Testing and Remediation
A nurse is assisting with admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorazepam (Ativan) preoperatively. Which of the following statements by the client indicates the medication has been effective?
"I feel very relaxed" is correct. Lorazepam is a benzodiazepine and is frequently given preoperatively to relieve anxiety. This statement by the client indicates the medication has been effective "My mouth is very dry" is incorrect. Lorazepam is a benzodiazepine and is not used to reduce secretions. Medications classified as an anticholinergic are used to reduce secretions. This statement by the client does not indicate the medication has been effective. "I am wide awake now" is incorrect. Lorazepam is a benzodiazepine and does not cause the client to become more awake. Instead, lorazepam's effect on the CNS can cause drowsiness. "My heart is racing" is incorrect. Lorazepam is a benzodiazepine and does not cause tachycardia. To prevent bradycardia during surgical procedures, medications classified as anticholinergics are often administered.
A nurse is reinforcing teaching to a client who was recently prescribed a 2000 mg sodium restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching?
1/2 cup of white rice is incorrect. Sodium-restricted diets are frequently prescribed to clients to treat hypertension and weight loss. A 1/2 cup of white rice contains approximately 5 mg of sodium; therefore, this food selection is appropriate for the client who is prescribed a 2,000 mg sodium-restricted diet. 1 slice of wheat bread is incorrect. Sodium-restricted diets are frequently prescribed to clients to treat hypertension and weight loss. A slice of wheat bread has approximately 148 mg of sodium; therefore, this food selection is appropriate for the client who is prescribed a 2,000 mg sodium-restricted diet. 1 cup of 2% milk is incorrect. Sodium-restricted diets are frequently prescribed to clients to treat hypertension and weight loss. A cup of 2% milk has approximately 120 mg of sodium; therefore, this beverage selection is appropriate for the client who is prescribed a 2,000 mg sodium-restricted diet. 3/4 cup of canned tomato juice is correct. Sodium-restricted diets are frequently prescribed to clients to treat hypertension and weight loss. This beverage selection has approximately 820 mg of sodium; therefore, this food selection is not appropriate for the client who is prescribed a 2,000 mg sodium-restricted diet. This selection indicates that further teaching is required by the nurse.
A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following appropriate to include in the client's diet? (Select all that apply)
Cooked oatmeal is incorrect. A full liquid diet is comprised of liquids and foods that turn to liquid at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Cooked oatmeal is appropriate for a soft diet, but should not be included in a full liquid diet. Grape juice is correct. Grape juice is appropriate to include in both a clear liquid and a full liquid diet. Applesauce is incorrect. It is appropriate for a soft diet, but should not be included in a full liquid diet. Ice cream is correct. Smooth peanut butter is incorrect. It does not turn liquid at room temperature.
A nurse is preparing to transfer a client from the bed to a chair. The nurse should take which of the following actions to prevent a lift injury?
Lock knees is incorrect. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should flex the knees instead of locking them. Flexing the knees increases the stability of the nurse. Stand close to the client is correct. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should stand close to the client. Standing close to the client decreases reaching for the client and reduces stress on the nurse's back. Move client by twisting at the waist is incorrect. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should keep the back, neck, pelvis, and feet in alignment instead of twisting at the waist. Maintaining proper body alignment reduces risk of injury to the lumbar vertebrae. Keep feet close together is incorrect. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should stand with the feet wide apart instead of close together. Standing with the feet wide apart provides a wide base of support, which improves stability.
A nurse is providers office is caring for a client who has depression and is taking St John Wort. The herbal supplement is thought to improve which of the following?
Mood is correct. St. John's Wort is widely used in the U.S. and other countries as an herbal supplement for treating mild to moderate depression and to relieve depression-related anxiety. Immunity is incorrect. Echinacea, not St. John's Wort, is sometimes taken to reduce the manifestations and duration of colds and flu-like illnesses. The expected effect of St. John's wort is not to improve immunity. Memory is incorrect. Ginkgo biloba, not St. John's Wort, is sometimes taken to increase cognitive functions in older adults and to delay the progression of Alzheimer's disease; however, its efficacy has not been established. The expected effect of St. John's wort is not to improve memory. Vitality is incorrect. Ginseng, not St. John's Wort, is sometimes taken to improve overall energy and vitality, particularly during times of fatigue or stress. The expected effect of St. John's Wort is not to improve vitality.
A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer?
Partial thickness skin loss is correct. Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage II pressure ulcer involves partial thickness skin loss and typically presents as an abrasion or blister. Visible subcutaneous fat is incorrect. Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage III pressure ulcer involves full-thickness skin loss and can have visible subcutaneous fat. Nonblanchable redness is incorrect. Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage I pressure ulcer involves intact skin with a localized area of nonblanching redness. Exposed muscle is incorrect. Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage IV pressure ulcer involves full-thickness tissue loss and exposed bone, tendon, or muscle. Slough or eschar can also be present.
A nurse on a rehabilitation unit is caring for a client who was admitted 3 days ago. Upon review of the client's medical record, which of the following actions should the nurse take? Click on the exhibit button for additional client information. Serum Labs Hemoglobin 15.4 g/dl Protein 7.2 g/dl BUN 8 mg/dl Glucose 72 mg/dl Physical Assessment 2+ peripheral edema BP 144/96 mm Hg Increased urinary output Respiratory Crackles b/l Health history Total hip arthoplasty 10 days ago 15 years Hx of DM 32 year history of heart failure
Restrict fluid intake is correct. Manifestations of fluid volume excess are indicated in the client's physical assessment findings of 2+ peripheral edema, elevated blood pressure, respiratory crackles bilaterally, and a BUN level that is below the expected reference range; therefore, it is appropriate for the nurse to restrict the client's fluid intake. Administer 4 oz of orange juice is incorrect. The client's glucose level is within the expected reference range; therefore, administering 4 oz of orange juice is not an appropriate action by the nurse. Request prescription for iron supplement is incorrect. The client's hemoglobin level is within the expected reference range; therefore, requesting a prescription for an iron supplement is not an appropriate action by the nurse. Encourage bed rest is incorrect. This client had total hip arthroplasty 10 days ago. To prevent a venous thrombus from developing, the client should begin ambulating in the early postoperative period, and leg exercises should begin in the immediate postoperative period; therefore, encouraging bed rest is not an appropriate action by the nurse.
A nurse in a provider office is reinforcing teaching to the parents of a child who has allergies and is prescribed diphenhydramine (Benadryl) 25 mg every 6 hours as needed. Available is diphenhydramine 12.5 mg/5mL syrup. How many teaspoons of diphenhydramine does the nurse instruct the parents to administer per dose?
STEP 1: What is the dose needed? Dose needed = Desired; 25 mg STEP 2: What is the dose available? Dose available = Have; 12.5 mg STEP 3: Do the units of measurement need to be converted? No (mg = mg) STEP 4: What is the quantity of the dose available? 5 mL STEP 5: Set up an equation and solve: Desired x Quantity / Have = Amount to be given; 25 mg x 5 mL / 12.5 = x mL; 25 x 5 / 12.5 = 125 ÷ 12.5 = 10 mL. Convert to tsp: Equivalents: 1 tsp = 5 mL; 5 mL / 1 tsp = 10 mL / x; 5x = 10; x = 2 tsp. STEP 6: Reassess to determine if the amount to be given makes sense. If there are 12.5 mg/mL and the prescribed amount is 25 mg, it makes sense to give 10 mL, which equals 2 tsp. The nurse should teach the parents to administer diphenhydramine 2 tsp per dose.
A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse preform first?
So, the question is asking which of the techniques the nurse should perform first when examining the abdomen. This is a positively worded, multiple choice item. The key word "first" in the question indicates this is a priority setting item, which means all four options are correct, but one takes priority over the others. In this item, all four techniques are performed when examining the abdomen, but one of the techniques should be performed before the others. Next you should review each option and determined which to perform first. Inspection is correct. Inspection should be performed first while conducting an abdominal assessment on a client. Inspection allows the nurse to note the contour and symmetry of the abdomen. Auscultation is incorrect. Auscultation should be the second technique used while conducting an abdominal assessment on a client to determine the frequency and intensity of bowel sounds. Normal bowel sounds occur 5 to 35 times per min. Auscultation also detects vascular sounds or bruits. Percussion is incorrect. Percussion is the third technique used while conducting an abdominal assessment on a client to discern the presence of tympany and dullness. It is performed to evaluate for the presence of gas in the intestines or fluid and masses in the abdominal cavity. Palpation is incorrect. Palpation should be the fourth technique used during examination of the abdomen to identify abdominal tenderness, masses, or distention. Both light and deep palpation techniques should be performed to identify unexpected masses or organ size outside the expected parameters.
A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. The nurse should include the disease is transmitted in which of the following ways?
Vector is correct. Vectors are arthropods, which carry and transmit certain illnesses. Examples of illnesses transmitted by vectors include malaria, which is transmitted by mosquitos, and Rocky Mountain spotted fever, which is transmitted by ticks. Lyme disease is transmitted by ixodid, or deer ticks, which is a vector. Airborne is incorrect. Airborne illnesses are transmitted through residue or evaporated particles that are suspended in the air. Examples of airborne illnesses include varicella zoster, measles, and mycobacterium tuberculosis. Lyme disease is not transmitted in this manner. Vehicle is incorrect. Vehicles include inanimate objects, such as contaminated items, water, and food. Illnesses that can be transmitted by a vehicle include MRSA, pseudomonas, salmonella, E. coli, and syphilis. Lyme disease is not transmitted in this manner. Bloodborne is incorrect. Bloodborne illnesses are transmitted through contact with infected blood. Examples of bloodborne illnesses include HIV, hepatitis B, and hepatitis C. Lyme disease is not transmitted in this manner.
A nurse is preparing to measure the blood pressure of a client who has HTN. Which of the following actions by the nurse when taking the BP can result in an accurately low reading?
Wrapping the cuff loosely around the arm is incorrect. Wrapping the cuff too loosely around the arm can result in a false high blood pressure reading. Using a cuff that is too wide is correct. Using a cuff that is too wide can result in a false low blood pressure reading. Leaving client's arm unsupported is incorrect. Leaving the arm unsupported can result in a false high blood pressure reading. Taking client's blood pressure immediately after client sits down is incorrect. This action can result in a false high blood pressure reading.
A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should be elicited over areas of consolidation during percussion?
Dullness is correct. Percussion over dense tissue or a fluid-filled body cavity produces a thud-like sound, which is described as dullness. This is the sound that will be elicited during percussion over areas of consolidation. Hyper-resonance is incorrect. Percussion over emphysematous lungs produces a booming sound, which is described as hyper-resonance. This is not the sound that will be elicited during percussion over areas of consolidation. Resonance is incorrect. Percussion over healthy lung tissue produces a hollow sound, which is described as resonance. This is not the sound that will be elicited during percussion over areas of consolidation. Tympany is incorrect. Percussion over an air-filled stomach produces a drum-like sound, which is described as tympany. This is not the sound that will be elicited during percussion over areas of consolidation
A nurse is caring for a client who is receiving Vancomycin (Vancocin) for a beta-hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor?
Hearing loss is correct. Ototoxicity, an auditory nerve injury, is the most serious adverse effect of vancomycin and can result in hearing loss. The nurse should monitor for this adverse effect. Hypertension is incorrect. Hypotension, not hypertension, is an adverse effect of vancomycin. Bradycardia is incorrect. Tachycardia, not bradycardia, is an adverse effect of vancomycin. Respiratory depression is incorrect. Difficulty breathing and wheezing, not respiratory depression, are adverse effects of vancomycin.
A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client?
Sims' is correct. The left side-lying, or Sims' position, places the client on the side with the knee flexed. This position allows the enema to flow along the curve of the sigmoid colon and rectum naturally, which improves retention of the solution. Prone is incorrect. The prone position places the client on the abdomen and is only used to determine extension of the hip joint, and examining skin and the buttocks. The client should not be placed in this position to administer an enema. Dorsal recumbent is incorrect. The dorsal recumbent position places the client prone with knees flexed. This position allows for relaxation of the abdominal muscles and facilitates assessment of the abdomen. The client should not be placed in this position to administer an enema. Lithotomy is incorrect. The lithotomy position facilitates insertion of a vaginal speculum to examine the female genitalia and genital tract. The client should not be placed in this position to administer an enema.
A nurse on a pediatric unit is caring for an infant who is diagnosed with laryngotracheobronchitis. While preforming a respiratory examination, the nurse hears the sound in the provided audio clip. Based on this finding, the nurse should conclude the client is exhibiting which of the following breath sounds?
So, the question is asking which of the manifestations the nurse hears when performing a respiratory assessment. This is an audio format item, which means you have to listen to the provided audio to determine the correct answer. There are four options; one which is correct, called the key, and three that are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Stridor is correct. Stridor is a harsh high-pitched sound heard on inhalation or expiration. It is caused by turbulent air flow secondary to a narrowing or blockage in the upper airway and is a common clinical manifestation of acute laryngotracheobronchitis. The breath sound on the audio clip is an example of stridor. Crackles is incorrect. Crackles are abnormal breath sounds that result from air passing through fluid. Rhonchi are course rattling sounds that are similar to snoring. Wheezes are abnormal breath sounds that are produced because of a narrowing passageway.
A nurse is preparing to administer an IM injection to an adult client who has BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle?
So, the question is asking which of the needle lengths is appropriate for administering an injection in the ventrogluteal muscle. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. 1 1/2 inch is correct. A 1 1/2 inch needle is used for IM injections in adults. This length of needle is appropriate to use when administering an IM injection in the ventrogluteal muscle, which is a site commonly used for IM injections, in adults who have a BMI of 30. 1 inch is incorrect. A 1 inch needle is used for IM injections in adults who have a low BMI; it would be inappropriate to use a needle of this length for an adult with a BMI of 30. 5/8 inch is incorrect. A 5/8 inch needle is used for subcutaneous injections in adults; it is inappropriate to use for an IM injection. 1/2 inch is incorrect. A 1/2 inch needle is used for subcutaneous injections in adults; it is inappropriate to use for an IM injection.
A nurse is caring for a client who is scheduled for biopsy of a tumor located in the left lower lobe of the lung. The client states, "I will quit smoking if the results don't come back positive for cancer." This statement indicates the client is in which of the following?
So, the question is asking which of the stages of grief is client is in. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Bargaining is correct. Denial, anger, bargaining, and acceptance are all stages of the dying and grief process. The statement made by the client is an example of bargaining. Clients or families might promise to improve or change habits as a part of the grieving process.
A nurse is examining a client's lymphatic system. Identify the site the nurse should palpate to assess the posterior cervical lymph nodes.
This area, known as the posterior cervical, is correct. While facing the client, the nurse should use the pads of the middle three fingers to gently palpate the nodes in a circular motion and evaluate each for consistency, characteristics, mobility, warmth, and tenderness. This is the location of the posterior cervical lymph nodes, which are a group of lymph nodes located on the sides of the neck.
A nurse is preparing to auscultate a client's heart. Which of the following positions is best for detecting a low pitched diastolic murmur?
This is the incorrect position. This image represents the supine position, which is appropriate for determining cardiac function at the various anatomical sites. While it can be possible to detect a low-pitched murmur in this position, there is another position that is best for detecting the presence of a low-pitched diastolic murmur. This is the correct position. This image represents the left lateral recumbent position, which is the best position for detecting a low-pitched diastolic murmur. This is the incorrect position. This image represents the sitting position, which is appropriate for determining cardiac function at the various anatomical sites. While it can be possible to detect a low-pitched murmur in this position, there is another position that is best for detecting the presence of a low-pitched diastolic murmur. This is the incorrect position. This image represents the dorsal recumbent position, which is appropriate for determining cardiac function at the various anatomical sites. While it can be possible to detect a low-pitched murmur in this position, there is another position that is best for detecting the presence of a low-pitched diastolic murmur.
