Practice Question Banks 91-105 (Not Required)

The home health nurse is reviewing a new prescription of enteral tube feedings for a client with a percutaneous endoscopic jejunostomy tube. Which tube feeding method would be best for this feeding route? Use tube for water and medication administration only Bolus feedings 4 times a day Continuous infusion over 24 hours Intermittent infusion for 12 hours on, then 12 hours off

A jejunostomy or percutaneous endoscopic jejunostomy (PEJ) tube is a type of weighted feeding tube that is percutaneously placed in the stomach and passed into the duodenum under endoscopic guidance; peristaltic action then advances the tube into the jejunum. This type of tube tends to decrease the risk for aspiration because gastric pooling is minimized. Therefore, a continuous feeding method of a constant rate over 24 hours is best. Continuous feeding into the jejunum is most similar to normal gastric emptying and reduces the risk for side effects such as nausea, vomiting and aspiration. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS jejunostomy tubeenteral tube feeding

The nurse in a public health clinic is caring for a female client diagnosed with genital herpes who reports dysuria, dyspareunia, leukorrhea, and lesions of the labia and perianal skin. Which interventions should the nurse include in the discharge instructions? Select all that apply. Soak in a tub of hot water Apply a wrapped ice pack to the sores Apply petroleum jelly to blistered areas Increase fluids to dilute urine Avoid any tight clothing Use lubrication during sexual intercourse

Apply a wrapped ice pack to the sores Correct Response Apply petroleum jelly to blistered areas Correct Response Increase fluids to dilute urine Correct Response Avoid any tight clothing Genital herpes is a sexually transmitted infection caused by the herpes simplex virus. Genital herpes can cause pain, itching, and sores/lesions/blisters to the genital and anal area. Other symptoms include painful urination, pain during sexual intercourse, and a whitish or yellowish discharge of mucus from the vagina. Interventions should include keeping the area clean to prevent blisters/ulcers from becoming infected. To reduce pain, the client should wrap an ice pack and apply to the sores, apply petroleum jelly to any blisters/sores to reduce pain during urination, drink sufficient amounts of fluids to help make passing urine less painful, and avoid tight clothing to reduce irritation to the blisters/sores. Clients with active lesions should not soak in hot water or have sexual intercourse until they are finished with their treatment and the lesions (blisters/ulcers) have disappeared. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM reproductive KEYWORDS STIherpes simplex virus

The nurse is teaching a client with stable angina about their new prescription for nitroglycerin transdermal patch. Which instructions should the nurse include? Select all that apply. Rotate the application area Plan for patch-free time, usually overnight Remove the patch if ankle edema occurs Apply a second patch with chest pain Apply the patch to a hairless area of the body Notify your provider for persistent dizziness or any fainting episode

Rotate the application area Correct Response Plan for patch-free time, usually overnight Apply the patch to a hairless area of the body Correct Response Notify your provider for persistent dizziness or any fainting episode Nitroglycerin (NTG) acts directly on vascular smooth muscle to promote vasodilation. It decreases the pain of exertional angina primarily by decreasing cardiac oxygen demand. NTG comes in a variety of routes of administration. NTG patches contain a reservoir from which the drug is slowly released. Following release, the drug is absorbed through the skin and then into the blood. The rate of release is constant and, depending on the patch used, can range from 0.1 to 0.8 mg/ hr. Effects begin within 30 to 60 minutes and persist as long as the patch remains in place (up to 14 hours). Patches are applied once daily to a hairless area of skin. The site should be rotated to avoid local irritation. Tolerance develops if patches are used continuously (24 hours a day every day). Accordingly, a daily "patch-free" interval of 10 to 12 hours is recommended. This can be accomplished by applying a new patch each morning, leaving it in place for 12 to 14 hours, and then removing it in the evening. NTG can cause orthostatic hypotension and the client should let their provider know if dizziness and lightheadedness persist or the client has a fainting (syncopal) episode as these may indicate that the NTG dose needs to be adjusted/decreased. The other instructions are not appropriate for this medication. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS anginachest painnitroglycerin CONFIDENCE

The nurse receives an order for flumazenil 200 mcg IV push to reverse the effects of procedural sedation. The supplied vial contains 0.5 mg flumazenil in 5 mL solution. How many mL will the nurse draw up? Record your answer to 1 decimal point. mL

Correct answer: 2.0 mLSteps:Step 1 Convert milligram (mg) to microgram (mcg): 0.5 mg x 1000 = 500 mcgStep 2 What is known: 5 mL contain 500 mcgStep 3 What is unknown: ? mL contain 200 mcgStep 4 Set-up equation to solve for unknown: 5 mL x 200 mcg, divided by 500 mcg = 2.0 mL LESSON Pharmacological (and Parenteral Therapies) Dosage Calculation COURSE RN Review KEYWORDS dosage calculation

The labor & delivery nurse is caring for a client in active labor. The client requests for only non-pharmacological pain management. Which interventions should the nurse include? Select all that apply. Amnioinfusion Counterpressure Aromatherapy Lamaze breathing techniques Intrauterine pressure catheter

Counterpressure Correct Response Aromatherapy Correct Response Lamaze breathing techniques Nonpharmacologic labor pain management techniques incorporate special attention to all the senses, using aromatherapy (the sense of smell), relaxing music (for the auditory channel), and using counterpressure, massage or effleurage (for the tactile sense). Initiation of breathing techniques to close the "gate" to nerve stimulation caused by pain is also used. The intrauterine pressure catheter, which provides an exact measurement of contractions, and amnioinfusion, which involves the infusion of fluid into the uterus during labor, are unrelated to pain management. Incorrect LESSON Basic Care and Comfort Nonpharmacological Comfort Interventions COURSE RN Review BODY SYSTEM reproductive KEYWORDS active laborpain managementnonpharmacological CONFIDENCE

A client is brought to the emergency department with a blood glucose level of 52 mg/dL. The client appears weak, tired, but is awake and talking. After drinking 4-ounces of juice, the client's blood glucose does not rise above 70 mg/dL. Which actions by the nurse would represent appropriate care of this client? Select all that apply. Determine blood sugar management medications Recheck blood sugar in 15 minutes Offer 8-ounce (237 mL) glass of milk Offer a 12-ounce (355 mL) can of cola with added sugar Instruct the client to not take more insulin today

Determine blood sugar management medications Correct Response Recheck blood sugar in 15 minutes Correct Response Offer 8-ounce (237 mL) glass of milk Treatment for hypoglycemia is to consume approximately 15-20 grams of glucose or simple carbohydrates. Common examples of 15 grams of simple carbohydrates include: 2 tablespoons of raisins; 118 mL of juice or regular soda (not diet); 237 mL of nonfat or 1% milk; and 1 tablespoon of honey. In a clinical setting, the client may also be given glucose tablets. If after 15 minutes the blood sugar is still below 70 mg/dL (3.89 mmol/L), the client can be given another 15-20 grams of simple carbohydrates (this is also known as the "15 - 15 rule.") It's always a good idea to confirm how the client manages his/her diabetes. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM endocrine KEYWORDS blood sugarinsulincarbohydrateoral hypoglycemicpharmacology

The nurse is planning to administer a series of vaccines to a 4-year-old child including the DTap, IPV, MMR, and VAR. Before administering the vaccines, what information should the nurse be aware of? Select all that apply. The vaccines all contain weakened live viruses Either the deltoid muscle of the arm or anterolateral thigh muscle can be used Multiple immunizations should be administered a minimum of 1 inch apart A 5/8 inch needle length is often used for subcutaneous (SubQ) injections The vaccines contain the preservative thimerosal A 20 gauge needle is used to administer the varicella (VAR) vaccine intramuscularly (IM) (1 attempt remaining)

Either the deltoid muscle of the arm or anterolateral thigh muscle can be used Correct Response Multiple immunizations should be administered a minimum of 1 inch apart Correct Response A 5/8 inch needle length is often used for subcutaneous (SubQ) injections Vaccinations for a 4 to 6 year-old child include diphtheria, tetanus, and whooping cough (DTaP), Polio (IPV), measles, mumps, and rubella (MMR), and chicken pox (Varicella). DTap is given intramuscularly (IM) and can be administered in either the deltoid muscle of the arm or the anterolateral thigh muscle. The IPV can be administered either subcutaneously (subq) or IM. If multiple vaccinations are to be administered, injections should be spaced a minimum of 1-inch apart. The MMR and Varicella are administered subq using a 5/8 inch, 25-gauge needle. Not all the vaccinations contain live viruses; IPV and DTaP. Vaccines no longer contain thimerosal, which is a form of mercury. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review KEYWORDS childvaccinationdeltoidanterolateral

The occupational health nurse is teaching a group of employees about prevention of carpal tunnel syndrome. Which interventions should the nurse include? Select all that apply. Regularly rest your hands throughout the workday Wear a brace or splint at night Perform wrist exercises Request workstation modifications such as an ergonomic keyboard Request an endoscopic carpal tunnel release

Regularly rest your hands throughout the workday Correct Response Wear a brace or splint at night Correct Response Perform wrist exercises Correct Response Request workstation modifications such as an ergonomic keyboard Carpal tunnel syndrome (CTS) is a type of repetitive strain injury (RSI) resulting from prolonged force or repetitive movements. CTS is caused by compression of the median nerve, which enters the hand at the wrist through the narrow carpal tunnel. The carpal tunnel is formed by ligaments and bones. CTS is the most common RSI in the upper extremity. It is associated with hobbies or work that require continuous wrist movement (e.g., musicians, carpenters, computer operators). Preventative measures include identification of risk factors, stop aggravating movement, resting the hand, ice, wrist immobilization with a hand splint, nonsteroidal anti-inflammatory drugs, wrist exercises and physical therapy. A carpal tunnel release is a surgical intervention, usually reserved until all noninvasive interventions have been exhausted. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS occupational healthcarpal tunnel syndrome

The nurse admits a 7-year-old to the emergency department after a leg injury. The X-ray reveals a fracture to the growth plate. While speaking with the child's parents, what response by the nurse is most appropriate when discussing the outcome of this injury? "In some instances this type of injury can cause stunted bone growth." "This type of injury shows more rapid union than that of younger children." "The injury is expected to heal quickly because of the bone's strong outer surface." "Bone growth is stimulated in the affected leg as therapy is initiated."

a A growth plate fracture affects the layer of growing tissue near the end of the bone. This area is the softest and weakest section of the skeletal system and any injury may affect how the bone will grow. If left untreated or treated improperly, the injury could result in a crooked or shorter than its opposite limb. Serious injuries usually require a cast or a splint. If the injury is not aligning into the joint, surgery may be necessary. Out of the other options, this is the most appropriate response. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS femurfracturegrowthchild

The nurse in a pediatric clinic is talking to the mother of a 1-month-old baby who is being breastfed. The mother is concerned about the baby's stools and reports that the stools are a lumpy yellow liquid. How should the nurse respond? "Those stools are normal for a baby who is breastfed." "If you eat more fiber, it will pass through your milk and harden the stools." "You should supplement breastfeeding with formula to thicken the stools." "The stools should be more of a brown color and formed by now." (1 attempt remaining)

a Breastfed infants who are 4 to 6 weeks old typically have stools that are frequent, and yellow to gold in color. The texture is often described as soft to a thick, seedy or curdy liquid. The mother is describing a normal finding for a breastfed infant. The other responses are incorrect or inappropriate for this infant. Incorrect LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review KEYWORDS stoolbreastinfant

The nurse is caring for a client undergoing chemotherapy for colon cancer. Which of the following statements made by the client should the nurse be most concerned about? "I take 10 different types of vitamins daily to help my immune system fight the cancer." "I am using relaxation techniques to help cope with the stress of having cancer." "I think the green tea I'm drinking is helping me to fight the cancer." "I pray several hours a day to God to help me deal with this cancer."

a The client statement of taking 10 different vitamins daily should be cause for concern. While other complementary and integrative health therapies may or may not have a direct beneficial effect on the cancer, the multitude of vitamins may interfere with chemotherapeutic medications and may have toxic effects. The client should speak with their oncologist for further evaluation of the continuation of the vitamins. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM immune KEYWORDS chemotherapytearelaxationcolonmultivitaminpharmacology

The nurse is caring for a client following total knee replacement surgery. Which intervention will be most effective in preventing the complication of deep vein thrombosis in this client? Encourage range of motion and ambulation Place pillows under the knees Use elastic stockings continuously Massage the legs twice daily

a; Mobility reduces the risk of deep vein thrombosis (DVT) in the postsurgical client. The postoperative client would wear either compression elastic stockings and/or external pneumatic compression devices; elastic stockings should be removed at least once a shift to assess skin integrity. Pillows should never be placed under the knees, as it can prevent appropriate venous return. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS thrombosispreventDVT

The nurse in the intensive care unit is caring for a 2-day-old child who recently underwent surgery of a meningomyelocele due to spina bifida. While accompanying the grandparents to the room, which response would the nurse first anticipate of the grandparents? Disbelief Depression Anger Frustration

a Spina bifida is a birth defect that affects a person's spine and spinal cord. Spina bifida can range from mild to severe, depending on the type of defect and accompanying complications. A meningomyelocele is when the spinal cord and the meninges protrude through the child's back. This requires surgical intervention due to the child being at high risk for developing bacterial meningitis. This news can be devastating to parents and grandparents, as they suffer from a variety of emotional experiences. The first phase of the grieving process is denial or disbelief. The nurse should anticipate this response and be available to answer any questions the family has regarding their loved one. The following stages are anger, bargaining, depression, and acceptance. Clients may often times go back and forth between stages or never achieve acceptance. Incorrect LESSON Psychosocial Integrity Grief, Loss COURSE RN Review KEYWORDS spina bifidasurgerydisbelief CONFIDENCE

The nurse obtains a new order to infuse 20 mEq of potassium chloride IV piggyback for a client with a serum potassium of 3.2 mEq/L (3.2 mmol/L). While reviewing the client's cardiac monitor, which ECG finding best indicates that the infusion of potassium should be stopped? Tall, peaked T waves Narrowed QRS complex Shortened PR interval Prominent U waves (1 attempt remaining)

a Tall, peaked T waves are a finding in hyperkalemia, and would necessitate a change in IV solution, to eliminate the potassium. If the potassium infusion were to continue it could cause worsening hyperkalemia and possible cardiac arrhythmias. The nurse should notify the health care provider of the ECG finding, and should request an order for a different IV solution without potassium. In addition, a stat serum potassium should be done to assess the severity of the hyperkalemia and to determine whether further intervention to reduce the potassium level is required. In conjunction with this, a serum creatinine should be checked to determine whether worsening renal function may have reduced potassium excretion, contributing to this new electrolyte abnormality. Incorrect LESSON Physiological Adaptation Unexpected Response to Therapies COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS potassiummonitorECGhyperkalemia

The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving initiative. In order to prepare for the "unfreezing" phase of change, which approach would be best for the nurse manager to take? Explain to the unit staff why change is necessary Clarify what the changes mean to the community and the hospital Discuss with the staff how to deal with any defensive behavior Assist the staff for an acceptance of the new changes (1 attempt remaining)

a The first phase of change, unfreezing, begins with awareness of the need for change. This can be facilitated by the manager who clearly understands the need and stands behind it and explains this to the staff. The phase is completed when the staff comprehend the need for change. Incorrect LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS downsizestaffpositionscost saving

A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 mL of whole blood, the hemoglobin and hematocrit are within normal limits. The client asks the nurse whether she should continue to breastfeed the infants. Which statement by the nurse is most supported by evidence-based practice? "Yes, because breastfeeding will help to contract the uterus and reduce the risk of bleeding." "No, because breastfeeding should be delayed until the "real milk" is secreted." "No, because breastfeeding twins will take too much energy after the hemorrhage." "Yes, the blood transfusion provides additional immunoglobulins to the infants."

a; The most supported evidence-based practice would be for the client to breastfeed the twins to help contract the uterus and reduce the risk of uterine bleeding. Stimulation of the breasts during breastfeeding releases oxytocin which contracts the uterus. This contraction is especially important to enhance the prevention of hemorrhage. The other statements are not correct or supported by the literature. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS hemorrhagebirthbreastfeed

The nurse is caring for multiple clients during their shift. Which method(s) would be the best approach to correctly identify each client? Select all that apply. Compare the client to a labeled photograph Ask a family member or visitor Check the client identification bracelet Ask clients to state their name Have clients state their birth date (1 attempt remaining)

a; Check the client identification bracelet Correct Response Ask clients to state their name Correct! Have clients state their birth date Correct Response The best approaches to correctly identify a client would be to check the client's identification bracelet, ask clients to state their name and date of birth, and compare the client to a labeled photograph. Two pieces of identification are required prior to any procedure and/or medication administration. In long-term care facilities, residents may not wear identification bands. In this case, a labeled photograph can be used as identification. Asking visitors and family members would not be the best approach to identify clients. Incorrect LESSON Safety and Infection Control Accident, Error, Injury Prevention COURSE RN & PN Review KEYWORDS identificationsafetymedication administration

The visiting nurse is evaluating an ambulatory client who reports weight gain and increased swelling in their feet and ankles during the day that disappears while they sleep. The client has a history of emphysema. Which follow-up question would be most appropriate? "Do you have any shortness of breath with activities?" "Did you start a new exercise regimen recently?" "Do you use any tobacco products?" "Have you made any significant changes to your usual diet?"

a; The client seems to be exhibiting signs and symptoms of heart failure (HF); in particular, right-sided HF. To gather further information, the most appropriate follow-up question from the nurse would be to inquire about any shortness of breath on exertion. Other signs and symptoms of HF include fatigue, weakness, swelling of the feet and ankles, ascites, bounding pulses and rapid or irregular heartbeat. The other questions do not relate to the symptoms the client is reporting. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS edemafeetanklesheart failureassessment

The nurse is teaching a group of clients who have been diagnosed with schizophrenia about atypical antipsychotic medications. Which statement by the client would require further education by the nurse? "I'm so glad that this medication won't cause any of the tremors or tics I had when I was taking my old medication." "I should be careful when I get out of bed because this medication can cause my blood pressure to drop." "I'll probably gain a lot of weight on this medication and I may even develop diabetes." "I know I need to be patient but I wish it didn't take so long for this medication to really start working."

a; Although atypical antipsychotics may cause fewer extrapyramidal side effects, the client should know that they may still cause some of the same symptoms, like tics, slow speech, tremors or retarded movement. Most of these medications take two to four weeks or more to take effect. In addition to weight gain and developing diabetes, there is a risk for higher cholesterol and triglyceride levels. Incorrect LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM nervous KEYWORDS neurolepticsschizophreniadrug

The nurse is in a crowded shopping area in an urban setting when a radiologic dispersal device (RDD) explodes scattering radioactive dust and material into the environment. What should the nurse instruct the victims in proximity to the explosion to do first? Keep the nose and mouth covered Remove all exposed clothing right away Stay out of any buildings until help arrives Lie down flat and cover the head with anything available (1 attempt remaining)

a; An RRD, or "dirty bomb," generates radioactive dust and smoke, which can be dangerous if inhaled. The nurse should initiate measures to limit contamination, instructing victims to cover their noses and mouths. Neither lying down or covering the head does anything to limit exposure. Victims should move into a building where the walls and windows have not been broken and then remove their outer layer of clothing (sealing them in a plastic bag, if available) to help minimize exposure. Incorrect LESSON Safety and Infection Control Emergency Response Plan COURSE RN & PN Review KEYWORDS bombradiationemergency

A client diagnosed with diabetes mellitus is referred for home care. During a care conference, a family member expresses concerns that the client seems depressed. When planning the initial home visit, which intervention should the nurse implement first? Observe the client's affect and behavior during the visit Inquire about use of alcohol or other non-prescribed substances Administer a standardized tool that measures depression Obtain a family health history, including emotional problems or mental illness

a; An initial home visit should consist of getting to know the client, establishing trust and building a therapeutic nurse-client relationship. Then the nurse should use the nursing process and begin with a physical assessment including visual inspection and observations; therefore, the nurse should first observe the client's affect and behavior during the visit to gather more data and ascertain if the family's concerns were valid and the client's emotional state merits further assessments and interventions. Incorrect LESSON Psychosocial Integrity Mental Health Concepts COURSE RN Review BODY SYSTEM nervous KEYWORDS depressiondiabetesassess

The nurse is caring for a client diagnosed with a fecal impaction. While preparing to manually remove the impaction, what essential information should the nurse remember? Cardiac dysrhythmias can result during the process Family members should be taught the procedure The procedure will require a mild sedative Increased dietary fiber can minimize such problems

a; Fecal impaction requires manual disimpaction or removal. While using a lubricated, glove, the nurse inserted the index finger into the rectum and attempts to break up the hardened stool using a circular or scissoring motion. This will allow the stool to be extracted. While performing the procedure, it would be essential for the nurse to remember that cardiac dysrhythmias could occur from vagal nerve stimulation. The other options are appropriate; however, they are not the priority or essential consideration. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS impactiondysrhythmia

A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer nutritional feedings and medications. Which nursing action is best to ensure patency of the tube? Adequately flushing the tube with water before and after use Warming nutrition feedings before administration Completely crushing all medications prior to administration Squeezing the tube to dislodge obstructions

a; Prior to using the tube, it must be checked to make sure it is free from obstruction and leaks. Milking the tube may help dislodge an obstruction, but flushing the tube before and after use is the best way to ensure patency (while providing hydration). Liquid medication preparations are best, but tablets and pills can be dissolved in water (and flushed with 30-50 mL of water afterwards.) If the client experiences abdominal bloating, the nurse can encourage the client to cough, which will speed up the removal of excessive air, but the tube still needs to be flushed with water before and after use. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN & PN Review BODY SYSTEM gastroinstestinal KEYWORDS amyotrophic lateral sclerosisPEGflush

The nurse is caring for two children who have had surgical repair of congenital heart defects. For which defect is it the highest priority to assess for findings of heart conduction disturbance? Ventricular septal defect Aortic valve stenosis Atrial septal defect Patent ductus arteriosus

a; While assessments for conduction disturbance should be included following repair of any defect, it is a priority for ventricular septal defect. A ventricular septal defect is an abnormal opening between the right and left ventricles. The atrioventricular bundle (bundle of His) is a part of the electrical conduction system of the heart. It extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening. Either method involves manipulation of the ventricular septum, thereby increasing risk of interrupting the conduction pathway. Consequently, postoperative complications often include conduction disturbances. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS arrhythmiaventricular septal defectdefectheartchildcongenitalprioritization

A client has just returned from the post anesthesia care unit (PACU) to the surgical unit after a cholecystectomy. When initial vital signs are taken the nurse notes a temperature of 94.8°F (34.8°C). Which action should the nurse implement first? Apply a warm blanket and check the temperature in 10 minutes Call the health care provider and obtain further orders for warming Ask the PACU nurse more details of what happened in PACU Continue to monitor the vital signs as indicated

a;A client's postoperative temperature should be at least 95° F (35° C). Post-surgical hypothermia can lead to cardiovascular complications, transfusion requirements, and risks of infection. The first action of the nurse should be to apply a warm blanket and recheck the temperature in 10 minutes. If the temperature does not increase after this time, the next step would be to call the health care provider for further actions, such as an electric warming blanket. Postoperative hypothermia may be due to an effect of surgery due to anesthetic drugs or if the client's skin was exposed for a long period of time. Incorrect LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN Review KEYWORDS cholecystectomytemperaturePACUblanket

A client is scheduled to have a pulmonary artery catheter inserted (PAC). Prior to the procedure, what information would be essential for the nurse to teach the client about a PAC? "The catheter will measure different pressures in the heart and lungs." "You will be unable to eat or drink anything for several hours after the procedure." "The catheter is inserted through the groin into the left side of the heart." "You will be under general anesthesia for this procedure by an anesthesiologist."

a;A pulmonary artery catheter, also known as a Swan-Ganz catheter or right heart catheterization, is inserted into the right side of the heart and into the arteries that lead to the lungs. It is inserted either through the groin or neck, using conscious sedation and local anesthetic, at the bedside (usually in an intensive care unit.) PAC can measure right atrial pressure, pulmonary artery pressure, and pulmonary capillary wedge pressure; these measurements can be used to assess oxygenation of the blood in the right heart and overall cardiac output. Clients can eat or drink after the procedure. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS PACpulmonary artery catheterSwan-Ganz

The emergency room nurse is caring for a child suspected of poisoning. The child's parent asks the nurse what the purpose of the prescribed activated charcoal is. How should the nurse respond? "The activated charcoal binds with the poison to limit absorption from the digestive tract." "The activated charcoal induces vomiting to remove the poison." "This substance inactivates the toxins that your child ingested." "This substance removes the poison from the body through the urinary system."

a;Activated charcoal may be used for accidently poisoning as it keeps swallowed substances from being absorbed from the gastrointestinal tract into the blood stream. Its action is to bind to other substances on its surface (adsorption) pushing the poison through the digestive system faster and decrease the amount absorbed into the body. It does not inactivate the poison but rather binds to it in the digestion system to be removed quicker. Incorrect LESSON Safety and Infection Control Home Safety COURSE RN Review KEYWORDS poisoningactivated charcoal

The nurse is caring for an adolescent after an injury from a fall who has a history of hemophilia A. While preparing to provide education, which statement should be emphasized to clients diagnosed with this condition? Safely exercising and taking part in sports are important Alternative sedentary and structured activities should be discussed Implications of taking risks after acute bleeding episodes should be emphasized Physical limitations must be explained to peer groups

a;An age-appropriate treatment goal is to establish an age-appropriate safe environment. Adolescents diagnosed with hemophilia should be aware that contact sports may trigger bleeding episodes. However, developmental characteristics of this age group, such as impulsivity, inexperience and peer pressure, place adolescents in unsafe environments. Incorrect LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS hemophiliateenadolescent

The nurse reviews the history of a client diagnosed with depression and anhedonia. What statement is consistent with the symptom of anhedonia? A lack of enjoyment in usual pleasures in life Reduced senses of taste and smell A report of difficulty falling and staying asleep An expression of persistent suicidal thoughts

a;Anhedonia is a symptom of depression that is described as the inability to feel pleasure. Certain things in life are not enjoyed such as riding a bike, listening to music, or hearing a baby laugh. There are two different types of anhedonia; social, not wanting to spend time with other people, and physical, not enjoying physical sensations (a hug, a particular food). Anhedonia can make developing or maintaining relationships challenging. Incorrect LESSON Psychosocial Integrity Mental Health Concepts COURSE RN Review BODY SYSTEM nervous KEYWORDS depressionanhedoniapleasure

The nurse is preparing to administer an enteral tube feeding to a client via a nasogastric tube. Prior to administration, which action should the nurse take first? Verify correct placement of the tube Ensure that feeding solution is at room temperature Aspirate abdominal contents to determine the residual Check that the feeding solution matches the dietary order (1 attempt remaining)

a;Before administering enteral feeding or anything else through the nasogastric tube, the nurse should verify that the tip of the tube is in the stomach to prevent aspiration. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS enteralfeednasogastricplacement

A 16-year-old adolescent is admitted for Ewing's sarcoma of the tibia. In discussing the care with the parents, the nurse should understand that the initial treatment for this diagnosis usually includes which approach? Chemotherapy with adjunctive radiation Amputation of the affected leg Bone marrow graft in the affected leg Surgical excision of the mass

a;Ewing's sarcoma is a rare type of cancerous tumor that grows on a person's bones or cartilage or nerves that surround the bone. Though there are different types of Ewing's sarcoma, the pelvis is typically where the tumor forms and then progresses to the femur. If left untreated, the tumor can spread to other bones, bone marrow, and other vital organs such as the heart, lungs, and kidneys. The initial treatment of Ewing's sarcoma is chemotherapy which may be combined with radiation to reduce the size of the tumor. Once the tumor is reduced in size, the next step is surgical excision of the tumor or oftentimes amputation of the affected leg or arm. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS Ewing'ssarcomatibiaradiationchemotherapypediatric

The nurse is caring for a client diagnosed with deep vein thrombosis who is receiving a continuous intravenous heparin infusion. The client's baseline activated partial thromboplastin time (aPTT) prior to starting the heparin infusion was 24 seconds. The most recent aPTT result was 55 seconds. What action should the nurse take? Maintain the current heparin infusion rate Decrease the heparin infusion rate Administer a heparin antagonist (protamine) Increase the heparin infusion rate

a;For clients on a heparin drip, the therapeutic aPTT goal is generally 1.5 to 2.5 times the client's baseline. The client's baseline aPTT was 24 seconds and the therapeutic range for this client should be between 36 to 60 seconds. Since the client's aPTT is 55 seconds, within the therapeutic range, the nurse should maintain the current heparin infusion rate. The other actions would not be appropriate for this client. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS heparinaPTT

The nurse is planning care for clients over the age of 70. Which consideration would be most appropriate when planning care for older clients? Start with the smallest dose and increase slowly as needed Avoid drugs with side effects that impact cognition Do not stop a medication entirely Review the drug regimen yearly

a;It would be most appropriate for the nurse to consider starting with the smallest dose of the medication and slowly increasing as needed. Example: If a 70+ year old client is requesting pain medications and the order is for one or two tablets, the nurse should first administer one tablet and evaluate if the other tablet is needed. Due to physiological changes of the older client, medications can accumulate to toxic levels and cause serious adverse reactions. This could lead to altered mental status and risk for serious complications of the body's systems. The nurse should educate the client on their medications more frequently than just a year. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review KEYWORDS olderadult

The postpartum nurse is reviewing the medical record of a client who had a vaginal delivery two hours ago. The record indicates that the client's amniotic membranes ruptured 36 hours before the birth. Which potential postpartum complication is of highest concern for this client? Infection Bleeding Dehydration Hypoxemia

a;Membranes that have been ruptured for more than 24 hours prior to the birth significantly increases the risk of infection to both the mother and the newborn. Therefore, the nurse's highest priority is to assess for signs and symptoms of infection including fever, chills, abdominal pain, foul-smelling lochia, tachycardia and hypotension. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS diagnosisdeliveryvaginalinfection

The nurse observes several preschool aged children playing in the hospital playroom. What activity would the nurse most likely expect to see? Playing cooperatively with others the same age Playing with their own toys alongside other children Playing competitive board games with older children Playing alone with hand-held computer games

a;Older preschoolers (4 years) will develop the necessary social, problem-solving and creative skills by playing with friends and engaging in simple games and activities. This is cooperative play. Younger preschoolers (3 years) and older toddlers engage in parallel play (playing with their own toys next to other children) or associative play (playing separately, but talking to each other.) School-age children follow rules designed by others, as in board games. Incorrect LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS childplayactivitycooperative

The home health nurse is developing a plan of care for an older adult client diagnosed with shingles (herpes zoster) lesions to the face and left eye. What is the priority nursing problem? Pain related to nerve root inflammation and skin lesions Risk for social isolation due to pain and location of rash Risk for impaired skin integrity related to skin lesions Knowledge deficit related to disease process

a;Shingles is a reactivation of the herpes zoster virus responsible for chickenpox. It is characterized by a vesicular rash in a unilateral dermatomal distribution. The first symptom of shingles is usually pain, tingling, or burning before the blisters form. The pain and burning may be severe, and can lead to long-term residual pain, known as postherpetic neuralgia. Using Maslow's hierarchy of needs and considering acute vs. at risk for problems, pain is the priority nursing problem for this client. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM integumentary KEYWORDS shinglesherpes zosteracute painprioritization

The nurse is teaching the parents of a 2-week-old infant about prevention of sleep-related death such as sudden infant death syndrome (SIDS). Which intervention is the priority? Place the infant on their back to sleep Place the infant on a firm surface to sleep Avoid placing stuffed animals near the sleeping infant Avoid exposing the infant to tobacco smoke

a;Sudden infant death syndrome (SIDS) is the death of a seemingly healthy infant less than one year of age that remains unexplained after a complete postmortem examination (autopsy), including an investigation of the death scene and a review of the case history to rule out abuse. The cause of SIDS is unknown; however research suggest it may have to do with the portion of an infant's brain that controls breathing and arousal from sleep. Highest risk for SIDS is associated with sleeping in a prone position (on the stomach); other risk factors include use of soft bedding; overheating (thermal stress); cosleeping with an adult, especially on a sofa or noninfant bed. Since 1994, the incidence of SIDS in the United States has steadily decreased due to the Back to Sleep campaign (supine (on their back) sleeping). Although all interventions listed are appropriate, placing the infant in a supine position/on their back to sleep is the priority. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM respiratory KEYWORDS SIDSinfant

A nurse is educating a client who was prescribed a monoamine oxidase inhibitor (MAOI) for depression to avoid foods high in tyramine. Which foods should the client avoid? Red wine, raspberries, aged cheese Hamburger, fries, strawberry shake Apple juice, ham salad, fresh pineapple Fresh juice, carrots, vanilla pudding

a;The body has two forms of MAO, named MAO-A and MAO-B. In the brain, MAO-A inactivates norepinephrine (NE) and 5-HT, whereas MAO-B inactivates dopamine. In the intestine and liver, MAO-A acts on dietary tyramine and other compounds. Although the MAOIs normally produce hypotension, they can be the cause of severe hypertension if the client eats food that is rich in tyramine. The client must be given a detailed list of tyramine-rich food and beverages to avoid, including avocados, figs, smoked meats, liver, processed deli meat such as salami and bologna, red wine, and practically all cheeses. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS parnatetranylcyprominedietcontraindicateMAOI

The nurse on a pediatric unit is developing a plan of care for a child with a hip spica cast. Which nursing intervention is the priority? Encourage deep-breathing exercises Monitor the skin at the cast edges Use a bedpan to help the child void Prevent the cast from getting wet

a;The hip spica cast is mainly used for femur fractures in children to immobilize the affected extremity and trunk. It extends from above the nipple line to the base of the foot and may include the opposite extremity up to an area above the knee or both extremities. The cast can interfere with chest expansion, leading to atelectasis and respiratory problems. Therefore, the priority intervention is to encourage deep-breathing exercises. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS hip spica castprioritization

A parent brings a 3 month-old infant into the clinic, reporting that the child seems to be spitting up all the time and has a lot of gas. The nurse expects which findings on the initial history and physical assessment? Restlessness and irritability Diarrhea and poor skin turgor Increased temperature and lethargy Increased sleeping and fatigue

a;This infant could be experiencing gastroesophageal reflux or perhaps an allergic response to the formula. Restlessness, irritability and increased mucus production can develop if an allergy is present. Soy-based formula may be recommended when allergies to the proteins in cow's milk formulas are suspected. Protein hydrolysate formulas are available when babies have a milk or soy allergy. Reflux would be treated with an acid-reducing medication such as ranitidine and positioning with the head elevated after feeding and while sleeping to reduce symptoms causing esophageal irritation. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS gasspitting upassessallergysoyformulainfant

The nurse is caring for a client diagnosed with superficial thrombophlebitis of the left leg. While developing a plan of care, the nurse should include which intervention? Elevate the affected leg Maintain complete bed rest Place the leg in an immobilizer brace Apply cool compresses

a;Unlike deep vein thrombosis, superficial thrombophlebitis involves a sudden inflammatory reaction (redness, pain, swelling), but it rarely involves a thrombus. Treatment consists of elevating the leg because dangling the extremity will increase the swelling and the pain. Other treatment options include warm compresses and analgesics; sometimes a low-molecular weight heparin is also prescribed. Clients do not need to be on bed rest or require an immobilizer brace. Incorrect LESSON Reduction of Risk Potential Potential for Alterations in Body Systems COURSE RN & PN Review BODY SYSTEM cardiovascular KEYWORDS thrombophlebitisedemaprioritization

The nurse is participating in a quality improvement (QI) project with a focus on improving pain management on a surgical unit. Which actions should be included in this QI project? Select all that apply. Developing a team approach for the entire health care team to participate in the process Designing a research study to produce evidence supporting the current protocol Reviewing pain management protocols for evidence-based practice Reviewing client satisfaction data related to pain management Determining pain management interventions proposed by the pharmacy department

abc Generally, quality improvement (QI) projects are directed at improving processes and client outcomes. For this particular project, actions are focused on pain management and should include reviewing evidence-based practice and client satisfaction surveys in relation to pain and pain management. A critical component of QI is teamwork and the team should include many different members of the health care team and not just a particular team member or department. A QI project is not the same as a traditional, quantitative research study. Incorrect LESSON Management of Care or Coordinated Care Performance Improvement (Quality Improvement) COURSE RN Review KEYWORDS quality improvementevidence-based

There is an order to administer an intramuscular influenza vaccine to an adult client. What actions should the nurse take before administration of the injection? Select all that apply. Check the expiration date on the vaccination bottle Record the site and time of injection Record the client's reaction to the injection Have the client sign the vaccination consent form Ask if the client ever had an adverse reaction to the flu vaccine Provide the client with the a vaccine information statement

acde;Prior to administration, the nurse should identify the expiration date on the bottle and give a current copy of the vaccine information statement to the client. The nurse should also verify any allergies or previous reactions to the vaccine, prior to administering the vaccine. A signed consent is required for vaccinations. Observing for a reaction to the injection and recording the site and time of injection should be performed after administering the vaccine. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN & PN Review BODY SYSTEM immune KEYWORDS influenzavaccine

A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce? With the average age of diagnosis at 50 years, the peptic ulcers may occur at unusual areas of the stomach or intestine It is critical to promptly report any signs of abdominal pain or gastric bleeding to your health care provider Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum) (1 attempt remaining)

b Night-time awakening with burning, cramp-like abdominal pain, vomiting (even hematemesis), and change in appetite are some of the findings of peptic ulcers. Abdominal pain, rigidity and tenderness can signal perforation of the ulcer and should be reported to the provider immediately. Zollinger-Ellison syndrome can occur in both children and adults. All of the other options are correct information about this syndrome but are less important to reinforce when teaching the client. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS Zollinger-Ellisonulcertumorpancreas

The nurse is caring for a client who is receiving a continuous intravenous heparin infusion. The client's most recent activated partial thromboplastin time (aPTT) is 120 seconds. Which medication should the nurse plan to administer? Naloxone Protamine Enoxaparin Vitamin K

b The client's aPTT is much higher than the typical desired therapeutic range of 1.5-2.5 the control value and places the client at great risk for uncontrolled bleeding. Protamine sulfate is the medication used to reverse the effects of heparin; it is a heparin antagonist. Neutralization of heparin occurs immediately and lasts for 2 hours, after which additional protamine may be needed. Protamine is administered by slow IV injection (no faster than 20 mg/ min or 50 mg in 10 minutes). Dosage is based on the fact that 1 mg of protamine will inactivate approx. 100 units of heparin. Vitamin K is used to reverse the effects of warfarin. Naloxone is used to reverse the effects of opioids. Enoxaparin is another anticoagulant (low molecular weight heparin). Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN & PN Review BODY SYSTEM cardiovascular KEYWORDS heparinintravenousoverdose

A client in the emergency department displays symptoms of tuberculosis that include cough, loss of appetite, night sweats and bloody sputum. Which action should the nurse perform first? Provide instruction to the client about cough etiquette Move the client to a private, negative pressure room Notify all assigned staff members about the suspected tuberculosis All staff caring for the client should wear a N95 disposable mask

b The priority is to initiate airborne precautions to prevent the spread of the infection. Then the nurse should implement the other actions. Correct! LESSON Safety and Infection Control Standard Precautions, Transmission-Based Precautions, Surgical Asepsis COURSE RN Review BODY SYSTEM respiratory KEYWORDS tuberculosisairborne precautions

A school-aged child had a long leg (hip to ankle) plaster cast applied four hours ago. Which statement from the parent indicates that additional teaching is necessary? "I can apply an ice pack over the area to relieve itching inside the cast." "My child will be able to stand on the casted leg within 24 hours." "The cast should be propped on at least two pillows when my child is lying down." "I will keep the cast uncovered for the next day to prevent burning of the skin." (1 attempt remaining)

b Unlike fiberglass casts, the set up and drying time of plaster casts can take up to 72 hours, especially with a long leg cast. Therefore, the child should not stand until the cast has dried. Clients may complain of a chill from the wet cast and can be covered with a sheet or blanket, but the cast should be uncovered for the first 24 hours. Applying ice in an ice bag is a safe method to relieve the itching. Swelling can be managed by elevating the leg when lying down. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS plastercastlegteachchild

A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What information would be essential for the nurse to know about this procedure when teaching the client? The procedure is a noninvasive radiographic examination of the coronary arteries. The procedure compresses plaque against the wall of the diseased coronary artery to improve blood flow. The procedure involves surgical repair with an incision of a diseased coronary artery to improve blood flow. The procedure involves placement of an automatic implanted cardiac defibrillator.

b A percutaneous transluminal coronary angioplasty (PTCA) is an invasive procedure performed to open blocked coronary arteries caused by coronary artery disease (CAD). The procedure is performed during a cardiac catheterization and does not involve implanting a cardiac defibrillator. A balloon is inflated once the catheter is in place in the diseased artery and compresses fatty tissue resulting in improved blood flow. A coronary artery bypass graft (CABG) is a surgical procedure that requires incisions to repair diseased coronary arteries. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS percutaneous transluminal coronary angioplastyPTCACADartery

During evening rounds, the nurse notices a foul smell in the room of a client diagnosed with pneumonia who was started on intravenous (IV) antibiotics 10 hours ago. Which statement by the client would best indicate a possible complication of this diagnosis? "I feel hot on and off and have been sweating all day." "I have been coughing up foul-tasting, brown, thick sputum." "I have been incontinent of urine and need to change my pad often." "I have a sharp pain in my chest when I take a breath."

b Foul smelling and tasting sputum signals the possible development of a lung abscess, a complication of pneumonia, particularly in aspiration pneumonia. This puts the client in grave danger because abscesses are often caused by anaerobic organisms. This client most likely would need a change of antibiotics. Sharp chest pain on inspiration called pleuritic pain is an expected finding with this type of pneumonia. The other options are expected in the initial 24 to 48 hours of therapy for any type of infection. Incorrect LESSON Physiological Adaptation Unexpected Response to Therapies COURSE RN Review BODY SYSTEM respiratory KEYWORDS pneumoniaantibioticcomplicationabscess

The nurse is teaching a client diagnosed with depression about a new prescription of nortriptyline. What information would be essential for the nurse to emphasize about this medication? Episodes of diarrhea can be expected The use of alcohol should be avoided Symptom relief occurs in a few days The medication must be stored in the refrigerator

b Nortriptyline is a tricyclic antidepressant used to manage chronic neurogenic pain and depression. Adverse reactions include central nervous system (CNS) side effects such as suicidal thoughts, drowsiness, fatigue, lethargy, and confusion. Clients who are prescribed this medication should be educated to avoid the use of alcohol consumption or other CNS depressant drugs as this can worsen the adverse reactions of the medication and cause injury. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS teachdepressionnortriptylinePameloralcohol

The nurse receives an order to administer intravenous (IV) iron sucrose to a client with anemia. Which statement best describes the purpose of administering this medication using the IV route? To provide more even distribution of the drug To prevent the drug from causing tissue irritation To ensure that the entire dose of medication is given To enhance absorption of the medication

b Iron sucrose is an iron supplement used to treat iron deficiency anemia. If given subcutaneously or intramuscularly, the tissue can become irritated and may result in bleeding into the muscle; therefore, the best route for this medication is intravenous (IV). The rate for administration will vary on the dosage but is typically at a slower rate due to the risk of adverse reactions. The other statements do not accurately describe the purpose for the IV route. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review KEYWORDS injectionIMironDextrandeep

A client diagnosed with delusional thoughts states to the nurse, "Don't waste good food on me. I'm dying from this disease I have." Which statement by the nurse would be most appropriate? "Try to eat a little bit, breakfast is the most important meal of the day." "I know you believe that you have an incurable disease, but you need to eat." "None of the laboratory reports show that you have any physical disease." "You need some nutritious food to help you regain your weight."

b The most appropriate response of the nurse should not challenge the client's delusional beliefs. This statement forms an alliance by providing reassurance of a desire to help the client. Incorrect LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS delusionreassurance

The nurse explains an autograft to a client scheduled for excision of a skin tumor. Which statement indicates that the client understands the nurses's teaching? "I will receive tissue from a pig." "I will receive tissue from my thigh." "I will receive tissue from a tissue bank." "I will receive tissue from synthetic skin."

b' Autografts are done with tissue transplanted from the client's own skin. Tissue from a pig is called a xenograft or heterograft, which means it is transplanted from an organism of one species to that of a different species. Cadaveric grafts are termed allografts, or homografts because they are transplanted from one individual to another within the same species. Correct! LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM integumentary KEYWORDS skintumorexcisionautograft

A client is recovering from an acute myocardial infarction. Which action by the nurse would best prevent complications associated with the Valsalva maneuver in this client? Assist the client with use of the bedside commode Administer stool softeners every day as ordered Administer antiarrhythmic medications PRN as ordered Maintain the client on strict bed rest

b'After myocardial infarction, the Valsalva maneuver can cause cardiac arrhythmias. Administering stool softeners every day will prevent the client from straining or bearing down on defecation (the Valsalva maneuver). If constipation occurs, laxatives would be necessary to prevent Valsalva. If the client experiences cardiac arrhythmias associated with straining on defecation, then administering antiarrhythmics would be appropriate. Maintaining bed rest with use of a bedpan can increase the likelihood of straining and difficulty with defecation as well as increased myocardial oxygen consumption, so use of the bedside commode is also appropriate to achieve this goal in this client. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS Valsalva maneuvermyocardial infarctionconstipationpharmacology

A client with a history of asthma is admitted for a minor surgical procedure. Preoperatively, the peak flow is measured at 480 liters/minute. Postoperatively, the client reports chest tightness and the peak flow is now 200 liters/minute. What should the nurse do first? Notify both the surgeon and primary care provider Administer the PRN dose of albuterol Repeat the peak flow reading in 30 minutes Apply oxygen at two liters per nasal cannula

b'Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma to determine the severity of the exacerbation and to guide the treatment. A peak flow reading of less than 50% of the client's baseline reading is a medical alert condition and a short-acting beta agonist must be taken immediately. Notifying the health care provider is important, but that is not what would be done first. First, the client needs assistance. Oxygen administration will not be effective if the airway constriction is not relieved with the albuterol. Leaving the client and returning in 30 minutes will do nothing to help a client in acute distress. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM respiratory KEYWORDS asthmasurgerypeak flow meteralbuterol

The nurse is caring for a client who has generalized anxiety disorder (GAD). While developing a plan of care, which intervention would be most appropriate to implement? Establish contact with reality Learn self-help techniques Express any anxious feelings Become desensitized to past trauma

b, Generalized anxiety disorder (GAD) causes a person to have excessive, persistent anxiety and worry about activities and events. The person may have difficulty with control and this affects how they physical feel which may lead to depression. It would be most appropriate for the nurse to have the client explore alternative coping mechanisms to decrease levels of anxiety to a manageable level. Along with the nurse, a counselor will be able to assist the client in learning self-help techniques to enhance their abilities to cope with anxiety. Incorrect LESSON Psychosocial Integrity Coping Mechanisms COURSE RN Review KEYWORDS anxietygoaltreatmentself-help

A client who is recovering from alcoholism asks the nurse, "What should I do when I start to recognize relapse triggers?" Which statement by the nurse is most appropriate? "Exercise daily and get involved in activities that will cause you not to think about drinking." "Let's talk about possible options you have when you recognize these relapse triggers in yourself." "Go to an AA meeting that week when you feel the urge to drink." "When you have an impulse to stop in a bar, contact sober friends and talk with them." (1 attempt remaining)

b, this option encourages the process of self-evaluation and problem solving and provides an avoidance of telling the client what to do. Encouraging the client to brainstorm about response to relapse trigger options validates the nurse's belief in the client's personal competency. These behaviors reinforce a coping strategy that will be needed when the nurse is not available to offer solutions. Correct! LESSON Psychosocial Integrity Chemical and Other Dependencies, Substance Use Disorder COURSE RN Review KEYWORDS alcoholrelapse

A male client at a public health clinic is diagnosed with epididymitis. Which additional information is most important for the nurse to obtain? "Do you have any questions about your care?" "Were you ever tested for a sexually transmitted infection?" "Did you know that a consequence of epididymitis is infertility?" "What are you taking for pain and does it provide total relief?"

b.Epididymitis is an inflammation of the epididymis which is a coiled tube at the back of the testicle which helps store sperm. Symptoms may include a swollen or reddened scrotum, testicular pain, penile discharge, and/or blood in the semen. This is most often caused by a bacterial infection, including sexually transmitted infections (STI) such as chlamydia or gonorrhea. Therefore, it is most important to inquire about testing for an STI so that the client can be treated and educated on prevention, as necessary. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM reproductive KEYWORDS epididymitischlamydiaSTIsexual activity

The nurse is performing an assessment on an infant recently diagnosed with cystic fibrosis. Which of the following findings should the nurse anticipate? Weight gain Persistent cough Watery nose Loose stools

b; Cystic fibrosis (CF) is an inherited disease that causes the lungs and digestive system to be severely damaged. Respiratory symptoms include persistent cough with thick, sticky mucus, wheezing, breathlessness and frequent lung infections. The child's nasal passages could become inflamed leading to a stuffy nose. Digestive symptoms include foul-smelling greasy stools, poor weight gain, and intestinal blockage that could lead to severe constipation. Respiratory failure is the most dangerous consequence of CF. The nurse must perform a thorough respiratory assessment and notify the health care professional immediately if signs or symptoms of respiratory distress are observed. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM respiratory KEYWORDS cystic fibrosiscoughsweat test

The charge nurse is reviewing assignments for the shift. The care team consists of a registered nurse (RN), a licensed practical nurse (LPN) and several unlicensed assistive personnel (UAP). Which of these clients would be most appropriate to assign to the RN? A 56-year-old admitted with atrial fibrillation who converted to normal sinus rhythm without cardioversion A 24-year-old newly diagnosed with type 1 diabetes mellitus who is scheduled for discharge An 80-year-old who is postoperative day 1 following a right hip replacement A 60-year-old with a history of asthma and reported shortness of breath during the previous shift

b; LPNs can care for clients whose conditions are not too complex or variable and if there is a low likelihood of an emergency. Also, RNs are responsible for providing client education; LPNs can only reinforce the plan of care and information already taught by the RN. Although the condition of the client scheduled for discharge would be considered "stable," the RN is responsible for discharge teaching and ensuring continuity of care after discharge; therefore, the 24-year-old client is most appropriate to assign to the RN. Correct! LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS assignmentscope of practice

The nurse in a neonatal unit is caring for a newborn with a myelomeningocele with an intact sac. Which type of dressing should the nurse use to cover the sac? Hydrocolloid dressing Sterile, moist nonadherent dressing Kurlix gauze, wrapped around the spine and abdomen Sterile pressure dressing

b;A meningocele is a neural tube defect where a sac is protruding from the spinal column. If not covered, there is a high risk of infection and it is essential to protect the exposed area of the spine. The nurse should apply a moist, sterile nonadherent dressing to prevent drying of the area. Dressings are to be changed frequently to keep the area moist. Treatment includes surgical closure and closing the overlying meninges and the skin. The other dressing choices are not appropriate for this condition. LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM integumentary KEYWORDS neural tube defectmeningocele

A client is admitted for placement of a suprapubic catheter. Which statement by the client should the nurse identify as a misunderstanding of self-care? "I will let my health care provider know if my urine looks cloudy." "I will rinse the drainage bag with bleach once a week." "I will drink lots of fluids to stay well-hydrated." "I will change the catheter every month."

b;A suprapubic catheter is an indwelling urinary catheter that has been surgically placed to drain urine from the bladder. The client will need to change the catheter approximately once a month. To help decrease infections, the client should drink plenty of fluids, especially after changing the catheter. If the client notices a smell or change in color of the urine or the urine is cloudy, the client should call the health care provider. To clean the drainage bag, the client can disconnect the bag, swish some warm soapy water around in it and then rinse the bag with a vinegar solution - never bleach. This can be done every few days or so. This client needs additional instruction on the proper care of the drainage bag. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM urinary KEYWORDS suprapubiccathetermedicationteachbladderurine

A 9-year-old child is taken to the emergency department with right lower quadrant pain and vomiting. During preparation for an emergency appendectomy, what should the nurse expect to be the child's greatest fear? An unfamiliar environment Perceived loss of control Guilt over being hospitalized Change in body image (1 attempt remaining)

b;According to Erikson's stage of development, this child is in the industry versus inferiority developmental stage. The age range for this stage is 5 to 13 years. Within this stage, children learn new skills and are influenced by their peers. They may feel competent or feel inferior and doubt themselves. Possible problems or concerns could include isolation from peers, inability to cope causing anger and shame, self-doubt, and perceived loss of control. Incorrect LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS Eriksondevelopmental stages CONFIDENCE

The nurse receives report on the following four clients. Which client should the nurse assess first due to a high risk of falling? The 59 year-old who had hip replacement surgery four days ago and is going to physical therapy The 81 year-old who fell at home last week who has altered mental status The 67 year-old who has diabetes and has chronic draining ulcers on the right leg The 79 year-old who has rheumatoid arthritis and walks with the aid of a walker

b;Although all of the individuals might be at risk for falling, evidence shows that the greatest risk of falling is a person who is older than age 80, is confused, and has a history of falling. Incorrect LESSON Safety and Infection Control Accident, Error, Injury Prevention COURSE RN & PN Review KEYWORDS fallconfusionwalkerrisk

The nurse is reviewing lab results for a client admitted with acute exacerbation of chronic obstructive pulmonary disease. Which lab result should be of highest concern? PaCO2 level of 52 mm Hg PaO2 level of 60 mm Hg Serum albumin level of 2.0 mg/dL Hematocrit level of 50% (1 attempt remaining)

b;COPD or chronic obstructive pulmonary disease is a chronic disease that causes obstructed airflow in the lungs due to inflammatory processes. Obstructed airflow may cause severe respiratory distress and affect a person's ability to exchange oxygen and carbon dioxide efficiently. The PaO2 level is significantly decreased (normal 80 to 100 mm Hg), indicating severe hypoxemia and should be of highest concern for the nurse. Clients with COPD chronically retain PCO2; thus, an elevated level is to be expected. The hematocrit level is at the upper end of the normal range. Although the albumin level is also significantly decreased, indicating malnutrition, it it of a lower priority than the low PAO2 level. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS embolismpulmonaryABG

The nurse is providing information to a client with diarrhea. Which foods should the client avoid until the diarrhea has resolved? Chicken broth and tea Raw vegetables and citrus fruits Cooked cream of wheat Soda crackers and applesauce

b;Clients with diarrhea should be advised to eliminate certain foods from their diet that may worsen their symptoms. Food choices to avoid include dairy products, spicy, fried, or greasy foods, processed foods, raw vegetables, citrus fruits, and alcohol or any type of caffeinated drinks. Food choices that are beneficial include cooked cereal like cream of wheat, soda crackers, applesauce, clear broths, electrolytes, and decaffeinated tea. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS diarrheafoodavoid

A client recently diagnosed with heart failure has been prescribed digoxin and furosemide. Which of the following foods should the nurse teach the client to eat at least one serving a day? Pear nectar Tomato juice Wheat cereal Blueberries

b;Digoxin, an antiarrhymic, and furosemide, a diuretic, are commonly prescribed for clients with heart failure. A common side effect for furosemide is depletion of potassium. Of the food choices, tomato juice is the highest in potassium. To reduce the risk of potassium depletion, the client should be encouraged to drink at least 1/2 cup of tomato juice every day which is about 400 mg of potassium. The other choices are low in potassium which would be recommended for clients diagnosed with chronic renal failure. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review KEYWORDS potassiumlanoxindigoxinfurosemidefooddiet

The nurse is caring for a client when the client starts to have a tonic-clonic seizure. Which intervention should the nurse implement first? Prepare for suctioning Turn the client on their side Administer the prescribed lorazepam Check the pulse

b;During a seizure, the nurse should use the airway-breathing-circulation prioritization approach. A tonic-clonic seizure causes a person to lose consciousness and have violent muscle contractions. Clients can vomit during a seizure and, therefore, protecting and maintaining an open airway should be done first. This can be accomplished by turning the client on their side. This position assists in maintaining an open airway, draining secretions, and reduce the risk of aspiration, if vomiting occurs. After this intervention, the nurse can prepare for possible suction and administer medications as prescribed. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS seizureaspirationprioritization

The nurse is providing the client who takes digoxin and furosemide with dietary instructions. The nurse should reinforce that the combination of these medications can result in which outcome? Oliguria Arrhythmias Edema Irritability

b;Furosemide is an effective diuretic but electrolyte depletion may occur. Concurrently taking furosemide and digoxin exaggerates the metabolic effects of hypokalemia, especially alterations in cardiac rate and rhythm, and contributes to digitalis toxicity. Digitalis toxicity may stimulate almost every known type of dysrhythmia. The effects of hypokalemia include fatigue (not excitability) and polyuria (not oliguria); digitalis toxicity can cause nausea, vomiting, anorexia and weight loss (not weight gain). Foods rich in potassium include avocados, bananas, peas and beans, spinach and tomatoes. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS dietpotassiumdigoxinhypokalemiaarrhythmia

An adult client is scheduled for a 300 mL bolus of enteral feeding that is scheduled every 4 hours. While preparing to administer the scheduled feeding, the nurse aspirates 100 mL of gastric residual volume (GRV). Which action should the nurse take? Hold the scheduled feeding Administer the feeding as ordered Notify the health care provider Flush the tubing with cold water

b;Many standing orders state to check residual volume every 4 hours and to only hold the feeding if the residual is greater than or equal to a specific amount (which may be as high as 400 mL). A GRV of 100 mL is within an acceptable range and the nurse should administer the feeding as ordered. Also, serial GRV measurements are more important than an isolated measurement. The health care provider should be notified if the client exhibits other signs of not tolerating the tube feedings such as gastric distention, diarrhea, and nausea and vomiting. The tubing should be flushed before and after each use to maintain patency, but with warm water, not cold water, to prevent cramping. Incorrect LESSON Reduction of Risk Potential Potential for Alterations in Body Systems COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS enteral nutritiontube feeding

A nurse at a pediatric clinic examines a toddler with a possible diagnosis of neuroblastoma. Which findings are consistent with the client's diagnosis? Lymphedema and nerve palsy Abdominal mass and weakness Headaches and vomiting Hearing loss and ataxia

b;Neuroblastoma is a type of cancer that commonly arises in and around the adrenal glands. This cancer may also develop in other areas of the abdomen in which the client will complain of abdominal pain or feel a mass underneath the skin. The client may also have changes in bowel habits such as constipation or diarrhea and unexplained weight loss. Client's will complain of weakness due to the symptoms of the cancer. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM nervous KEYWORDS neuroblastomapediatricabdominal mass

During a lunch break, nurse colleagues discuss their nursing practice. Which of the following statements best represents nursing practice guidelines? National nursing associations are responsible for developing specific regulations for licensed registered nurses (RNs) and licensed practice nurses (LPNs). Specific regulations for licensed registered nurses (RNs) and licensed practical nurses (LPNs) will vary from state to state. The healthcare agency is ultimately responsible for developing practice guidelines for licensed nurses. The federal government ensures the safety of clients by developing nursing practice guidelines.

b;Nursing guidelines and regulations are developed to protect those who are receiving care. It is the state's duty to ensure licensed nurses provide safe, competent nursing care. Boards of nursing are state governmental agencies that are responsible for licensing nurses in each state and enforcing the rules and regulations of the nurse practice act. Nursing scope of practice may vary from state to state. It is the responsibility of the licensed nurse to be aware of their state's scope of practice. The other statements are not true in regards to nursing practice guidelines. Incorrect LESSON Management of Care or Coordinated Care Legal Rights and Responsibilites COURSE RN & PN Review KEYWORDS statelicenseNPAregulation

The nurse expresses concerns to colleagues regarding their nurse manager. The nurse states that the manager makes all the decisions and rarely seeks input from staff. What is the best description of the nurse manager's management style? Laissez-faire leadership Transformational leadership Autocratic leadership Participative leadership

b;The manager's leadership style is that of autocratic. Autocratic leadership is a management style where one person controls all decisions and rarely seeks input from others. Leaders who follow this style make choices based on their own beliefs and do not involve others nor seek suggestions or advice. Transformational leadership aims to improve employee morale and promoting inclusion by creating a vision for their employees and communicating often. Laissez-Faire leadership allows employees to choose their actions freely and does not provide sufficient supervision. Participative leadership encourages employees to participate in decision-making but then makes the final decision for the group based on suggestions and feedback. Correct! LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS managerstudentautocraticleadership

The nurse is caring for a client who was recently prescribed atropine as a treatment for symptomatic bradycardia. Which condition should the nurse question as a contraindication when taking this medication? Right-sided heart failure Glaucoma Urinary incontinence Increased intracranial pressure

b;The nurse should question the use of atropine with a client who has glaucoma. Atropine is contraindicated in clients with angle-closure glaucoma because it can cause pupillary dilation with an increase in aqueous humor. This can lead to an increase in optic pressure causing blurred vision and ocular pain. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS atropinebradycardiaglaucoma

The nurse measures the head and chest circumference of an 18-month-old infant. When comparing the data, the nurse notes the two measurements are the same. What action should the nurse take next? Notify the health care provider Record the findings in the chart Palpate the anterior fontanel Feel the posterior fontanel (1 attempt remaining)

b;These are expected findings and the nurse will record the measurements in the client's chart. Between 6 months and 2 years, an infant's head circumference and chest circumference measurements are about the same. A newborn's head is usually about 2 centimeters larger than the chest size; after age 2 years, the chest size becomes larger than the head. Incorrect LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review KEYWORDS headchestcircumferenceinfant

A nurse is planning for her new role as the nurse manager of a 30-bed inpatient medical unit in a busy acute care hospital. Which strategy should the nurse use to help with time management? Plan to work a few extra hours on weekends Set daily, prioritized goals of management tasks Limit direct care of clients to 2 to 3 hours per day Delegate tasks and skip unimportant meetings

bTime management strategies include setting goals and prioritization of not only management tasks but issues that arise on a daily basis on the unit. This is similar to time management of direct care for clients where the nurse prioritizes which clients to see first or which tasks to perform first. Still providing direct care would be a poor use of the manager's time. Direct client care should be done by a nurse manager only in extreme circumstances. The nurse manager will be expected to attend all required meetings and working "extra hours" does not help with managing time and completing management tasks within the expected work week. Incorrect LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS nurse managertime managementprioritization

The nurse is caring for a client who is the mother of a close friend. The friend asks the nurse for an update about their mother's condition on a social networking website. How should the nurse best respond? Do not use the social networking website to answer the question; call the friend instead. Respond on the social networking website, directing the friend to ask the question in person. Do not disclose any information to the friend on the social networking website. Answer the question on the social networking website because only trusted contacts can access the information.

c A nurse cannot disclose information about a client except to those who are directly involved in the care of the client. Also, clients must be informed about how their personal health information will be used and given the opportunity to object to or restrict the use or release of information. Nurses cannot use social networking websites, like Facebook, to disclose patient information, even with the use of privacy settings or when no names are used. Each health care organization has strict policies prohibiting the disclosure of protected health information. Incorrect LESSON Management of Care or Coordinated Care Confidentiality, Information Security COURSE RN & PN Review KEYWORDS social mediainformation

A 76 year-old client is prescribed an anticholinergic metered dose inhaler (MDI) for chronic obstructive pulmonary disease (COPD). Why would the nurse suggest the client use a spacer? To increase client compliance to take the medication To enhance the administration of the medication To help control the intake of the medication To prevent further exacerbation of COPD (1 attempt remaining)

c An anticholinergic is used for maintenance therapy of airway obstruction due to chronic obstructive pulmonary disorder (COPD) including bronchitis and emphysema. The therapeutic effects are to cause bronchodilation and improve efforts of breathing. To improve the administration of the medication the nurse should suggest the client to use a spacer. This will help control the intake of the medication and reduce the amount of the medication that remains on the throat or tongue. Correct! LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM respiratory KEYWORDS MDIanticholinergicinhalerCOPDspacer

The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important action to prevent skin breakdown? Lubricating the skin with lotion Massaging the skin frequently Turning at least every two hours Applying heat to reddened areas (1 attempt remaining)

c Clients who are on bed rest are at risk of many complications. Complications include pneumonia, constipation, blood clots to the legs, and skin breakdown. To prevent skin breakdown, the nurse should turn the clients every two hours and assess the skin for any redness or injury. Repositioning frequently will relieve prolonged pressure on any one area. All the other options are not the most important to prevent skin breakdown. Correct! LESSON Basic Care and Comfort Mobility, Immobility COURSE RN Review BODY SYSTEM integumentary KEYWORDS skinbreakdownturnbed rest CONFI

The community health nurse is participating in a health policy forum. Which statement by the nurse best describes the purpose of community health research? To evaluate illness in the community To identify the health conditions of the environment To describe the health conditions of populations To explain the health conditions of families

c Community health focuses on the maintenance, protection, and improvement of health especially of groups, populations and communities. The purpose of community health research is best described as research that focuses on the health of populations in a community, rather than the health of an individual. Community health nurses focus on short and long-term care for disease prevention such as controlling the spread of communicable diseases, support self-management of chronic diseases, and providing education to vulnerable and underserved populations such as the homeless, elderly and minority groups. Incorrect LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS community healthpopulation healthresearch

A new parent calls the pediatrics office to speak to the nurse. The parent reports that their 4-week-old infant sleeps almost 16 hours a day and the parent expresses concern that there might be something wrong with their child. How should the nurse respond? "Please make an appointment for the baby to be seen by the pediatrician." "That is normal for a baby that age. You do not need to worry." "Tell me more about other behaviors of the baby." "Why do you think that your baby is abnormal?"

c Using therapeutic communication techniques and following the nursing process, the nurse should gather more information from the parent about their baby, in order to be able to determine if the child should be seen in the office. Although sleeping 16 hours a day is within the normal range for a 4-week-old infant, the nurse should encourage the parent to describe other behaviors such a feeding and how the baby acts when awake."'Why" questions or dismissing the parent's concern are nontherapeutic. Incorrect LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review KEYWORDS infanttherapeutic communicationnursing process

A client is being transfused with one unit of packed red blood cells. Within 15 minutes of the transfusion, the client reports having chills and a headache. Which action should the nurse take first? Notify the health care provider Obtain a urine specimen Stop the transfusion Obtain a set of vital signs

c The first action of the nurse should be to stop the blood transfusion. Based on the client's symptoms, they are having a hemolytic transfusion reaction. This could be caused by mismatched blood types. Most frequent symptoms include fever, chills, itching, hives, and a headache. It would be essential for the nurse to assess for this manifestations within the first 15 minutes of the transfusion, throughout, and 90 minutes after. After the nurse stops the infusion, the health care provider and the blood bank should be notified for further evaluation and treatment. Correct! LESSON Pharmacological (and Parenteral Therapies) Blood and Blood Products - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS bloodtransfusionchillsreaction

The nurse is eating in the hospital cafeteria when a toddler at a nearby table begins to choke on a piece of food and turns slightly blue. What initial action should the nurse take? Give the child water to help with swallowing Call for the emergency response team Perform abdominal thrusts Begin mouth to mouth resuscitation

c The initial response should be to perform abdominal thrusts. Since this child is actively choking, it would be essential to begin this step in order to dislodge the foreign object. Once this action is being done, the nurse should yell for help or for someone to call the rapid response team. If the child stops breathing and/or is unconscious the nurse should open the mouth and look for the object, if no object is seen perform mouth to mouth resuscitation using a barrier device, continue to do the Heimlich remover, and call for help. Correct! LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM respiratory KEYWORDS chokeabdominal thrustchild

A nurse is caring for a client with chronic kidney disease who is in fluid overload after being given an intravenous fluid bolus. Which assessment finding should the nurse anticipate? Hypoventilation Thready pulse S3 heart sound Flattened neck veins

c; Chronic kidney disease is characterized by a gradual loss of kidney function and decreases the body's ability to excrete wastes and fluids efficiently. When receiving a large about of intravenous fluids, the poorly functioning kidneys are unable to excrete properly and the fluid builds up in the body. Symptoms the nurse should anticipate are shortness of breath, crackles in the lungs, swelling in the arms or legs (edema), distended neck veins, and bounding pulse. Auscultation of the heart will also reveal an S3 heart sound as this is any early sign of volume overload and heart failure due to the excessive fluid left in the ventricles. Incorrect LESSON Pharmacological (and Parenteral Therapies) Parenteral, Intravenous Therapies - RN COURSE RN Review KEYWORDS intravenousrapid

The nurse is caring for a client with orders for complete bed rest. Which action by the nurse is most important in the prevention of the formation of deep vein thrombosis (DVT)? Apply knee high support stockings Encourage isometric leg muscle exercises Prevent pressure at back of the knees Elevate the foot of the bed

c; Deep vein thrombosis (DVT) is a blood clot that forms in a vein in the body, typically found in the lower extremities. DVTs can be caused by a variety of reasons. Prolonged bed rest in the hospital setting puts this client at high risk for developing a DVT due to decreased venous stasis or blood flow to the lower extremities. To prevent any obstruction in blood flow, the nurse would want to prevent pressure at the back of the knees. Other actions that may be implemented after this action include elevating the foot of the bed, apply pneumatic stockings and/or applying knee high support stockings, and encouraging the client to perform ankle pumps to promote blood flow back through the body. Correct! LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS preventionDVTthrombosisbed rest

The nurse is reviewing the assessment data of a client suspected of having diabetes insipidus. Which of the following findings should the nurse expect after a water deprivation test? Increased edema and weight gain Rapid protein excretion Unchanged urine specific gravity Decreased serum potassium

c; Diabetes insipidus (DI) is a condition in which the kidneys are unable to conserve water. Symptoms of DI are excessive thirst and excessive urine output. Even when fluids are restricted, as with the fluid deprivation test, the client continues to excrete large amounts of urine. Normally, urine becomes more concentrated in situations of reduced fluid intake. Clients with DI do not have an increase in edema or weight gain. Due to the excessive urine output, these clients would be more apt to lose weight. Although clients who have DI are at risk for hypokalemia, participating in a water deprivation test would not alter the client's potassium level. If an individual was deprived of water, their specific gravity level should increase. This is a normal response. However, if a client suffers from DI, their specific gravity level would remained unchanged if they were deprived of water. Rapid protein excretion does not occur in a water deprivation test with clients who have DI. Correct! LESSON Reduction of Risk Potential Diagnostic Tests COURSE RN Review BODY SYSTEM urinary KEYWORDS assessdiabetes insipiduswater deprivationtesturin LESSON Reduction of Risk Potential Diagnostic Tests COURSE RN Review BODY SYSTEM urinary KEYWORDS assessdiabetes insipiduswater deprivationtesturine

The nurse is teaching parents about dietary needs for a 4-month-old infant with gastroenteritis and mild dehydration. Which diet would be most appropriate for the infant to rehydrate? Milk and ginger ale Low sodium broth and tea Formula and breast milk Water and apple juice

c; Gastroenteritis, or stomach flu, is inflammation of the lining of the intestines either caused by bacteria, a virus, or parasites. This can be spread through contaminated food or water or by contact with an infected person. Symptoms may include watery diarrhea, vomiting, stomach pain, or fever. The nurse must watch for furthering signs of dehydration; however, this child just has mild dehydration. The treatment plan would be for the child to continue drinking as much formula or breast milk as they are able. The other choices would not be the most appropriate diet for this child's age. Correct! LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS gastroenteritisdehydrationdietinfant

The visiting nurse is evaluating a 2-month-old child who had bilateral leg casts applied for the treatment of clubfoot. Which nursing goal is the priority for this child? Muscle spasms will be relieved Minimal pain with cast application Tissue perfusion will be maintained Mobility will be managed as tolerated

c; Immediately following cast application, the priority goal is to maintain circulation and tissue perfusion around the cast. Although most casts do not cause problems, the risk for complications such as compartment syndrome does exist. Compartemtn syndrome means the pressure in an extremity that can cause so much pressure that blood flow and tissue perfusion is impaired. Permanent tissue damage can occur in the limb within a few hours, if perfusion is not maintained. Therefore, assessment and monitoring of the extremity for the 6 Ps (pain, paresthesia, pallor, paralysis, pulselessness) of poor tissue perfusion/ischemia is the most important during this period. Correct! LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS clubfootcast care

During the morning rounds, the nurse observes that a client diagnosed with heart failure has developed sudden anxiety, diaphoresis and dyspnea. The nurse auscultates crackles bilaterally. Which nursing intervention should be performed first? Contact the health care provider Take the client's vital signs Sit the patient on the edge of the bed Administer the PRN IV morphine

c; Place the client in a sitting position with legs dangling to pool the blood in the legs. This helps to diminish venous return to the heart and minimize the pulmonary edema and helping the client breathe more easily. The next actions would be to contact the heath care provider, then take the vital signs and then administer the IV morphine. Intravenous diuretics will also be indicated to reduce the fluid volume excess. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS heart failurepulmonary edemadyspneaposition

A nurse is caring for a client who suffers from major depressive disorder. During which time does the nurse know the client would be at highest risk for a suicide attempt? Within 24 to 48 hours following an angry outburst with staff or the client's family. Within 1 to 2 days after being admitted to an unfamiliar inpatient facility. Seven to 14 days after initiation of antidepressant medication and psychotherapy When the client is removed from the security room and placed in an individual room

c; as the depression lessens, clients often have renewed energy to implement their plan of suicide. Thus, the discharge plan needs to inform the family members of what behaviors of the client to monitor for. The characteristic alert is a sudden change in the client's mood to elation or happiness that was not present before the sudden change. Correct! LESSON Psychosocial Integrity Mental Health Concepts COURSE RN Review KEYWORDS depressionsuicide

The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention? Blood pressure of 94/50 Temperature of 102 F (38.8 C) Respiratory rate of 32 Pulse rate of 98 beats per minute

c;A deep vein thrombosis (DVT) is a blood clot formed in a vein deep in the body. Typical location of a DVT is in the lower leg or thigh and causes increased swelling, redness, and pain. If left untreated, the clot can travel to the lungs and cause respiratory distress. A clot that forms in the lung is called a pulmonary embolism (PE). The clot lodges in one of the pulmonary arteries and can cause lung damage and hypoxia. The most common symptoms of a PE are sudden shortness of breath, a rapid respiratory rate, and chest pain. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS thrombosispulmonary embolismtachypneadyspneapainDVT

A 2 year-old child is being treated with amoxicillin suspension, 200 milligrams per dose, for acute otitis media. The child weighs 33 lb (15 kg) and the daily dose range is 20 to 40 mg/kg of body weight, in three divided doses every eight hours. Using principles of safe drug administration, what should a nurse do next? Recognize that antibiotics are over-prescribed Hold the medication because the dosage is too low Give the medication as ordered Call the health care provider to clarify the dose

c;Amoxicillin continues to be the drug of choice in the treatment of acute otitis media. The dose range is 20 to 40 mg/kg/day divided every eight hours; 15 kg x 40 mg = 600 mg, divided by 3 = 200 mg per dose. The prescribed dose is correct and should be given as ordered. Correct! LESSON Pharmacological (and Parenteral Therapies) Dosage Calculation COURSE RN Review KEYWORDS amoxicillinotitisdose

The nurse is caring for a client who is two days post-reconstructive nasal surgery. Which task would be most appropriate to delegate to the unlicensed assistive person (UAP)? Ask the client if the medication for pain was effective Observe for restlessness or changes in breathing patterns Remind the client to report increased pain or changes in comfort Suggest that the client ask for pain medication every few hours

c;Any activity that requires independent, specialized nursing knowledge, skill or judgement cannot be assigned to the UAP. Only the RN can assess and evaluate the client's level of pain or teach the client about pain management. However, the UAP can reinforce the nurse's teaching about pain management. Correct! LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS assignUAPsurgerytask

A client is recently diagnosed with Barrett's esophagus. Which of the following statements made by the client demonstrates that further teaching is needed about this illness? "I should avoid eating anything for two hours before I go to sleep." "I will buy a wedge pillow to raise the head of my bed." "I will cut back on my smoking to 1 pack a day." "I will need regular endoscopies to monitor this illness."

c;Barrett's esophagus is a complication of gastroesophageal reflux disease (GERD) and is associated with an increased risk for esophageal cancer. Endoscopies are used to monitor the progression of the disease and catch any cancer in its earliest stages. Treatment for Barrett's esophagus is the same as for GERD. Lifestyle changes include weight loss, avoiding acidic foods and fluids, not eating 90-120 minutes before bedtime, and sleeping with the head of the bed elevated or in a left side-lying position. Cutting back on smoking is too ambiguous. Since smoking aggravates GERD and is linked to the development of cancer, this client should be advised about smoking cessation programs. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS Barrett's esophagusGERD

The nurse is caring for a client who recently had surgery. When assisting the client with a clear liquid diet, the client begins to cough forcefully. Which action should the nurse take first? Call the client's family for more information Order a soft diet for the next meal Refer the client for a swallowing assessment Add a thickening agent to the fluids

c;If the nurse notes a client coughing forcefully after drinking or eating liquids, the first step would be to contact the health care provider and request a swallow evaluation. The first step of the nursing process is assessment and further assessment in this situation is necessary. Coughing on fluids could indicate the client is aspirating which could lead to respiratory distress or aspiration pneumonia. Thickening fluids may be required, but following the swallow evaluation from a speech therapist. Calling the client's family may be required following the swallow evaluation. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS pneumoniaaspirationcoughgag reflex

The nurse is caring for a neonate born 12 hours ago who is exhibiting a hyperactive Moro reflex and slight tremors. The previous nurse reported that the neonate's mother was using methadone during pregnancy. While developing a plan of care, which of the following actions is the nurse's priority? Hold the infant at frequent intervals Administer loperamide to stop diarrhea Assess for neonatal abstinence syndrome Offer fluids to prevent dehydration

c;Neonatal abstinence syndrome (NAS) is a cluster of findings that occur in a newborn who was exposed to opiates while in the mother's womb. Two major types of NAS is due to addictive illegal use of opiates or opiate prescription drugs, such as methadone. Symptoms of NAS depend on the type of drug the mother used, how often the drug was used, and how much. Withdrawal symptoms could include tremors, irritability, high-pitched cry, hyperactive reflexes, and/or seizures. The priority nursing action is the assess the neonate for withdrawal symptoms and notify the health care provider immediately for further orders of treatment. Correct! LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM nervous KEYWORDS newbornmethadoneMorotremormortalitywithdrawal

During the morning rounds, the nurse observes that a client diagnosed with heart failure has developed sudden anxiety, diaphoresis and dyspnea. The nurse auscultates crackles bilaterally. Which nursing intervention should be performed first? Contact the health care provider Take the client's vital signs Sit the patient on the edge of the bed Administer the PRN IV morphine

c;Place the client in a sitting position with legs dangling to pool the blood in the legs. This helps to diminish venous return to the heart and minimize the pulmonary edema and helping the client breathe more easily. The next actions would be to contact the heath care provider, then take the vital signs and then administer the IV morphine. Intravenous diuretics will also be indicated to reduce the fluid volume excess. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS heart failurepulmonary edemadyspneaposition

The nurse is assessing a client with portal hypertension. Which of the following assessment findings is consistent with the client's diagnosis? Dilated pupils Blurred vision Abdominal distension Expiratory wheezes

c;Portal hypertension can occur in a client with right-sided heart failure, cirrhosis of the liver, or cancer. Portal hypertension can lead to ascites causing increased abdominal distension, pain, and difficulty breathing due to the buildup of fluid. Fluid builds up in the peritoneal cavity due to increased portal pressure and decreased colloid osmotic pressure. Decreased osmotic pressure is due to low serum albumin which causes fluids to leave the intravascular space and leak into the interstitial space in the body. Other manifestations include gastrointestinal bleeding, encephalopathy or confusion, and reduced levels of platelets. Correct! LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS portalhypertensionassess

A nurse experiences a needle stick with a used hypodermic needle. What action should the nurse perform immediately? Notify the supervisor and risk management Look up the policy on needle sticks Wash the affected area with soap and water Contact employee health services

c;The immediate action of vigorously washing will help remove possible contamination. Then the sequence would be to notify the supervisor and risk management, look up the policy and then contact employee health services. Correct! LESSON Safety and Infection Control Accident, Error, Injury Prevention COURSE RN Review BODY SYSTEM integumentary KEYWORDS washneedlestick

The nurse is teaching child preparation classes to a group of parents. One couple asks about their rights to develop a birth plan. Which response by the nurse would be most appropriate? "Have you talked with your health care provider about this?" "What is your reason for wanting such a plan?" "Let us discuss your rights as a couple." "Write your ideal plan for the next class"

c;The most appropriate response from the nurse would be to discuss their rights as a couple. Once their question is answered, the nurse should encourage them to speak with their health care provider about their specific plan. They can be encouraged to write their plan out and share it with the nurse at their next class once they have all the information they need and input from their health care provider. A simple birth plan can help ensure the couple's wishes are known and respected by the whole team. The plan needs to be realistic and allow for the best approach in case any complications arise. Correct! LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS birthteachplanrights

The nurse is caring for a client who is receiving intravenous total parenteral nutrition (TPN). Which action by the nurse would represent appropriate care of this client? Maintain strict intake and output records Record the number of stools per day Sterile technique for dressing change at IV site Monitor for cardiac arrhythmias

c;The nurse is caring for a client who is receiving intravenous total parenteral nutrition (TPN). Which action by the nurse would represent appropriate care of this client? Maintain strict intake and output records Record the number of stools per day Sterile technique for dressing change at IV site Monitor for cardiac arrhythmias

The nurse is caring for a client with a chest tube who is one day post-op following a thoracotomy. While performing an assessment, the nurse observes bubbling in the water seal chamber when the client coughs. Which intervention should the nurse do first? Instruct the client to avoid coughing for the next day Clamp one of the chest tubes and ask the client to cough again Continue to monitor the client to see if the bubbling increases Call the surgeon immediately for potential return to surgery

c;The nurse is caring for a client with a chest tube who is one day post-op following a thoracotomy. While performing an assessment, the nurse observes bubbling in the water seal chamber when the client coughs. Which intervention should the nurse do first? Instruct the client to avoid coughing for the next day Clamp one of the chest tubes and ask the client to cough again Continue to monitor the client to see if the bubbling increases Call the surgeon immediately for potential return to surgery

A nurse is preparing to perform a physical examination on an 8-month-old child who is sitting happily on the mother's lap. Which assessment should the nurse perform first? Elicit the deep tendon reflexes Measure the height and weight Auscultate the heart and lungs Examine the mouth and ears

c;The nurse should auscultate the heart and lungs during the first quiet moment with the infant so as to be able to hear sounds clearly. Other assessments may follow in any order. Correct! LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review KEYWORDS physicalexaminationassess

A client is admitted with low T3 and T4 levels and an elevated thyroid stimulating hormone (TSH) level. On initial assessment, the nurse should anticipate which of these findings? Heat intolerance Diarrhea Lethargy Tachycardia

c;The thyroid gland produces two hormones, triiodothyronine (T3) and thyroxine (T4). These hormones help regulate metabolism, stimulate the sympathetic nervous system, regulate body temperature, heart rate, and brain development. If these levels are low, the client will suffer from an underactive thyroid gland known as hypothyroidism. With low T3 and T4, the nurse can expect the client to show symptoms of weight gain, constipation, feeling tired, having an intolerance to cold, bradycardia, and/or memory loss. If T3 and T4 are low, the pituitary gland will attempt to stimulate the thyroid by stimulating TSH, which will be elevated. Correct! LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM endocrine KEYWORDS T3T4TSHthyroidassessment

The nurse in a pediatrician's office is assessing a 4-month-old infant's motor skills. Which action by the infant should the nurse expect at this age? Banging blocks Drinking from a cup Waving good bye Grasping a rattle

d A child between the ages of 3 to 6 months should be able to reach and grab things. Grasping a toy, like a rattle, would be an expected finding. The other actions would be seen in older infants. Children between the ages of 6 to 9 months will start to be weaned from the bottle and introduced to a "sippy" cup. Children between the ages of 9 to 12 months may recognize a few familiar sounds a say and wave goodbye and play more with blocks and other toys. Incorrect LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS infantassessmentmotor skills

The nurse is planning to care for a preschool-aged child with a recent illness. Which nursing intervention would be most appropriate for the nurse to implement based on the child's developmental needs? Allow the child to make realistic goals Allow the child to explore the playroom Encourage the use of imaginary play Encourage the opportunity to make choices

d A preschool-aged child's age ranges from 3 years to 5 years. During these years, Erikson's stage of development puts them in the initiative versus guilt stage. Within this stage, the nurse should allow the child an opportunity to make their own choices and act upon those choices. This will allow the child to have increased initiative and learn to make decisions for themselves. If they make the wrong decision they will feel guilty and will need further guidance. Allowing the child to make realistic goals does not occur until ages 6 to 11 while in the industry versus inferiority stage. Imaginary play and having the child explore the playroom is at a much younger stage, autonomy versus self-doubt, and the child should have resolved that stage. Correct! LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS preschooldevelopmentalneedbehaviorconcernErickson

The nurse is caring for a client who has a prescription for an insulin sliding scale to manage the client's hyperglycemia. At 11 am, the client's blood glucose level was 285 mg/dL. According to the following sliding scale parameters, how many units of insulin should the nurse administer? For glucose less than 140, give 0 units of insulin aspart. For glucose between 140 to 180, give 2 units of insulin aspart. For glucose between 181 to 220, give 4 units of insulin aspart. For glucose between 221 to 260, give 6 units of insulin aspart. For glucose between 261 to 300, give 8 units of insulin aspart. For glucose greater than 300, notify the health care provider. 2 units 4 units 6 units 8 units

d According to the prescribed sliding scale, for a blood glucose level of 285 mg/dL, the nurse should administer 8 units of insulin aspart. Incorrect LESSON Safety and Infection Control Accident, Error, Injury Prevention COURSE RN Review BODY SYSTEM endocrine KEYWORDS insulinsliding scaleblood glucose CONFIDENCE

The nurse is providing care to a client who is receiving oxygen therapy via nasal cannula. During the provision of care, which nursing intervention would be most appropriate? Maintain sterile technique when handling the tubing Lubricate the tips of the cannula before insertion in the nose Determine that adequate mist is supplied Inspect the nares and areas around the ears for skin breakdown

d Oxygen therapy by nasal cannula can cause drying of the nasal mucosa. Pressure from the plastic tubing can cause skin irritation inside the nares or around the tops of the ears (padding is available, which helps, but does not eliminate, the problem around the ears). Nasal cannula tips for the administration of oxygen should be cleaned regularly and should never be lubricated with petroleum jelly. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM respiratory KEYWORDS nasal cannulaearsnaresoxygen

The nurse is planning care for a 3-month-old infant who needs a cleft lip and soft palate repair. During the immediate postoperative phase, the nurse should give priority to which intervention? Position the infant on the side or back and assess the skin. Initiate clear liquid feedings by bottle when alert and acting hungry. Provide the infant's family with instructions about care of the sutures. Remove the soft elbow/arm restraints every 2 hours and assess the infant.

d The priority intervention after surgery is to protect the new repair and stitches, by applying soft elbow and arm restraints. These restraints are used to prevent the infant from putting their hands in their mouth risking injury to the suture line. The nurse should also be assessing for circulation, movement, and sensation every two hours. When the infant acts hungry, they will be given a clear liquid feeding using either a syringe fitted with a special soft tubing or a special cleft lip feeder. The infant should be repositioned on their side and back to prevent skin breakdown; however, another choice is higher priority. Before the infant is dismissed, the nurse will want to provide education to the family regarding the care of the sutures and need to wear the soft restraints for the first 10 days after the surgery. Incorrect LESSON Safety and Infection Control Use of Restraints, Safety Devices COURSE RN & PN Review BODY SYSTEM integumentary KEYWORDS cleft liprepairrestraint

The nurse is assessing a client in early labor. While positioning the client to perform a vaginal exam, the client reports feeling dizzy and nauseous. The client appears pale and has low blood pressure. Which action should the nurse take initially? Encourage deep breathing Elevate the foot of the bed Call the health care provider Turn her to her left side

d While in the supine position, the weight of the uterus can put pressure on the vena cava and aorta. The client is experiencing symptoms of hypotension and dizziness due to constriction of blood flow. To relieve the pressure on the vena cava and aorta, the nurse should initially turn the client to the left side to reduce pressure and relieve postural hypotension. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN & PN Review BODY SYSTEM reproductive KEYWORDS laborvaginalexamnauseaturnside

A nurse is caring for a child diagnosed with Reye's syndrome. Which action should be given the highest priority by the nurse? Monitor intake and output Assist with range of motion Provide good skin care Assess level of consciousness

d Reye's syndrome is a rare disorder that causes liver and brain damage. This syndrome may happen at any age; however, it is more prevalent with children. Reye's syndrome occurs after a child has had a recent viral infection, like the flu or chickenpox. Signs and symptoms may include confusion, seizures, and loss of consciousness that would require emergency treatment. The highest priority for the nurse would be to assess the child's level of consciousness. The other interventions may occur after if there are no complications. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM lymphatic KEYWORDS Reye'svaricellachildlevel of consciousness

A client diagnosed with bipolar disorder is prescribed lithium. Which intervention would be essential for the nurse to emphasize when teaching the client about this medication? Reduce fluid intake to minimize diuresis Use antacids to prevent heartburn Take the medication before meals Maintain adequate daily salt intake (1 attempt remaining)

d Lithium levels need to be regularly monitored. Clients should be advised to drink 8 to 10 glasses of water or other liquids every day and keep their salt intake the same because too little salt may cause lithium levels to rise (and more salt may cause lithium levels to fall). Lithium is a naturally occurring mineral with an electrical charge similar to salt. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM nervous KEYWORDS bipolarlithiumLithanesaltteach

The nurse is reviewing the medical record of an older adult client with a history of constipation, heart failure, renal insufficiency and dehydration. Which medication should the nurse clarify with the client's health care provider? Fiber supplement daily Stool softener daily Glycerine suppository as needed Osmotic laxative as needed

d Osmotic laxatives consist of laxative salts (e.g., sodium phosphate, magnesium hydroxide) that are poorly absorbed salts whose osmotic action draws water into the intestinal tract. Accumulation of water causes the fecal mass to soften and swell, thereby stretching the intestinal wall, which stimulates peristalsis. Osmotic laxatives can cause a substantial loss of water, increasing the risk for dehydration. In clients with renal impairment, osmotic laxative made with magnesium can accumulate to toxic levels. Therefore, magnesium salts are contraindicated in clients with renal insufficiency. Sodium-based osmotic laxatives can cause acute kidney injury and fluid retention, thus exacerbating heart failure. Incorrect LESSON Basic Care and Comfort Elimination COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS constipationosmotic laxative

The nurse is caring for a client diagnosed with bulimia nervosa. Which finding is consistent with the client's diagnosis? Aspiration pneumonia, dysphagia Bacterial gastric infections, spastic colon Metabolic acidosis, ulcerative colitis Tooth decay, enlarged parotid glands

d; Dental erosion and parotid gland enlargement occur as a result of the purging. These are common complications of binge eating followed by self-induced vomiting. Often these clients will have a callous on one of the fingers on either hand. This is from the use of the finger to gag self until emesis occurs. Incorrect LESSON Psychosocial Integrity Mental Health Concepts COURSE RN Review KEYWORDS bulimiadental erosionparotidgag

A client diagnosed with gouty arthritis is admitted with severe pain and cellulitis of the right foot. Which intervention would be essential for the nurse to include in the client's plan of care? High protein diet of beef Hot compresses to affected joints Active range of motion exercises Fluid intake of at least 3000 mL/day

d; Fluid intake should be increased to prevent precipitation of urate in the kidneys; a lack of sufficient fluids enhances the formation of urate renal calculi or kidney stones. Treatment for acute attacks include supportive measures, such as applying ice and resting the affected joint. The client should avoid eating foods high in purines, such as organ meats (liver), and limit eating beef, pork and lamb. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS goutpain

The nurse is caring for a 16-year-old client who had surgical repair of a fractured femur 14 hours ago. Assessment findings include tachycardia, increased shortness of breath, a temperature of 100.2 F (37.8 C), feelings of anxiety, and an oxygen saturation level of 88%. The nurse immediately notifies the health care provider, recognizing that the client is at risk for which complication? Compartment syndrome Atelectasis Sepsis Fat embolism

d; Since the client recently had an orthopedic surgery, these symptoms are cardinal signs of fat embolism. A fat embolism is a piece of intravascular fat that lodges within a blood vessel and causes obstruction of blood flow. While fat emboli can generally resolve on their own, this complication can lead to fat embolism syndrome which can cause inflammation, multi-organ failure, and neurological changes that may be fatal. Early-onset of sepsis wouldn't appear until at least day 2 or 3, not within 14 hours of the procedure. Compartment syndrome does not cause increased shortness of breath or anxiety. Atelectasis occurs when ventilation is decreased and secretions accumulate. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS fracturefemursurgerytachycardiashortness of breathembolismpediatric

The licensed practical nurse (LPN) from the pediatric unit is reassigned to work on an adult ortho-neuro unit. Which client assignment would be most appropriate for this nurse? The client who experienced a stroke and is ready to be transferred to a long term care facility The client with a newly applied long leg cast experiencing uncontrolled pain The client who is one day post total knee arthroplasty experiencing shortness of breath The client in balanced traction admitted three days ago after a motor vehicle accident

d; The licensed registered nurse (RN) can assign clients to the LPN as long as the care required is not too complex and there is a low likelihood of an emergency. The most stable client is the client in balanced traction who was admitted three days ago. The client experiencing shortness of breath and uncontrolled pain are unstable and need further assessment by the RN. Admitting or discharging a client is a complex process and requires the knowledge and skills of the RN. Correct! LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS LPNstablereassign

A client scheduled for surgery with general anesthesia refuses to remove their dentures prior to leaving the unit for the operative room. What would be the most appropriate nursing action? Ask the client why they are refusing to take their dentures out prior to the procedure Explain to the client that the dentures must come out as they may get lost or broken in the operating room Notify the operating room nurse and the anesthesia department of the client's refusal Ask the client if they would prefer to remove their dentures in the perioperative area (1 attempt remaining)

d; To foster a professional relationship with the client, the nurse should inquire about personal preferences. Clients anticipating surgery may experience a variety of fears. Allowing the client a choice and a sense of control over the situation fosters the client's self-esteem and self-concept. Correct! LESSON Psychosocial Integrity Therapeutic Environment COURSE RN Review KEYWORDS surgerydenturesanestheticfear

The nurse is caring for a newborn with hyperbilirubinemia who is being treated with a biliblanket for phototherapy. Which intervention is most appropriate during this type of therapy? Restrict holding the newborn during treatment Discontinue breastfeeding during treatment Rotate the neonate to treat all of his/her skin Provide frequent feedings of breast milk or formula

d;A biliblanket consists of a fiber-optic pad and a portable illuminator. This form of phototherapy allows the baby to be diapered, clothed, held, and nursed during treatment. Frequent feedings of breast milk or formula are necessary to help with bowel motility, which, in turn, will increase excretion of bilirubin from the body. Discontinuing breastfeeding will disrupt the establishment of milk production. It is not necessary to rotate the baby during treatment. Correct! LESSON Physiological Adaptation Alternations in Body Systems COURSE RN & PN Review BODY SYSTEM integumentary KEYWORDS fiberoptichyperbilirubinemianeonate

The nurse is caring for an obese client who says, "I just started a diet and I am eating no more than 800 calories a day." Which of the following information should the nurse reinforce with the client? Very low-calorie diets often have severe and irreversible side effects Very low-calorie diets are adequate if balanced with fruits and vegetables Very low-calorie diets are appropriate for long-term weight management Very low-calorie diets are intended for short-term use only

d;A very low-calorie diet (VLCD), less than 1,000 calories a day, is a short-term weight loss method for obese people (BMI greater than 30) and can result in a loss of about 3 to 5 pounds (1.36-2.72 kg) per week. Anyone considering this type of diet should be under the care and supervision of a health care provider (HCP). VLCDs are generally considered safe and common side effects, such as fatigue, constipation or diarrhea, are usually minor and improve within a few weeks. The best way to maintain weight loss though, is through a combination of behavioral therapy, exercise and more modest caloric restrictions of around 1,200 calories per day. Every diet should contain fruits and vegetables, but those foods are low in calories and would not make a VLCD more balanced. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN & PN Review KEYWORDS obesityweight loss

The nurse is caring for a 68-year-old male client who had a transurethral resection of the prostate (TURP) 12 hours ago. The client has an indwelling 3-way catheter with continuous bladder irrigation. Which finding requires the nurse's immediate intervention? Occasional suprapubic cramping about every hour Reports of a feeling of discomfort from the urinary catheter Light-pink urine with a continuous stream into the collection bag Minimal drainage into the urinary collection bag

d;All of the options, except the lack of drainage into the collection bag, are expected findings after this procedure. Urine will be bright red from bleeding immediately after the procedure, lightening over time as bleeding decreases. A lack of drainage needs to be reported immediately because minimal urinary drainage puts the client at risk for bladder rupture. The cause of this is likely to be a blood clot in the catheter or obstructing the catheter tip, which requires sterile irrigation of the catheter to restore its patency. The flow rate of the continuous irrigation would need to be slowed until urine flow has been restored. In some facilities, an order for syringe bladder irrigation as needed is a standing order accompanying the orders for continuous bladder irrigation. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM urinary KEYWORDS catheterbladderirrigationTURPprostatehematuriageriatric

The nurse is speaking with the parents of a 2-year-old child who was just diagnosed with cystic fibrosis. Which recommendation by the nurse is best? Restrict activities to inside the house Schedule frequent rest periods Limit exposure to other children Allow the child to continue normal activities

d;Although cystic fibrosis causes severe damage to the lungs, physical activity remains important for the child's emotional development as well as disease management. A 2-year-old is developing autonomy and remaining active will support chest physical therapy. Exercise tends to mobilize mucus and help with expectoration. Therefore, the best recommendation is to allow the child to continue their normal activities. The other recommendations are not appropriate or necessary for this child. Incorrect LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN Review BODY SYSTEM respiratory KEYWORDS cystic fibrosis

A nurse is caring for an 83-year-old client diagnosed with Parkinson's disease. Which findings should the nurse anticipate? Muscle spasm and a bent over posture Voluntary tremor and jerky movement of the elbows Nonintention tremors and urgency with voiding Muscle rigidity and a shuffling gait

d;Clients with Parkinson's disease have a very distinctive gait with quick short steps (shuffling) that may increase in speed so that they are unable to stop, as well as muscle rigidity. In the other options, only one of the two findings listed is associated with Parkinson's disease: clients may have nonintention tremors, but there is no urgency with voiding; their posture may be "bent over," but there are no muscle spasms; and while they may experience a cogwheel or jerky movement of the elbows, their tremors are not voluntary. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM nervous KEYWORDS Parkinson'sgaitassessgeriatric

The nurse is caring for a client who has been taking furosemide for the past week. Which manifestation would indicate that the client may be experiencing a negative side effect? Edema of the ankles Weight gain of five pounds Gastric irritability Decreased appetite

d;Furosemide (Lasix) causes a loss of potassium if a supplement is not taken. Findings of hypokalemia include anorexia, fatigue, nausea, decreased gastrointestinal motility, muscle weakness and dysrhythmias. Correct! LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS Lasixfurosemidepotassium

While caring for a postpartum client during the first hour after a noncomplicated vaginal delivery, the nurse determines that the uterus is boggy and there is a moderate amount of vaginal bleeding. Which action should the nurse take first? Document the findings Provide perineal care Check for any abnormal vital signs Massage the fundus until firm (1 attempt remaining)

d;Massage the fundus until firm Correct Response A boggy uterus means that the uterine muscle is not contracting firmly and more flaccid than desired. This is also referred to as "uterine atony." A flaccid uterus can lead to prolonged bleeding and hemorrhage; therefore, the first action of the nurse should be to massage the fundus to promote good uterine tone and prevent postpartum hemorrhage. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS deliveryuterusboggybleeding

The medical-surgical nurse is developing a plan of care for a client with sickle cell disease who was admitted for an acute sickle cell crisis. Which intervention is the priority? Increase fluid intake to 3 to 4 liters a day Encourage increased caloric intake Ambulate in hallway four times a day Administer prescribed analgesics

d;Sickle cell crisis is pain that begins suddenly and may last several hours or even days. This crisis beings when sickled red blood cells block small blood vessels that carry blood to a person's bones. This can cause a person to have severe pain in their back, knees, legs, arms, and chest. The pain can be described as throbbing, sharp, dull, or stabbing. Although all of interventions are appropriate for the client in sickle cell crisis, the priority intervention is effective pain management and administering prescribed analgesics. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS sickle cell diseasesickle cell crisispain management

The nurse is caring for a 19-year-old client who was paralyzed from a car accident. Which statement indicates that the client is using the mechanism of "suppression"? "I'd rather not talk about it right now." "My mother is heartbroken about this." "It was the other drivers fault! They were going too fast!" "I don't remember what happened to me."

d;Suppression is willfully putting an unacceptable thought or feeling out of one's mind. A deliberate exclusion, "voluntary forgetting," is generally used to protect one's own self-esteem. Correct! LESSON Psychosocial Integrity Coping Mechanisms COURSE RN Review BODY SYSTEM nervous KEYWORDS egodefense mechanismsuppression

The pediatric emergency room nurse is triaging several children. Which of the following children is at highest risk for an adverse respiratory event? A child with a congenital heart defect A child with an acute febrile illness A child with a fractured leg A child found submerged under water

d;The child who was found submerged under water is at highest risk for an adverse respiratory event such as acute respiratory failure and respiratory arrest due to the likely aspiration of water into the lungs. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS cardiac arrestchildhypoxemiamanagement

The health care provider orders blood tests for a client diagnosed with acute hepatitis B (HBV). Which lab finding should the nurse anticipate to be elevated? WBC (white blood cells) BUN (blood urea nitrogen) Albumin ALT (alanine aminotransferase)

d;The health care provider orders blood tests for a client diagnosed with acute hepatitis B (HBV). Which lab finding should the nurse anticipate to be elevated? WBC (white blood cells) BUN (blood urea nitrogen) Albumin ALT (alanine aminotransferase)

The nurse is caring for a 68-year-old client who had a total hip replacement three days ago. Which client statement requires the nurse's immediate attention? "I have bad muscle spasms in my lower leg, below the incision." "It seems that the pain medication is not working as well today." "I have to use the bedpan to pass my water at least every hour." "I seem to have trouble breathing when I am resting in bed."

d;The nurse would be concerned about all of these comments, however the most life threatening is the respiratory focus (think ABCs). Clients who have had hip or knee surgery are at risk for developing pulmonary embolism. Sudden dyspnea, tachycardia and a feeling of impending doom are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Frequent urination may indicate a urinary tract infection, particularly since the client likely had an indwelling urinary catheter during surgery. Although the thought that medication is not effective requires further investigation, it is not life-threatening. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN & PN Review BODY SYSTEM respiratory KEYWORDS hipreplacementpulmonary embolismsurgerygeriatric

The parents of a 3-year-old ask the nurse about preventing injuries. What is one of the most effective methods caregivers can use to teach young children about injury prevention? Make sure the child understands safety rules Protect the child from outside influences Ensure the child wears protective devices Encourage the parents to set good examples

d;The preschool years (3 to 6 years) are the time for caregivers to begin emphasizing safety principles as well as providing protection. Parents should provide examples of safe behavior because preschoolers often imitate behaviors in others and they are quick to notice discrepancies between what they see and what they are told to do. Preschoolers are in the "preoperational" stage (Piaget) and their logic is ruled by perception, not reasoning. Incorrect LESSON Safety and Infection Control Accident, Error, Injury Prevention COURSE RN Review KEYWORDS toddlerparentcaregiverinjuryprevention

The nurse is caring for a client admitted with a diagnosis of myocardial infarction (MI). Which lab finding is most consistent with the client's diagnosis? Elevated myoglobin Elevated proBNP Elevated creatine kinase Elevated troponin

d;ll of these lab tests may be elevated during an MI. Although CK-MB (along with total CK) is a very good test, it has been replaced by troponin. Elevation of troponin is the most reliable because it is more specific to heart damage; it elevates within a few hours and remains elevated for about 10 days. CK-MB is one of three separate forms (isoenzymes) of the enzyme creatine kinase (CK); it is found mostly in heart muscle and rises when there is damage to the heart. An elevated C-reactive protein is associated with a risk of cardiovascular disease. Correct! LESSON Reduction of Risk Potential Laboratory Values COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS labmyocardial infarctionMI

The nurse in a pediatric intensive care unit is developing a plan of care for a 2-year-old child scheduled for surgery to correct a congenital heart defect. Which nursing outcome is the priority following the surgery? Effective pain management Maintenance of adequate cardiac output Reduction of separation anxiety and emotional distress Prevention of respiratory complications

dPrevention of respiratory complications Correct Response The nurse should use the airway-breathing-circulation (ABC) strategy to prioritize nursing goals, interventions and outcomes; therefore, preventing respiratory complications is the priority. Areas of atelectasis are common after surgery as a result of deflation of the lung during cardiopulmonary bypass. Other pulmonary complications include pneumothorax, pulmonary edema and pleural effusion. Frequent assessments of the child's respiratory status should be performed and include auscultation, respiratory rate and effort, oxygen saturation, and skin color. Incorrect LESSON Reduction of Risk Potential System Specific Assessments - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS congenital heart defectpostoperative careprioritization

The nurse is caring for a client diagnosed with an aspirin overdose who is in respiratory alkalosis. Which finding was most likely the cause of this imbalance? Vomiting Hyperpyrexia Hypokalemia Tachypnea

dThe client is suffering from salicylate poisoning due to the over-consumption of aspirin. Classic symptoms of salicylate poisoning are ringing in the ears, nausea, abdominal pain, and fast breathing rate. The fast breathing rate, or tachypnea, is causing the client to hyperventilate which is decreasing carbon dioxide (CO2) levels as the client blows out air. This will eventually progress to hypoventilation and respiratory failure. Respiratory alkalosis is characterized by a higher ph, low PaCO2, and normal bicarbonate (HCO3). Incorrect LESSON Physiological Adaptation Fluid and Electrolyte Imbalances COURSE RN Review BODY SYSTEM respiratory KEYWORDS adolescentrespiratory alkalosisaspirinoverdosetoxicitypharmacology

The public health nurse is teaching parents about injury and accident prevention in children younger than 4 years old. Which interventions should the nurse include? Select all that apply. Store medications where the child cannot reach them Make sure the child is up-to-date on all required immunizations Never leave the child unattended around a pool or body of water Always have the child sitting in an approved car safety seat when driving Store any firearms in a locked container with the ammunition removed Monitor the child for signs of substance use such as alcohol or smoking

eveyrthing eccept b and f Injuries are the most common cause of death and disability to children in the United States. The child's developmental stage partially determines the types of injuries that are most likely to occur at a specific age and helps provide clues to preventive measures. Drowning and burns are among the top three leading causes of deaths for males and females throughout childhood. In addition, improper use of firearms is a major cause of death among males. Every year, approximately 95% of medication-related ED visits in children younger than 5 years are due to ingesting medication while unsupervised. Motor vehicle injuries are the leading cause of death in children older than 1 year of age. The majority of fatalities involve occupants who are unrestrained. Incorrect LESSON Safety and Infection Control Accident, Error, Injury Prevention COURSE RN Review KEYWORDS injury preventionchildren