HURST REVIEW NCLEX-RN Readiness Exam 1|125 Questions and Answers 2023, Exams of Nursing

Download HURST REVIEW NCLEX-RN Readiness Exam 1|125 Questions and Answers 2023 and more Exams Nursing in PDF only on Docsity!

HURST REVIEW NCLEX-RN Readiness Exam 1|

Questions and Answers 2023

The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat for an adult client. What is the least amount of time that the nurse can safely administer this medication?

1. 1 minute
2. 2 minutes
3. 5 minutes

4. 10 minutes - Correct answer 2. Correct: The rate of IV administration should not exceed

50 mg/min. for adults and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes.

1. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1- mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. Giving this dose over only one minute could lead to these or other potential harmful effects.
2. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1- mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. Five minutes would be longer than required to be able to safely administer the medication.
3. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults and 1- mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg can safely be delivered over a period of at least 2 minutes. Ten minutes is much longer than required to be able to safely administer the medication.

A client, hospitalized with possible acute pancreatitis secondary to chronic cholecystitis, has severe abdominal pain and nausea. The client is kept NPO, an NG tube is inserted, and IV fluids are being administered. What is the rationale for the client being NPO with an NG tube to low suction?

1. Relieve nausea
2. Reduce pancreatic secretions
3. Control fluid and electrolyte imbalance

4. Remove the precipitating irritants - Correct answer 2. Correct: In clients with

pancreatitis, the pancreatic enzymes cannot exit the pancreas. These enzymes, when activated, begin to digest the pancreas itself. The enzymes become activated in the pancreas when fluid or food accumulates in the stomach. The goal in treating this client is to stop the activation of the pancreatic enzymes. Treatment is focused on keeping the stomach empty and dry. This allows the pancreas time to rest and heal. Note: Autodigestion (pancreas digesting itself) is painful for the client and can lead to other problems such as bleeding.

1. Incorrect: The primary purpose of the NG tube to suction is to keep the stomach empty and dry to decrease pancreatic enzyme production, not to relieve nausea.
2. Incorrect: Because gastric contents are removed, the NG tube to suction may lead to fluid and electrolyte disturbances rather than helping to control them.
3. Incorrect: Although the food in the stomach causes the pancreatic enzymes to become activated in the pancreas due to the obstruction, the food is not considered an irritant. Precipitating irritants are not a part of the pathophysiology occurring with pancreatitis. The nurse is working with a committee at the local school to develop an emergency preparedness plan for tornados. What should be included in the plan?
4. Identification of safe zones.
5. Methods for accounting for all people present in the building.
6. Warning system activation.
7. Identification of the gymnasium as the routine safe place.

5. Regular practice protocols. - Correct answer 1., 2., 3. & 5. Correct: Everyone should be

aware of safe zones within the school. Personnel should be given this information and signs posted in safe zones. There must be systems in place to accurately determine the number of people in the building at any given time. There also must be a system in place to alert personnel and students of tornado warnings. Regular practice prepares everyone for an actual event.

4. Incorrect: Gymnasiums are not considered safe places due to wide expanse of roof. Safe zones should be on interior walls, no windows, and a strong concrete floor if possible. What should a nurse teach family members prior to them entering the room of a client who has agranulocytosis?
5. Meticulous hand washing is needed.
6. Do not visit if you have any infection.
7. The client must wear a mask.
8. Children under 12 may not visit.

5. Flowers are not allowed in the room. - Correct answer 1., 2., 4., & 5. Correct: Protective

isolation is needed for this client because of the presence of a low white blood cell count. We are protecting the client from acquiring an infection. So any visitors will need to have meticulous hand washing prior to entering. The visitor should not enter if he or she has any type of infection. To decrease the risk of infection, small children should not visit. Even the mildest symptom of infection could be detrimental to the client. Flowers have bacteria and should not be brought into the room.

3. Incorrect: A mask must be worn by the visitor, not the client. The mask is worn by visitors to prevent a possible spread of an airborne infection to the immunocompromised client. A client diagnosed with major depression has been taking a selective serotonin reuptake inhibitor for the past 6 weeks. When visiting the mental health center, the nurse discusses the medication and response with the client. The nurse's assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation?
4. Are you having trouble sleeping at night?

2. Do you have periods of muscle jerking?
3. Are you having any sexual dysfunction?

4. Is your mood improving? - Correct answer 2. Correct: Myoclonus, high body

temperature, shaking, chills, and mental confusion are some of the symptoms of serotonin syndrome. This client may be having symptoms of this adverse reaction which, if severe, can be fatal.

1. Incorrect: Sleep disturbances are common with depression. Selective serotonin reuptake inhibitors (SSRIs) may cause insomnia; however, there is a more pertinent question needed for assessment of this client. You should be concerned with the more serious or life-threatening issue.
2. Incorrect: Sexual dysfunction may occur with the SSRIs; however, the client is exhibiting significant symptoms of an adverse reaction which would take priority.
3. Incorrect: The response to the SSRI medications is important; however, there is a more significant issue in this case. The possible serotonin syndrome is a serious situation that would be the priority for the nurse to address. A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar with this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the nurse expect on assessment?
4. Fever and shivering
5. Agitation
6. Decreased body temperature
7. Constipation

5. Increased heart rate - Correct answer 1., 2. & 5. Correct: Serotonin syndrome is a group

of symptoms that can result from the use of certain serotonin reuptake inhibitors. These symptoms can range from mild to severe and include high body temperature, agitation, increased reflexes, diaphoresis, tremors, dilated pupils and diarrhea. The client is likely to experience shivering with fever. Increased heart rate and blood pressure are also commonly

experienced. More severe symptoms, including muscle rigidity and seizures, can occur. If not treated, serotonin syndrome can be fatal.

3. Incorrect: Increased body temperature is expected as is increased diaphoresis.
4. Incorrect: Diarrhea, not constipation, is a symptom of serotonin syndrome. The emergency department nurse is assessing a client who presents with severe epigastric pain. The client reports that three rolls of calcium carbonate were consumed in the past eight hours to treat the indigestion. Which blood gas report does the nurse associate with this situation?
5. pH - 7.49, pCO2 - 40, HCO3 - 30
6. pH - 7.32, pCO2 - 48, HCO3 - 20
7. pH - 7.38, pCO2 - 52, HCO3 - 32

4. pH - 7.29, pCO2 - 54, HCO3 - 26 - Correct answer 1. Correct: These ABGs are indicative

of metabolic alkalosis. The pH is high, the pCO2 is within normal limits and the bicarb is high (alkalosis). So, the excess Tums (calcium carbonate) could have caused metabolic alkalosis.

2. Incorrect: The client is not hypoventilating and would not be in metabolic acidosis because he ate 3 rolls of Tums which is a base. These ABGs are indicative of acidosis. The pH is low (acidosis), the pCO2 is high (acidosis) and the bicarb is low (acidosis).
3. Incorrect: The client is not a long-term COPD client as these ABGs might suggest. These ABGs are indicative of fully compensated respiratory acidosis. The pH is normal. The pCO2 is high (as with chronic retention) and the bicarb is high to help compensate.
4. Incorrect: These ABGs are the result of an acute ventilation problem. They are indicative of respiratory acidosis. The pH is low, the pCO2 is high, and the bicarb is normal. No compensation has begun at this point. Which prescriptions would the nurse recognize as being appropriate for the client with shingles?
5. Private room

2. Negative pressure airflow
3. Respirator mask
4. Face Shield

5. Positive pressure room - Correct answer 1., 2. & 3. Correct: According to the current

standards of Standard Precautions per the CDC, the client with shingles should be placed on airborne precautions which require the use of a private room with negative pressure airflow and a N-95 respirator mask.

4. Incorrect: A face shield is used when there is risk of splashing or spraying of blood or body fluids. This is not required for airborne precautions.
5. Incorrect: Negative pressure is required in order to prevent the airborne infection from spreading outside of the room. Positive pressure is used only in protective environments such as when immunocompromised clients require protection from potential infectious agents outside of the room. A healthy newborn has just been delivered and placed in the care of the nurse. What nursing actions should the nurse initiate? Place in the correct priority order. Assess newborn's airway and breathing. Bulb suction excessive mucus. Assess newborn's heart rate. Place identification bands on newborn and mom.

Administer sterile ophthalmic ointment containing 0.5% erythromycin. - Correct answer

Remember Maslow's hierarchy of needs will guide your assessment. First, Assess newborn's airway and breathing. The most critical change that a newborn must make physiologically is the initiation of breathing. The nurse should assess the newborn's crying. If the cry is weak, it may indicate a respiratory disturbance. Other signs of respiratory compromise may include: stridor,

grunting, retractions, apnea or diminished breath sounds. Normal respiration are 30 - 60 breaths a minute. Second, Bulb suction excessive mucus. It is important to assure that the throat and nose are kept clean of secretions to prevent respiratory distress. Third, Assess newborn's heart rate. If there is no respiratory distress, the nurse continues the assessment by checking the heart rate and other vital signs. Fourth, Place identification bands on newborn and mom. These are critical for ensuring babies and moms will be appropriately matched at all times but does not take priority over respiration and circulation. Fifth, Administer sterile ophthalmic ointment containing 0.5% erythromycin. This is a legally required prophylactic eye treatment to prevent Neisseria gonorrhea. However, this would never be a priority over Maslow's hierarchy of needs. What information should a nurse include when educating a client regarding buccal administration of a medication?

1. This route allows the medication to get into the bloodstream faster than the oral route.
2. Stinging may occur after placing the medication in the cheek.
3. If swallowed, the medication may be inactivated by gastric secretions.
4. The buccal dose of medication will need to be increased from the oral dose.

5. Remove the tablet from buccal area after 15 seconds. - Correct answer 1., 2., & 3.

Correct: These are correct statements about buccal administration of medication. Buccal administration involves the medication being placed between the gums and cheek, where it dissolves and becomes absorbed into the bloodstream. The cheek area has many capillaries that allow the medication to be absorbed quickly without having to pass through the digestive system. The degree of stinging experienced depends on the medication being administered. Some effects of certain medications can be lessened by digestive processes.

4. Incorrect: When given by the buccal route, the medication does not go through the digestive system. This means that the medication is not metabolized through the liver, and thus a lower dose can be used.
5. Incorrect: Placement should be maintained until the tablet is dissolved in order to get the dosage and effects desired. Which signs and symptoms would the nurse expect to see in a client who has taken prednisone for two months?
6. Weight loss
7. Decreased wound healing
8. Hypertension
9. Decreased facial hair

5. Moon face - Correct answer 2., 3. & 5. Correct: Decreased wound healing is a side effect

with prolonged steroid use due to the immunosuppressive effects. All steroid medications, such as prednisone, can lead to sodium retention which then leads to dose related fluid retention. Hypertension is seen due to this fluid and sodium retention. Cushingoid appearance (moon face) is a side effect that is created from the abnormal redistribution of fat from prolonged steroid use.

1. Incorrect: Within one month after corticosteroid administration, weight gain is seen rather than weight loss.
2. Incorrect: Facial and body hair increase with prolonged steroid use. This excessive growth of body hair, known as hirsutism, is one of the numerous potential side effects of prednisone. A nurse is at highest risk for blood-borne exposure during which situation?
3. When removing a needle from the syringe.
4. While placing a suture needle into the self-locking forceps.

3. Prior to inserting the intravenous (IV) line, the client moves causing a needle stick to the nurse.

4. A clean needle sticks the nurse through blood-soiled gloves. - Correct answer 4. Correct:

A clean needle that moves through blood-soiled gloves to stick the nurse is considered to be potentially contaminated and results in a blood-borne exposure. All other answers are considered a clean stick.

1. Incorrect: This is considered a clean stick. The needle is sterile initially and has not been contaminated prior to removal of the needle from the syringe.
2. Incorrect: This is considered a clean stick since the suture needle has not been inserted into the client prior to the needle stick.
3. Incorrect: This is considered a clean stick. The IV insertion device is sterile and has not been contaminated since it was not inserted into the client. A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book, the nurse crushes the tablet and mixes it into 3 ounces of applesauce. The new nurse proceeds to the client's room. What priority action should the supervising nurse take?
4. Tell the new nurse to recheck the drug reference book before administering the medication.
5. Suggest that the new nurse reconsider the client's developmental needs.
6. Check the prescription order and the client dose.

4. Observe the new nurse administer the medication. - Correct answer 2. Correct: Mixing

medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce a new food during an illness.

1. Incorrect: There is nothing in the stem about a problem with the medication dose or route.
2. Incorrect: There is nothing in the stem about a problem with the medication dose or route.

4. Incorrect: This is an appropriate action. However, it is not the priority over ensuring that the new nurse knows how to appropriately prepare the medication for this client. An adult client has just returned to the nursing care unit following a gastroscopy. Which intervention should the nurse include on the plan of care?
5. Vital sign checks every 15 min x 4
6. Supine position for 6 hours
7. NPO until return of gag reflex
8. Irrigate NG tube every 2 hours

5. Raise four side rails - Correct answer 1., & 3. Correct: Vital signs post procedure are

important to monitor for any post-procedure complications such as bleeding or any signs of respiratory compromise. VS are checked frequently for the first hour post procedure. Any client who has a scope inserted down the throat and has received numbing medication in the back of the throat to depress the gag reflex should be kept NPO until the gag reflex returns.

2. Incorrect: Supine position for 6 hours is contraindicated. The HOB should be elevated. In the event the client vomits, he/she is less likely to aspirate with the HOB elevated. Supine position for 6 hours is used after a heart catheterization.
3. Incorrect: A client who is going for a gastroscopy procedure cannot have a nasal gastric tube. An NG tube would interfere with the procedure.
4. Incorrect: Raising all side rails is a form of restraint. Have the bed in low locked position. Raise three side rails, and have call light within reach. The family member of a schizophrenic client asks the nurse why the client is receiving chlorpromazine and benztropine. What is the best response by the nurse?
5. The chlorpromazine makes the benztropine more effective so a smaller dose of both drugs can be used.
6. Benztropine is given to treat the side effects produced by the chlorpromazine.

3. Chlorpromazine is used for severe hiccups that can occur with the use of benztropine.
4. Chlorpromazine is used for psychosis and benztropine is used for preventing agranulocytosis.

• Correct answer 2. Correct: Benztropine is used to treat parkinsonism of various causes and drug-induced extrapyramidal reactions seen with chlorpromazine, which is an antipsychotic agent. Extrapyramidal symptoms are neurologic disturbances in the area of the brain that controls motor coordination. This disruption can cause symptoms that mimic Parkinson's disease, including stiffness, rigidity, tremor, drooling and the classic "mask like" facial expression. These symptoms can be treated and are reversible using such medications as benztropine.

1. Incorrect: Chlorpromazine does not potentiate the effects of benztropine, so dosage regulation is not appropriate. 3 Incorrect: Chlorpromazine can be used for severe hiccups, but the hiccups are not the result of using benztropine. Chlorpromazine is also used for psychosis in the schizophrenic client.
2. Incorrect: Benztropine is not used to prevent agranulocytosis. A nurse is planning to provide information regarding suicide to a high school assembly. What information should the nurse include?
3. Do not keep secrets for the suicidal person.
4. Express concern for a person expressing thoughts of suicide.
5. Teens often don't mean what they say, so only take suicide seriously if grades are dropping as well.
6. Inform group of suicide intervention sources.

5. Do not leave a suicidal person alone. - Correct answer 1., 2., 4. & 5. Correct: If a person

reveals that suicide is being considered, this should never be kept secret. Help should be sought for the person immediately. It is also important to be direct and non-secretive with suicidal clients. It is appropriate to express concern for their thoughts. The use of empathy, warmth and concern indicates to the client that their feelings are being understood and viewed as real, which helps to build trust with the client. Resources for assistance are important to include in all

health teaching programs. The teens need to know what resources are readily available if someone is considering suicide. The client contemplating suicide should not be left alone. This is for the client's safety until further assistance can be obtained

3. Incorrect: Most clients who commit suicide have told at least one person that they were contemplating suicide before thy actually committed the act. Therefore, suicidal comments should be considered important risk factors that require evaluation, and all comments should be taken seriously. Anyone expressing suicidal feelings needs immediate attention. The nurse is caring for a client who was admitted to the hospital following a severe motor vehicle crash (MVC) in which the client was trapped in the car for several hours. The client is being closely monitored for the development of renal failure. Which assessment finding would warrant immediate reporting?
4. Creatinine 1.1 mg/dl (97.24 mmol/L)
5. Urinary output of 150 mL per hour.
6. Gradual increase of BUN levels.

4. Calcium levels of 9.0 mg/dL (2.25 mmol/L) - Correct answer 3. Correct. Gradual

accumulation of nitrogenous wastes results in elevated BUN and serum creatinine. This is an indication of impaired renal function.

1. Incorrect. This is a normal creatinine level. Gradual accumulation of nitrogenous wastes from impaired renal function results in elevated BUN and serum creatinine.
2. Incorrect. This is a normal output level. This level alone would not necessarily be an indicator of acute renal failure and that value alone would not warrant reporting it to the primary healthcare provider.
3. Incorrect. Calcium level of 9.0 mg/dL (2.25 mmol/L) is considered normal. When observing for renal functioning you would assess the BUN and creatinine levels. In addition, the calcium level may drop (hypocalcemia) in renal failure inverse relationship change due to the rising serum phosphate levels. However, the calcium level presented is within normal limits (WNL).

A female client taking captopril for hypertension tells the clinic nurse that she is planning to get pregnant. What recommendation should the nurse make?

1. "Captopril can be taken safely during pregnancy, but we will need to decrease your dose so you do not become hypotensive."
2. "We will need to increase your dose of captopril once you become pregnant."
3. "In order to prevent neural tube defects, start taking folic acid."
4. "Captopril can cause serious harm to an unborn baby, so you must prevent pregnancy while

taking this medication. " - Correct answer 4. Correct: Captopril should not be taken during

pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy.

1. Incorrect: Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy.
2. Incorrect: Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy.
3. Incorrect: Captopril should not be taken during pregnancy because serious harm (possibly fatal) to the unborn baby can result when taken during pregnancy. The problem being presented in the stem is not related to general prevention of neural tube defects. Folic acid would not prevent the harm to the fetus caused by captopril. A client diagnosed with glomerulonephritis presents with generalized malaise, weight gain, generalized edema, and flank pain. The primary healthcare provider prescribes antibiotics and strict bedrest. What is the best explanation to give the client regarding the strict bedrest prescription?
4. Promotes diuresis
5. Prevents injury
6. Promotes rest

4. Stimulates RBC production - Correct answer 1. Correct: Bedrest and the supine position

promote diuresis. When the client is supine, there is a gradual shift of fluids away from the legs toward the thorax, abdomen and head. This increased volume causes the right atrium of the

heart to stretch and release ANP, which leads to diuresis: renal blood flow increases due to vasodilation, and aldosterone and ADH secretion are inhibited.

2. Incorrect: Bedrest can keep the client from falling and injuring self; however, that is not why it has been prescribed.
3. Incorrect: Promotion of rest is good, but this is not why the primary healthcare provider prescribed it. Simply promoting does not help improve the symptoms listed. The reason the client needs bedrest should focus on relieving the symptoms listed in the stem.
4. Incorrect: No relationship between bedrest and red blood cell production exists. A newly admitted client with schizophrenia has an unkempt appearance and needs to attend to personal hygiene. Which statement by the nurse is most therapeutic?
5. A shower will make you feel better.
6. It is time to take a shower.
7. Have you thought about taking a shower?

4. I need you to take a shower. - Correct answer 2. Correct: Schizophrenia is a thought

disorder. Many clients with schizophrenia are concrete thinkers and have difficulty making decisions. The nurse needs to be direct, clear and concise in communicating with the client. This is a direct, clear and concise statement that guides the client to perform the needed activity.

1. Incorrect: Many clients with schizophrenia are concrete thinkers. The nurse needs to be direct, clear and concise in communicating with the client. The client may not comprehend how the shower improves the overall sense of well-being and would remain reluctant to take the shower.
2. Incorrect: Clients diagnosed with schizophrenia often have trouble making decisions. The client needs to be guided with simple, direct instructions.

4. Incorrect: This focuses on the nurse's need, not the client's need. Do not select answers that focus on the nurse. This does not improve the client's decision making ability nor does it provide guidance to the client for meeting the hygiene needs. Which clients would be appropriate for the RN to assign to an LPN/LVN?
5. Seventy four year old client with unstable angina who needs teaching for a scheduled cardiac catheterization.
6. Sixty year old client experiencing chest pain scheduled for a graded exercise test.
7. Forty eight year old client who is five days post right-sided cerebral vascular accident (CVA).
8. Eighty four year old client with heart disease and mild dementia.
9. Newly admitted ninety year old client with decreased urinary output, altered level of consciousness, and temperature of 100.8°F (38.2°C)
10. Sixty six year old client with chronic emphysema experiencing mild shortness of breath. -

Correct answer 3., 4., 6. Correct: The client who is five days post CVA is one of the most

stable clients and could be assigned to the LPN/LVN. There is nothing in the option to indicate that this client is unstable. There is no indication that the eighty-four year old client with heart disease and dementia is unstable so this client can be assigned to the LPN/LVN. The client with chronic emphysema will experience shortness of breath. There is nothing to indicate that this client is unstable.

1. Incorrect: This client is unstable and should be cared for by the RN. Additionally, the RN is responsible for teaching.
2. Incorrect: This client is experiencing chest pain and is thus considered unstable and should be cared for by the RN.
3. Incorrect: This client has s/s that could indicate sepsis, so is considered unstable and should not be assigned to the LPN/LVN. While examining a client's health history, which data indicates to the nurse that the client is at increased risk for developing cancer?
4. Family history

2. Alcohol consumption
3. Spicy diet
4. Human papillomavirus

5. Tobacco use - Correct answer 1., 2., 4., & 5. Correct: Family history of cancer increases

the risk for having the same type of cancer. Alcohol and tobacco use increase the risk of cancer. When used together, they have a synergistic effect. Human papillomavirus (HPV) increases the risk of cervical, head, and neck cancers.

3. Incorrect: Although there are some dietary factors associated with cancer development, a spicy diet does not necessarily increase the risk of cancer. A nurse is caring for a client admitted with chronic fatigue and weakness. During the physical assessment, the nurse notes jaundiced sclera, abdominal distension, swelling in the legs and ankles, and bruises in various stages of healing throughout the body. What nursing interventions should the nurse initiate?
4. Measure abdomen
5. Monitor intake and output
6. Obtain daily weight
7. Place on fall precautions
8. Provide three meals per day

6. Dangle legs - Correct answer 1., 2., 3., & 4. Correct: The symptoms presented are

indicative of liver disease. Measuring abdominal girth will monitor for accumulating ascitic fluid. Clients with liver disease have fluid volume problems, so daily weight and I&O are indicated. This client is at risk for injury related to chronic fatigue and weakness, so fall prevention is indicated. The client may need help eating if fatigue is severe.

5. Incorrect: Poor tolerance to larger meals may be due to abdominal distension and ascites. Clients should eat smaller, more frequent meals (6/day). The recommended diet is high calorie and low sodium with protein regulated based on liver function. Between meal snacks should be provided.

6. Incorrect: Elevating legs enhances venous return and reduces edema in extremities. Dangling the leg would cause the fluid in the lower extremities to accumulate more. A client experiencing chest pain is prescribed an intravenous infusion of nitroglycerin. After the infusion is initiated, the occurrence of which symptom would prompt the nurse to discontinue the nitroglycerin?
7. Frontal headache
8. Orthostatic hypotension
9. Decrease in intensity of chest pain

4. Cool, clammy skin - Correct answer 4. Correct: This assessment finding of cool, clammy

skin is an indication of decreased cardiac output that could be the result of too much vasodilatation. Cardiac output could continue to decrease if the nitroglycerin is not discontinued.

1. Incorrect: A headache is an expected common side effect of nitroglycerin administration. The headache is treated with medication.
2. Incorrect: A decrease in blood pressure when rising from a supine or sitting position is a common effect of the vasodilatation that occurs with the administration of nitroglycerin. The client should be advised to change positions slowly.
3. Incorrect: The decrease in the intensity of the client's chest pain is the desired outcome of the nitroglycerin administration. During an assessment interview with a client, what alternative healing modalities should the nurse inquire about?
4. "Tell me about your use of teas, herbs, and vitamins."
5. "What traditional or folk remedies are used in your family?"
6. "Do you meditate, pray, or use relaxation techniques for healing purposes?"
7. "What prescription medications are you taking?"

5. "What alternative therapies have you used?" - Correct answer 1., 2., 3., & 5. Correct:

These are all inquiries the nurse should make when conducting an assessment interview in order to find out about alternative healing modalities. Alternative or complementary medicine is used to describe over 1800 therapies practiced around the world. Approximately 65 to 80% of the world's population use non-conventional (alternative) healing modalities. These alternative healing modalities can be such things as: Natural products (herbs, dietary supplements, etc.) mind and body practices (yoga, mediation, prayer, etc.), folk remedies and other non-traditional practices.

4. Incorrect: Prescription medications would be part of traditional, western medicine. Although the nurse needs to find out what prescription medications are being taken, it is not part of alternative medicine. The nurse in the emergency department suspects that a client's lesion is caused by anthrax. What assessment question is most important?
5. Have you traveled out of the United States recently?
6. Have you recently worked with any farm animals or any animal-skin products?
7. Have you experienced any gastrointestinal upset recently?

4. Have you eaten any home-canned foods recently? - Correct answer 2. Correct:

Cutaneous anthrax may be contracted by working with contaminated animal-skin products. Anthrax is found in nature and commonly infects wild and domestic hoofed animals.

1. Incorrect: Cutaneous anthrax is also found in the United States, so asking about travel abroad would not be necessary.
2. Incorrect: Cutaneous anthrax can be contracted by spores entering cuts or abrasions in the skin. This is cutaneous anthrax that causes edema, itching and macule or papule formation, resulting in ulceration. Ingestion of anthrax can cause GI symptoms such as nausea and vomiting, abdominal pain, and bloody diarrhea. Inhalation of anthrax may result in flu-like symptoms that progress to severe respiratory distress.
3. Incorrect: This question would be appropriate if botulism were suspected in a client.

When preparing a client for surgery, the nurse realizes the operative permit has not been signed. The client tells the nurse he understands the procedure, but received his preoperative medication approximately 10 minutes ago. What would be the appropriate action by the nurse?

1. Have the client sign the permit, as he verbalizes understanding.
2. Witness the form after having the client sign it.
3. Have his wife sign the form as she witnessed his statement that he understands.

4. Call the surgical area and explain that the surgery will have to be cancelled. - Correct

answer 4. Correct: The client must sign the operative permit or any other legal document

prior to taking preoperative drugs that can affect judgment and decision-making capacity.

1. Incorrect: The client's verbal understanding does not override the fact that he has received medication that can alter thought processes and decision-making.
2. Incorrect: Witnessing would not make this document legal. The consent would not be valid because the client has already received the pain medication that could alter the thought process.
3. Incorrect: When a client is of legal age (unless an emancipated minor) and of sound mind, it would be inappropriate for the spouse to sign the form for surgery. In order to be valid it must be the client who signs it, unless there is a legal power of attorney, durable power of attorney, or healthcare surrogate. A child is being admitted with possible rheumatic fever. What assessment data would be most important for the nurse to obtain from the parent?
4. 102° F (38.89° C) temperature that started 2 days previously.
5. History of pharyngitis approximately 4 weeks ago.
6. Vomiting for 3 days.

4. A cough that started about 1 week earlier. - Correct answer 2. Correct: Rheumatic fever

is often the result of untreated or improperly treated group A β-hemolytic streptococcal infections (GABHS), such as pharyngitis. Therefore, the history of pharyngitis or upper

respiratory infection is a key assessment finding for establishing a diagnosis of rheumatic fever. Subsequent development of rheumatic fever usually occurs 2 to 6 weeks following the GABHS, so the assessment should include a remote history of pharyngitis.

1. Incorrect: The fever with rheumatic fever is usually low grade and is considered a minor manifestation of rheumatic fever.
2. Incorrect: Vomiting is not a commonly associated symptom with rheumatic fever and is not considered a major manifestation of rheumatic fever. Although the child may have a history of vomiting, this finding would not be specific to rheumatic fever.
3. Incorrect: A cough is not an associated symptom of rheumatic fever. The time frame for the development of rheumatic fever is not appropriate if the cough started 1 week earlier, even if it had been associated with an upper respiratory streptococcal infection. The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat through a non-tunneled central venous catheter lumen with no other medication or fluid infusing. In what order should the nurse administer this prescription? Cleanse access port Connect 10 mL normal saline to access port Gently aspirate for blood Flush saline using push-pause method Administer phenytoin

Flush with normal saline, then with heparin - Correct answer Proper administration of

medication through a non-tunneled central venous catheter: First, cleanse the access port. Failure to cleanse the port first would increase the risk of infection from contamination when the port is accessed.

Second, connect 10 mL normal saline to access port. This 10 mL syringe will be connected to first check patency and then for flushing prior to medication administration. At least 10 mL of normal saline is used to flush central lines. Third, gently aspirate for blood. Fourth, flush saline using push-pause method. This method is utilized to help clear the catheter of blood or drugs that could potentially adhere to the internal surface of the central line catheter. This creation of turbulent flow from pausing then pushing causes swirling of the fluid and theoretically removes blood and medications from the walls of the catheter, which reduces the risk of occlusion in the catheter. Fifth, administer phenytoin. Sixth, flush with normal saline, then with heparin. Standard flushing solutions used most frequently for central venous access devices include normal saline and/or heparinized sodium chloride. Low dose heparin flushes are generally used to fill the lumen of the central line between use in order to prevent thrombus formation and maintain patency of the catheter for a longer period of time. An elderly male, diagnosed with chronic renal failure and depression, lives alone. Which question should the home health nurse ask first when assessing this client?

1. Have you had suicidal thoughts in the past?
2. How are you feeling today?
3. Have you had thoughts of harming yourself?

4. Do you have guns in your home? - Correct answer 3. Correct: Suicide assessment should

begin with direct questions about the presence of suicidal thinking. The nurse should recognize that elderly men are at higher risk for committing suicide, especially those with a history of depression, chronic illness and isolation.

1. Incorrect: This question should be asked, but only after determining if suicidal thinking is present.

2. Incorrect: This question could be an introductory question to establish rapport, but it is not direct enough to use in suicide assessment.
3. Incorrect: This question should be asked if the client is considering using gun as a method of suicide or if he has a history of suicide attempts with a gun. What medication should the nurse anticipate giving to a client in preterm labor to stimulate maturation of the baby's lungs?
4. Magnesium sulfate
5. Terbutaline
6. Methotrexate

4. Betamethasone - Correct answer 4. Correct: Betamethasone is used to stimulate

maturation of the baby's lungs in case preterm birth occurs. This medication is given to help prevent respiratory distress syndrome (RDS) by improving storage and secretion of surfactant that helps to keep the alveoli from collapsing.

1. Incorrect: Magnesium sulfate is given to stop preterm labor, however, if delivery is imminent, then Betamethasone should be given to stimulate maturation of the baby's lungs.
2. Incorrect: Terbutaline is contraindicated in preterm labor, however, if delivery is imminent, then Betamethasone should be given to stimulate maturation of the baby's lungs.
3. Incorrect: Methotrexate is used to stop the growth of the embryo in ectopic pregnancy so that the fallopian tube can be saved. It is not an agent used in the management of preterm labor. Which client could the charge nurse assign to an LPN/VN?
4. Eight year old in diabetic ketoacidosis (DKA)
5. Six year old in sickle cell crisis

3. Two month old with dehydration

4. Five year old in skeletal traction - Correct answer 4. Correct: The fracture would be most

appropriate for an LPN/VN and is within the scope of practice. This LPN/VN would need minimal assistance from the RN. Possibly, the other clients could have intravenous fluid (IVF) needs and medications that would require skill from an RN.

1. Incorrect: The child with DKA is in metabolic acidosis. The child is also at risk for other problems such as dehydration and electrolyte disturbances. Therefore, the child will need close observation and the RN's assessment skills.
2. Incorrect: IV fluid management is crucial for clients in a sickle cell crisis Assessment of the child's cardiovascular status, tissue perfusion and neuro status are priorities. Pain management is also very important in these clients. Therefore, the child with sickle cell will need close observation and the RN's assessment skills.
3. Incorrect: The baby with dehydration will need close observation and the RN's assessment skills, including monitoring for impending shock. Renal function and electrolyte levels should be monitored closely. The care of the child will likely involve IV fluids. Which statement made by a client post-thyroidectomy would require further investigation by the nurse?
4. "I have a tingling feeling of my fingers."
5. "It hurts when I move my head."
6. "I feel pressure in my arm when you take my blood pressure."

4. "My legs are weak." - Correct answer 1. Correct. After this procedure the nurse should

worry about the possibility of some of the parathyroids being accidentally removed with resulting hypoparathyroidism. Hypoparathyroidism results in hypocalcemia. Signs and symptoms include tingling, burning, or numbness of lips, fingers, and toes. The muscles may become tight and rigid, and seizures can result.

2. Incorrect. Pain is expected here. The incision is at the base of the neck, so movement of the head would increase the pain.

3. Incorrect. The sensation of pressure in the arm is considered normal when the BP is being measured. You worry if you see carpal spasm (+ Trousseau's) which is indicative of neuromuscular excitability caused by hypocalcemia secondary to the inadvertent removal of some of the parathyroids.
4. Incorrect. Weak/flaccid extremities would be seen with hyperparathyroidism. In this case, we are concerned that the parathyroids may have been removed, resulting in hypoparathyroidism. The weakness in the legs is apparently from a different cause. However, the signs of possible hypoparathyroidism would be the priority to investigate. The parents of a 4 year old child are concerned about whether the child will adapt to the newborn baby they are expecting in two weeks. What suggestions should the nurse make to assist with sibling adaptation?
5. Allow child to be one of the first to see the newborn.
6. Have child stay with parents during labor and delivery.
7. Arrange for one parent to spend time with the child while the other parent cares for the newborn.
8. Provide a gift from the newborn to give to the child.

5. Have child care for a doll. - Correct answer 1., 3., 4., & 5: These are good

recommendations for the nurse to make to the parents in an effort to promote sibling adaptation. Make the 4 year old part of the process as much as possible. Demonstrate the importance of the child by allowing the child to see the baby first. Provide personal time with the 4 year old. This shows that the 4 year old is important to the family. The baby is providing a gift to the child which promotes a bond between the two and demonstrates to the child that he or she is important. Having a 4 year old care for a doll gets the child involved in caring for another. The child can learn what a newborn needs both physically and emotionally by imitating the parents.

2. Incorrect: This child is young and may not understand what is happening with their mother during contractions and delivery. Does not promote sibling adaptation. This is a 4 year old who would not understand what is going on during labor and delivery. It can be very frightening to the child and does nothing to support sibling adaptation.

A 70 year old client was admitted to the vascular surgery unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's BP is 198/94. What would be the best action for the charge nurse to delegate at this time?

1. Ask the UAP to put the client back in bed immediately.
2. Tell the UAP to take the BP in the opposite arm in 15 minutes.
3. Have the LPN/LVN administer the 0900 furosemide and enalapril now.

4. Ask the LPN/LVN to assess the client for pain. - Correct answer 3. Correct: The nurse

should recognize the need for measures to reduce the blood pressure. Administering the client's blood pressure medicine is aimed at correcting the problem. It is appropriate to administer the medications at this time in relation to the time that the next dose is due.

1. Incorrect: This is an appropriate action, but does not address the problem of lowering the client's blood pressure.
2. Incorrect: This is an appropriate action, but does not address the problem of lowering the client's blood pressure.
3. Incorrect: This is an appropriate action, but does not address the problem of lowering the client's blood pressure. After reviewing the nursing notes on a client receiving a unit of packed red blood cells, what action should the charge nurse take?
4. Decrease the transfusion rate to 50 mL/hour.
5. Assess the client for a transfusion reaction.
6. Check primary healthcare provider prescription for prescribed administration time.
7. Stop the transfusion and send blood bag to the lab. Exhibit: Nursing Notes: