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ARCHER CAT EXAM 1.
Save The nurse manager reviews client assignments. Which client assignment would be inappropriate for a licensed practical/vocational (LPN/VN) nurse? Correct A. Obtaining an occult blood sample from a 15-year-old client with ulcerative colitis. [10%] B. Assessing a 35-year-old client newly admitted for chest pain. [69%] C. Reinforcing education to a 25-year-old first-time mother on how to properly care for her new baby. [12%] D. Providing pin care and data collecting on neurovascular status for a client in cervical traction. [9%] - ANSWERChoice B is correct. LPN/VNs should be assigned the most stable client with a predictable outcome. A client newly admitted for chest pain would not be stable or predictable and, thus, require intervention. Choices A, C, and D are incorrect. Reinforcing education, obtaining stool samples, and providing pin care to a client in cervical traction is within the scope of an LPN/VN. The nurse is caring for a client who is immediately postoperative. It would be appropriate for the nurse to initially data collect on the client's Correct A. respiratory status.
[65%]
B. level of consciousness. [29%] C. level of pain. [4%] D. ability to move extremities. [1%] - ANSWERExplanation Choice A is correct. Respiratory status should always be given priority in any assessment. Data collection for a client immediately postoperative is continuous, using preoperative and intraoperative data as bases for comparison. The data collection performed on a client who is immediately postoperative includes respiratory status (airway, pulse oximetry), cardiovascular status (blood pressure), temperature, central nervous system status (level of alertness, movement, shivering), fluid status, wound status, GI status (nausea and vomiting), and general condition. These assessments are initially made every 10 to 15 minutes. Choices B, C, and D are incorrect. Although all of these ANSWER options should be addressed, the nurse's first priority is that of stable respiratory status. The nurse has received four physician orders. The nurse should initially implement which order? See the image below. Correct A. irrigate a wound for a client with a stage III pressure ulcer. [6%] B. complete pin care for a client with a halo fixation device. [8%]
Your Score/Max +/- Scoring Rule "Everyone in my family needs to go and see the doctor for TB testing." "I will continue to take the isoniazid until I am feeling completely well." "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag." "I will change my diet to include more foods rich in iron, protein, and vitamin C." - ANSWERChoices A, C, and D are correct. A: Family members should be tested because of their repeated exposure to the client. C: Respiratory hygiene practices, such as covering the mouth and nose when coughing or sneezing and properly disposing of used tissues, are essential to prevent the spread of TB bacteria to others. D: Good nutrition, including foods rich in iron, protein, and vitamin C, can support the client's immune system and overall health during TB treatment. Adequate nutrition is important for the body's ability to fight off the infection and promote healing. Choice B is incorrect. Clients taking isoniazid must continue the drug for six months, regardless of whether symptoms seem to have improved or not. Additional Info ✓ TB, tuberculosis, is a severe bacterial disease. It is spread from person to person through the air. TB may scar the lungs and other parts of the body, including the kidneys, bones, or brain. Although medications are available to treat TB, not every person affected responds within the same time frame.
✓ Nurses are responsible for providing client education and making sure that the client understands what he/she is being taught to help prevent the spread of disease. To help prevent the spread of TB, clients should be instructed to: Make sure that family, friends, and close co-workers are tested. Avoid close contact with others until the physicians say it's OK. Keep your hands clean. Cover the mouth and nose with a tissue when sneezing Put used tissue in a closed bag and throw it away. ✓ LPNs can provide the client with written educational materials or pamphlets about TB, its treatment, and infection control measures. Written materials can serve as a reference for the client to review at home and share with their family members, further supporting the education process. The nurse is caring for a client with pulmonary tuberculosis. Which action should the nurse take? Correct ANSWER(s): D A. Place a box of disposable respirators inside the client's room [14%] B. Remove alcohol-based sanitizers from the client's room [1%] C. Assign the client to a private room with a positive airflow [28%] D. Remove the portable fan from the client's bedside table [56%] - ANSWERExplanation
[18%] - ANSWERExplanation Choice A is correct. The client is experiencing intraabdominal bleeding with manifestations confirming shock. The client will need to have the blood volume replaced with emergent surgery. Type-specific PRBCs would be preferred; however, if the client is critical, O-negative blood may be transfused. Choices B, C, and D are incorrect. FFP would not be prescribed because this client is not experiencing blood loss related to warfarin or DIC. Platelets would be prescribed to treat thrombocytopenia. Granulocytes are rarely prescribed, but if they are prescribed, they are indicated for severe aplastic anemia, neutropenia, and neonatal sepsis. Additional Info ✓ FFP is indicated for deficiency of certain clotting factors. ✓ This blood product may also be used for warfarin toxicity and Vitamin K. ✓ FFP may also provide some volume resuscitation; however, its primary purpose is to assist with clotting. ✓ FFP is administered to a client over 15-30 minutes. When assessing the posterior tibial pulses, what is the correct method to document that the client's pulse is weak and thready? Correct A. Grade C posterior tibial pulse. [7%] B. Posterior tibial pulse is Grade B.
[5%]
C. The client's posterior tibial is +2. [22%] D. Posterior tibial pulse is +1. [65%] - ANSWERExplanation Choice D is correct. When assessing pulses, the strength, volume, and fullness of the peripheral pulses are categorized and documented as follows: 0: Absent pulses 1: Weak pulse 2: Normal pulse 3: Increased volume 4: Abounding pulse Choices A and B are incorrect. Alphabetical grades and grading are not used to document pulses. Choice C is incorrect. The pulse is weak and thready, not normal. Additional Info ✓ Use gentle and consistent pressure while palpating the posterior tibial pulses to accurately assess their strength. Assess the pulses on both sides for comparison and to ensure accuracy. ✓ If the pulses are consistently weak and thready, as this problem states, the LPN should collaborate with the healthcare team to determine the appropriate interventions or follow-up assessments.
✓ The client receiving mechanical ventilation should always be assessed over the alarm ✓ The nurse needs to ensure these alarms are functional, but the client's assessment is the priority if the alarm sound goes off ✓ The low-pressure alarm indicates either disconnection, extubation, or low cuff pressure ✓ The high-pressure alarm indicates airway obstruction by the client biting on the tube or secretions in the airway The nurse should understand the regulations of nursing practice as put forth by the Nurse Practice Act. Which of the following statements are correct? Select all that apply. Some other issues covered by the Nurse Practice Act include grounds for disciplinary action, licensure requirements, and the rights of the nurse licensee if disciplinary action is taken. The Nurse Practice Act defines the scope of nursing practice. All nurses have the responsibility to know the provisions of the act for the state or province in which they work. The Nurse Practice Act is a series of statutes enacted by the federal government in order to regulate the practice of nursing. - ANSWERExplanation Choices A and B are correct. Nurse practice acts (NPAs) contain a provision that creates and empowers a state board of nursing to regulate nursing practice in that state. All 50 states, the District of Columbia, and the four U.S. territories have established nursing boards. Although NPAs can vary from state to state, they all have standard components because states used ANA guidelines in developing their regulations. A state's nurse practice act usually includes the following: The authority of the board of nursing, its composition, and powers
A definition of nursing and the boundaries of nursing practice Standards for the approval of nursing education programs The requirements for licensure of nurses Grounds for disciplinary action against a nurse's license Which of the following should the nurse include in the education provided to a client who is taking lisinopril? Select all that apply. 2/ Your Score/Max +/- Scoring Rule "It may take several months for your blood pressure to return to normal." "You must have your potassium monitored from time to time." "This medication may change your vision at times." "You may notice a change in your sensation of taste." - ANSWERExplanation Choices A, B, and D are correct. A: Lisinopril may require 2-3 weeks of adjustment to reach maximum effectiveness. Several months of therapy may be needed for a client's functional status to return to normal. B: High potassium levels may occur during therapy. The use of potassium supplements or potassium-sparing diuretics should be avoided. Electrolyte levels should be monitored periodically. D: Other side effects associated with lisinopril include cough, taste disturbances, and hypotension. Angiotensin-converting enzyme (ACE) inhibitors reduce the afterload on the heart and lower blood pressure. They are drugs of choice in the treatment of heart failure. ACE inhibitors have been shown to slow heart failure
C. Fat soluble vitamin [4%] D. Albuterol [14%] - ANSWERExplanation Choice A is correct. Administering the IV antibiotic is the top priority in a client with cystic fibrosis (CF) that develops a fever. Due to the excessive, thick mucus that builds up in their bronchi and bronchioles, children with CF are incredibly susceptible to respiratory infections. A fever is an indication of infection and aggressive management is the top priority. Choice B is incorrect. Pancreatic enzymes are administered to children with CF within 30 minutes of any meal and snack. These are given to aid in digestion since the excessive, sticky mucus clogs up the pancreatic duct in these clients. This is a standard medication given every day but is not the top priority when this client develops a fever. Choice C is incorrect. Fat-soluble vitamins are a daily medication for children with CF. Due to the buildup of excessive, sticky mucus in their bile duct, children with CF do not absorb fat normally. This leads to a deficiency in fat- soluble vitamins, which are vitamins A, D, E, and K. This is a standard medication given every day but is not the top priority when this client develops a fever. Choice D is incorrect. Albuterol is a bronchodilator frequently given as a nebulizer treatment to clients with CF. Although this medication might be given top priority if the client was experiencing respiratory difficulty, the question states they have developed a fever. Due to this finding, IV antibiotics are the top priority as these clients are very susceptible to infections. Additional Info
✓ Given the client's history of cystic fibrosis, closely monitor their respiratory status. Auscultate lung sounds for any changes, increased crackles, or wheezing. Document any changes in respiratory effort or oxygen saturation levels. ✓ Engaging in regular physical activity is important for teenagers with CF. Physi The nurse is caring for a client with schizophrenia. The nurse should anticipate a prescription for which medication? Correct A. lithium [25%] B. bupropion [10%] C. sertraline [12%] D. risperidone [52%] - ANSWERExplanation Choice D is correct. Schizophrenia is treated with antipsychotic medications. Typical (or first-generation) antipsychotic drugs include haloperidol, fluphenazine, and chlorpromazine. Atypical (second generation) antipsychotic medications include quetiapine, ziprasidone, and risperidone. Choices A, B, and C are incorrect. Lithium is indicated for the treatment of Bipolar disorder. Bupropion is an atypical antidepressant indicated in major depressive disorder. Sertraline is a selective serotonin reuptake inhibitor and is indicated for major depressive and anxiety disorders.
agitation. Alcohol withdrawal puts this patient at risk for seizures. Of the options provided, the nurse's first priority would be to initiate seizure precautions immediately. Choice B is incorrect. The nurse should already have assessed the patient's pain prior to giving the PRN medication. This would not be a higher priority than the patient's safety. Choice C is incorrect. The question does not indicate that the patient is presenting with aggressive or threatening behaviors at this time, so restraints would not be appropriate. Choice D is incorrect. Assessment of neurological status is appropriate due to the patient's new symptoms but is not a higher priority than the patient's safety with suspected alcohol withdrawal. Diabetes insipidus is a potential complication of which of the following procedures? Correct A. Surgical removal of the pituitary gland [70%] B. Reduction of mass on the thyroid gland [19%] C. Hysterectomy [5%] D. Dilation and curettage [6% - ANSWERExplanation Choice A is correct. Damage to the pituitary gland or hypothalamus from surgery increases the risk for diabetes insipidus. This is because the posterior pituitary is the gland that regulates the production, storage, and release of
antidiuretic hormone (ADH). A decreased amount of ADH results in diabetes insipidus. Choice B is incorrect. A reduction of mass in the thyroid gland would not result in an increased risk for diabetes insipidus. Choice C is incorrect. A hysterectomy would not result in an increased risk for diabetes insipidus. Choice D is incorrect. A dilation and curettage The client using over-the-counter nasal decongestant drops reports unrelieved and worsening nasal congestion. What is the appropriate instruction for this client? Correct ANSWER(s): A A. Discontinue the medication for several days. [63%] B. Use a combination of oral medications and drops for better results. [23%] C. Switch to a stronger dose of the decongestant drops. [7%] D. Increase the frequency of the nasal decongestant drops. [6%] - ANSWERExplanation Choice A is correct. Due to their local action, intranasal sympathomimetics produces fewer systemic effects. However, one side effect associated with their use is rebound congestion. Prolonged use causes hypersecretion of mucus and worsened nasal congestion once the drug effects wear off. This rebound effect sometimes leads to a cycle of increased drug use as the condition worsens. Due to the risk of rebound congestion, intranasal sympathomimetics should be used for no longer than 3-5 days. Prolonged use
D. An RN case manager ordering therapies and medications. [6%] - ANSWERExplanation Choice C is correct. Speech/language therapists assess and treat patients with swallowing disorders, and with communication and speech problems that occur following a stroke. Understanding the role of each member of the healthcare team is essential. It helps foster accountability within the organization and also helps to ensure that each person acts within his/her role. Choice A is incorrect. Occupational therapists assist clients with ADLs and provide assistive devices. Choice B is incorrect. Physical therapists perform restorative and rehabilitative care including helping clients with balance/gait exercises and ambulation. Choice D is incorrect. Case managers coordinate care along the continuum of care, and they manage insurance reimbursements. Physicians order medications and therapies. Which action taken by the school nurse will have the most impact on the incidence of infectious disease in the school? Correct ANSWER(s): A A. Ensure that students are immunized according to national guidelines. [59%] B. Provide written information about infection control to all patients. [2%] C. Make soap and water readily available in the classrooms. [26%] D. Teach students how to cover their mouths when coughing.
[12%] - ANSWERExplanation Choice A is correct. The incidence of once-common infectious diseases such as measles, chickenpox, and mumps have been most effectively reduced by immunization of all school-aged children. School-aged children are at risk for exposure to viruses, respiratory infections, and parasitic infections (such as scabies or lice). Vaccination protects children from severe illness and complications of vaccine-preventable diseases, including amputation of an arm or leg, paralysis of limbs, hearing loss, convulsions, brain damage, and death. The nurse is caring for a group of children on the medical-surgical unit. The nurse should initially follow up on the child who Correct A. is receiving treatment for Hirschsprung's disease and has a temperature of 101°F (38.3°C). [59%] B. has an indwelling urinary catheter and reports burning at the insertion site. [31%] C. has scant blood in their newly established ostomy pouch. [7%] D. has friends writing words on their fiberglass cast with different colored markers. [2%] - ANSWERxplanation Choice A is correct. A major complication of Hirschsprung's disease is the development of enterocolitis manifested by fever, abdominal distention, vomiting, and increased abdominal pain. Emergent intervention is necessary because the child may develop sepsis leading to septic shock.
