM or at 1PM Explain: To ensure cooperation with the regimen, the nurse should offer the child choices. The most appropriate choice to give the child is whether he wants to ambulate at 9 AM or at 1 PM.
A nurse is caring for a client receiving metformin. Which of the following laboratory data should be reported to the provider?
Decreased glomerular filtration rate (GFR) Explain: Metformin is an oral anti-diabetic indicated for type 2 diabetes mellitus. Metformin may cause renal impairment and a decrease in glomerular filtration rate (GFR) would be such evidence. During Metformin therapy, the client's renal function will be periodically monitored.
The client using over-the-counter nasal decongestant drops reports unrelieved and worsening nasal congestion. What is the appropriate instruction for this client?
Discontinue the medication for several days Explain: Due to their local action, intranasal sympathomimetics produce few systemic effects. However, one side effect associated with their use is rebound congestion. Prolonged use causes hypersecretion of mucus and worsened nasal congestion once the drug effects wear off. This rebound effect sometimes leads to a cycle of increased drug use as the condition worsens. Because of the risk of rebound congestion, intranasal sympathomimetics should be used for no longer than 3-5 days. Prolonged use of decongestant drops (3 to 5 days) can lead to rebound congestion, which is relieved by discontinuing the medication for 2 to 3 weeks.
After administering an insulin injection to a patient on a sliding scale, the nurse realizes that a high dose was erroneously given. Which of the following would be the best response by the charge nurse to prevent future errors?
Discuss events preceding the error with the nurse
Which assessment question would be most appropriate for a patient who is experiencing dyspareunia?
Do you use antihistamines? Explain: Factors contributing to dyspareunia include diabetes, hormonal imbalances, vaginal, cervical, or rectal disorders, antihistamine, alcohol, tranquilizer, or illicit drug use, and cosmetic or chemical irritants to the genitals. Dyspareunia is painful sexual intercourse due to medical or psychological causes. The pain can primarily be on the external surface of the genitalia, or more profound in the pelvis upon deep pressure against the cervix. It can affect a small portion of the vulva or vagina or be felt all over the surface.
Chorionic villus sampling (CVS) test
A. CVS uses ultrasound, and a full bladder allows for an acoustic window to ensure accurate imaging. B. No eating or drinking restrictions are in place during preprocedure
The nurse is assessing a client who is suspected of having myasthenia gravis. Which of the following would be an expected finding? Select all that apply.
A. Diplopia B. Facial muscle weakness C. Ptosis Explain: Key clinical features of myasthenia gravis (MG) include diplopia, ptosis, facial muscle weakness, and may progress to respiratory failure. Some of the earlier manifestations associated with MG are ocular.
While performing a head-to-toe assessment on the newly admitted medical patient. The nurse would note which integumentary condition is a normal process of aging?
A. Dry, itchy skin B. Decreased skin pigmentation C. Decreased nail growth with an increase in nail thickness
Which of the following are management functions that nurse managers fulfill?
A. Empowering B. Directing C. Planning D. Organizing E. Staffing
You are taking care of an infant newly diagnosed with hydrocephalus. Which of the following assessment findings do you expect? Select all that apply.
A. Increased head circumference B. Macewen's sign C. Setting sun eyes
A 25-year-old female client at ten weeks gestation has mild fatigue. While reassuring her that this is expected, the nurse also knows that which of the following are regular changes during various trimesters of a healthy pregnancy?
A. Maternal blood volume increases B. Diastolic blood pressure decreases
The nurse is teaching a group of students the causes of hypokalemia. It would indicate a correct understanding of the student if they stated which condition causes this electrolyte imbalance?
A. Metabolic alkalosis B. Cushing's syndrome C. Alcoholism
The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse anticipate from the primary healthcare provider (PHCP)?
A. Neomycin B. Lactulose Explain: Neomycin is an antibiotic and is indicated for hepatic encephalopathy. This oral medication is taken to decrease ammonia's gastrointestinal production, which is contributing to encephalopathy. Lactulose is central in treating hepatic encephalopathy because it traps ammonia in the colon and increases its transit. Thereby decreasing serum ammonia levels.
While working in the emergency department, you are assessing a 3-month-old infant who was brought in by parents for poor feeding, irritability, and vomiting. Upon auscultating the heart sounds, you note a machine-like murmur. Which conditions does the nurse suspect?
A. Patent Ductus Arteriosus (PDA) B. Congestive Heart Failure (CHF)
The nurse is caring for a client with an ectopic pregnancy. Which findings does the nurse expect? Select all that apply.
A. Pelvic pain B. Vaginal bleeding C. Positive pregnancy test D. Increased human chorionic gonadotropin (hCG) levels causing a positive pregnancy test
Crutches
A. Placing weight on the crutch and then steps up the first step of stairs with the unaffected leg B. Placing the crutch down to the step below and then moves the affected leg down C. With both of their elbows flexed between 15 and 30 degrees D. The basic crutch stance is the tripod position, formed when the crutches are placed 6 inches in front of and 6 inches to the side of each foot.
The nurse is teaching a class on acid-base imbalances. It would be correct for the nurse to identify which of the following would cause respiratory acidosis? Select all that apply.
A. Pneumothorax B. Opioid overdose Explain: pneumothorax causes shallow breathing, which causes the retention of CO2 (an acid). Opioids are central nervous system depressants. When the client is exposed to toxic levels, the effect causes hypoventilation and the retention of CO2.
The nurse is caring for a client with an acute exacerbation of Bell's palsy. Which of the following prescriptions would the nurse anticipate?
A. Prednisone B. Valacyclovir Explain: Bell's palsy classically causes facial nerve paralysis. It is usually idiopathic. However, etiologies such as herpes simplex virus may be present. Exacerbations of Bell's palsy are treated with corticosteroids (prednisone, choice A) and antivirals (valacyclovir, choice D). Corticosteroids decrease facial nerve inflammation, and antivirals address the possible underlying viral etiology.
The nurse is assessing a client with hepatitis A. Which of the following would be an expected finding? Select all that apply.
A. Pruritus B. Abdominal pain C. Scleral icterus Hepatitis A produces an array of symptoms that usually last for 28 days. The symptoms have an abrupt onset and include nausea, vomiting, abdominal pain, fever, anorexia, dark urine, scleral icterus, pale stools, jaundice, and pruritus.
The nurse is caring for a client who had a fenestrated tracheostomy tube placed one week ago. Which statements are true regarding fenestrated tracheostomies?
A. The client with a fenestrated tracheostomy can speak B. A fenestrated tracheostomy can be capped if the cuff is deflated Explain: It is true that clients with a fenestrated tracheostomy can speak. Fenestrated tracheostomy tubes have a small opening in the outer cannula. This allows some air to escape through the larynx, which means that the client will be able to speak with this type of tube. A fenestrated tracheostomy can be capped if the cuff is deflated. It is very important to remember to deflate the cuff if capping a fenestrated tracheostomy tube, because if the tube is capped and the cuff is still inflated the client will not be able to breathe at all.
You are assigned to administer hydromorphone to a patient with post-operative pain. You should be aware of which of the following legal mandates in terms of controlled substances? Select all that apply.
A. The verification of the narcotic count at the beginning and the end of the shift B. The secure locking of controlled substances to prevent diversion and theft Waste at the time of removal from the storage. Witnessing nurses must watch the administering nurse as the correct dose is drawn. Witnessing nurses must observe as the unneeded portion is wasted in the approved manner. Document the waste electronically or in writing. Witness the wasting of controlled substances then verify product label, the number of wastes matches what is documented, and that the medication is wasted in an irretrievable location. Two nurses, both the administering nurse and the witness, are responsible for documenting the wastage. Either a Registered Nurse or a Licensed Practical Nurse can witness and sign. A nurse should never document seeing controlled substance wastage that was not observed.
Which of the following educational points should the nurse reinforce with the parents of a toddler diagnosed with an imperforate anus?
A. Toilet training will take longer for your child B. Normal bowel habits can be established for your toddler over time C. Bowel irrigations may help your toddler achieve normal bowel function Bowel irrigations will help the toddler achieve normal bowel function. They may not need them every day, but bowel irrigations will likely be needed frequently to achieve regular bowel function.
The nurse is caring for a client who was prescribed carbidopa and levodopa for Parkinson's disease. The nurse should instruct the client that this medication may cause Select all that apply
A. urine to appear darker B. Hallucinations C. Dizziness upon standing
While working in a post-operative unit, the nurse is assigned to take care of a 32-year-old who is post-op day one after an appendectomy. The patient has not eaten for the past three days and is asking when she will be allowed to have a meal again. Upon consulting with the interdisciplinary team, the provider decides it is time to place a diet order for your patient. Which diet does the nurse expect the provider will order?
Clear liquid diet Explain: A clear liquid diet is the most appropriate choice for this patient. Clear liquid diets consist of foods and liquids that are transparent to light and are liquid when at body temperature. This diet is best for patients who have not had oral intake for some time as well as for the first time a patient eats after complete bowel rest.
A 16-year-old adolescent client is brought to the emergency department following an injury at a skating rink. The client's left knee is bruised and swollen. Upon interview, the nurse finds out that the client has hemophilia A. Which medication would be most appropriate for this client?
Codeine phosphate Explain: Codeine phosphate is an analgesic medication with no aspirin components and is used for moderate to severe pain.
Which of the following would the nurse expect to be administered to treat a newborn with Respiratory Distress Syndrome (RDS) ?
Colfosceril
What is the first assessment the nurse should make when a patient reports he hurt his knee playing baseball and the knee appears swollen?
Compare the swollen knee with the other knee Explain: The first step of any assessment is always inspection. The first step the nurse should take is to compare the knees for symmetry.
A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will you need to put on when preparing to assess the client?
Herpes zoster - contact and airborne precaution
A client in a psychiatric clinic tells the nurse, "I want to kill my wife. The moment I see her, I am going to kill her." Which of the following should be the nurse's next action?
Notify the client's psychiatrist of the comments Explain: Confidentiality plays a critical role in client care; however, there may be certain circumstances where confidentiality must be breached to not only ensure the safety of the client, but also to protect a third party (or parties). This concept is referred to as the 'duty to warn' or 'duty to protect.' These types of situations most often arise when a client reports suicidal ideation (SI), homicidal ideation (HI), or when the client makes a threat against an identifiable third party, even if the threat was made during a private therapy session.
The nurse preceptor supervises a new nurse caring for a child with epiglottitis. Which action by the new nurse would require the nurse preceptor to intervene? The new nurse
Obtains a throat culture Explain: Obtaining a throat culture would require immediate follow-up because this may cause acute laryngospasm leading to respiratory obstruction. The culture may be obtained once an artificial airway has been established.
Which of the following statements are true about special populations and the administration of analgesics? Incorrect
Oncology clients do not have a dosage limitation in terms of analgesics Explain: Oncology clients do not have a dosage limitation in terms of analgesics until effective pain management is accomplished. At times, very high dosages of analgesic medications are essential to relieve pain. However, on some occasions, the medication dosage may have to be titrated downward when the side effects of the drug outweigh its benefits in terms of pain relief.
The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure?
Suction equipment Explain: A cheiloplasty is a procedure to repair a cleft lip (CL). This procedure is typically done by age three to six months. A concern after this procedure is that the child may have excessive secretions that may trigger aspiration. The nurse should have a bulb syringe or some other suction equipment available if the infant begins to choke. While routine suctioning is not done to minimize pain or trauma, this is necessary to have it available to prevent respiratory distress.
While most preschoolers can manage to be away from their parents for school, illness adds another stressor, making separation increasingly tricky. Parents should be encouraged to stay with their children as much as possible.
T2 N0 M0 Explain: The TNM tumor staging system explores tumor size (T), node involvement (N), and distant metastasis (M). This patient has a small tumor measuring 4.3 cm limited to one portion of the lung, giving it a T staging of T2. Without nodal involvement or metastasis, both N and M are 0. This question is intended to test the representation of N0 and M0 for negative lymph nodes and negative metastases, respectively. The nurse is not required to know "T" staging details.
You are caring for a client with chronic pain secondary to degenerative arthritis and osteoporosis. What information should you primarily consider in terms of this client's pain assessment?
The client's performance in terms of their basic activities of daily living Explain: The client's performance of their necessary activities of daily living should be primarily considered and collected for this client's chronic pain assessment. Other assessment information should include a complete pain history, the location, duration, character, and intensity of the pain in addition to assessing other characteristics of chronic pain, including client withdrawal, client depression, and indications that the parasympathetic nervous system is activated.
Olecranon bursitis
a common form of bursitis that occurs at the tip of the elbow. It typically presents as a large, soft, red, painful nodule due to inflammation of the bursa