NCLEX Review Practice Questions: Special Populations, Exams of Nursing

Download NCLEX Review Practice Questions: Special Populations and more Exams Nursing in PDF only on Docsity!

Saunder's Comprehensive NCLEX

Review Practice Questions with

complete solutions 2024

Which jteaching jmethod jis jmost jeffective jwhen jproviding jinstruction jto jmembers jof jspecial jpopulations?

1. jTeach-back
2. jvideo jinstruction
3. jwritten jmaterials
4. jverbal jexplanation j- jANS ✓✓ -1. jTeach-back Rationale: jWhen jproviding jeducation jto jmembers jof jspecial jpopulations, jreturn jexplanation jand jdemonstration j(teach-back) jof jare jparticular jimportance jto jensure jsafety jand jmutual junderstanding. jThis jmethod jis jthe jmost jreliable jin jconfirming jthe jclient junderstands jthe jinstructions. Which jhealth jconcerns jshould jthe jnurse jbe jaware jof jas jrisk jfactors jwhen jcaring jfor jclients jof jAfrican jAmerican jdescent? jSelect jall jthat japply:
5. jcancer
6. jobesity
7. jhypertension
8. jheart jdisease
9. jhypothyroidism
10. jdiabetes jmellitus j- jANS ✓✓ -1, j2, j3, j4, j 6 j Rationale: jobesity, jdiabetes jmellitus, jhypertension, jheart jdisease, jasthma, jand jcancer jare jprevalent jamong jAfrican jAmericans. The jnurse jis jplanning jcare jfor ja jclient jof jNative jHawaiian jdescent jwho jrecently jhad ja jbaby. jThe jnurse jdevelops ja jteaching jplan jand jincludes jinfo jabout jwhich jmeasure jthat's jrelated jto ja jnewborn jcomplication jwithin jthis jethnic jgroup?
11. jsafe jsleeping

2. jcar jseat jsafety
3. jbreast-feeding
4. jbaby-proofing j- jANS ✓✓ -1. jSafe jsleeping j Rationale: jThe jnative jHawaiian jpopulation jhas ja jdisproportionately jhigher jrate jof jinfant jmortality jcompared jwith jother jethnic jgroups. jSudden jInfant jDeath jSyndrome j(SIDS) jis ja jmajor jcause jof jinfant jmortality. jSafe jsleeping jis jan jimportant jmeasure jto jprevent jthis jnewborn jcomplication. The jnurse jis jplanning jcare jfor jan jassigned jclient. jThe jnurse jshould jinclude jinfo jin jthe jplan jof jcare jabout jthe jprevention jof jHIV jfor jwhich jindividuals jspecifically jat jrisk?
5. jlesbian jpersons j
6. jmen-who-have-sex-with-men j(MSM)
7. jwomen-who-have-sex-with-women j(WSW)
8. jFemale-To-Male j(FTM) jtransgender jpersons j- jANS ✓✓ -2. jMSM Rationale: jMSM j(men jwho jhave jsex jwith jmen) jare jat ja jhigher jrisk jfor jHIV jand jAIDS. Which jtherapeutic jcommunication jtechnique jis jmost jhelpful jwhen jworking jwith jtransgender jpersons?
9. jusing jopen-ended jquestions
10. jusing jtheir jfirst jname jto jaddress jthem
11. jusing jpronouns jassociated jwith jbirth jsex
12. janticipating jthe jclient's jneeds jand jmaking jsuggestions j- jANS ✓✓ -1. jUsing jopen-ended jquestions Rationale: jThe juse jof jopen-ended jquestions jis jthe jmost jhelpful jin jcommunicating jwith jtransgender jpersons jbecause jit jassists jin jrefraining jfrom jjudgment jand jallows jthe jclient jthe jopportunity jto jexpress jtheir jthoughts jand jfeelings. Which jspecial jpopulation jshould jbe jtargeted jfor jbreast jcancer jscreening jby jway jof jmammography? jSelect jall jthat japply:
13. jmale-to-female j(MTF)
14. jfemale-to-male j(FTM)
15. jmen-who-have-sex-with-men j(MSM)
16. jwomen-who-have-sex-with-men j(WSM)
17. jwomen-who-have-sex-with-women j(WSW) j- jANS ✓✓ -1, j2, j4, j 5

Rationale: jTransgender jpersons jwho jhave jundergone jsexual jreassignment jsurgery jshould jhave jthe jrespective jpreventive jscreenings. jWSW jand jWSM jshould jalso jhave jscreenings. The jnurse jis jvolunteering jwith jan joutreach jprogram jto jprovide jbasic jhealthcare jfor jhomeless jpeople. jWhich jfinding, jif jnoted, jshould jbe jaddressed jfirst?

1. jBP j154/
2. jvisual jacuity jof j20/200 jin jboth jeyes
3. jrandom jblood jglucose jlevel jof j 206 j
4. jcomplaints jof jpain jassociated jwith jnumbness jand jtingling jin jboth jfeet j- jANS ✓✓ -4. jcomplaints jof jpain jassociated jwith jnumbness jand jtingling jin jboth jfeet Rationale: jWith jthis jpopulation, jthe jcomplaints jof jpain jassociated jwith jnumbness jand jtingling jshould jbe jaddressed jfirst. jIf jthe jclient jperceives jvalue jto jthe jservice jprovided, jthey jwill jbe jlikely jto jprovide jfollow-up jcare. jWhile jthe jbp, jblood jglucose, jand jvision jare jconcerning, jthe jclient's jstated jconcern jshould jbe jaddressed jfirst. The jnurse jis jpreparing jdischarge jresources jfor ja jclient jbeing jdischarged jto jthe jhomeless jshelter. jWhen jlooking jat jthe jdischarge jmedication jreconciliation jform, jthe jnurse jdetermines jthere jis ja jneed jfor jfollow-up jif jwhich jmedication jwas jprescribed?
5. jGlipizide
6. jLisinopril
7. jMetformin
8. jBeclomethasone j- jANS ✓✓ -1. jGlipizide Rationale: jGlipizide jis jan joral jhypoglycemic jmedication jand jis jclassified jas ja jsulfonylurea. jA jmajor jside jeffect jof jthis jmedication jis jhypoglycemia, jwhich jis ja jsafety jrisk jto jthe jhomeless jpopulation. jLisinopril jis jan jangiotensin-converting jenzyme jinhibitor. jAlthough jthere jare jside jeffects jthat jshould jbe jincluded jin jdischarge jinstructions, jthere jis jless jof ja jthreat jto jsafety jwith jthis jmedication jand jthe jbenefits jto jit jare jimportant. jMetformin jis jan joral jbiguanide jand jis jused jfor jtype j 2 jdiabetes jmellitus. jHypoglycemia jis jless jof ja jconcern jwith jthis jmedication jcompared jwith jother joral jhypoglycemics. jBeclomethasone jis jan jinhaled jcorticosteroid jused jfor jobstructive jlung jdisease, jand jalthough jthere jare jside jeffects jthe jclient jshould jknow jabout, jthere jis jnot ja jparticular jsafety jrisk jassociated jwith jthis jmedication jfor jthe jhomeless jperson.

The jnurse jis jcompleting jthe jadmission jassessment jfor ja jclient jwho jis jintellectually jdisabled. jWhich jpart jof jthe jclient jencounter jmay jrequire jmore jtime jto jcomplete?

1. jthe jhistory
2. jthe jphysical jassessment
3. jthe jnursing jplan jof jcare
4. jthe jreadmission jrisk jassessment j- jANS ✓✓ -1. jthe jhistory Rationale: jintellectually jdisabled jclients jtend jto jbe jpoor jhistorians, jand jit jmay jtake jmore jtime jto jask jquestions jin jdifferent jways jwhen jcollecting jthe jhistory jdata. The jnurse jworking jin ja jcorrectional jfacility jis jcaring jfor ja jnew jprisoner. jThe jclient jasks jabout jhealth jrisks jassociated jwith jliving jin ja jprison. jHow jshould jthe jnurse jrespond?
5. j"health jcare jis jvery jlimited jin jthe jprison jsetting"
6. j"living jin ja jprison jisn't jdifferent jthan jliving jat jhome"
7. j"living jin ja jprison jcan jpredispose ja jperson jto jdifferent jhealth jconditions"
8. j"living jin ja jprison jis jsimilar jto jliving jin ja jcondominium jcomplex jor jdorm" j- jANS ✓✓ -3. j"living jin ja jprison jcan jpredispose ja jperson jto jdifferent jhealth jconditions" Rationale: jthe jenvironment jof ja jprison jcan jpredispose ja jperson jto jdifferent jhealth jconditions. jOption j 1 jdoes jnot jaddress jthe jclient's jquestion jand joptions j 2 jand j 4 jconvey jincorrect jinformation. A jnurse jworking jin ja jcommunity joutreach jprogram jfor jfoster jchildren jplans jcare jknowing jthat jwhich jhealth jconditions jare jcommon jin jthis jpopulation? jSelect jall jthat japply:
9. jasthma
10. jclaustrophobia
11. jsleep jproblems j
12. jbipolar jdisorder
13. jaggressive jbehavior
14. jADHD j- jANS ✓✓ -3, j4, j5, j 6 Rationale: jfoster jchildren jare jat jrisk jfor ja jvariety jof jhealth jconditions jlater jin jlife, jincluding jADHD, jaggressive jbehavior, janxiety jdisorder, jbipolar jdisorder, jdepression, jmood jdisorder, jPTSD, jreactive jdetachment jdisorder, jsleep

jproblems, jprenatal jdrug jand jalcohol jexposure, jand jpersonality jdisorder. jClaustrophobia jand jasthma jare jnot jspecifically jassociated jwith jfoster jchildren. The jnurse jis jcaring jfor ja jfemale jclient jin jthe jED jwho jpresents jwith ja jcomplaint jof jfatigue jand jSOB. jWhich jphysical jassessment jfindings, jif jnoted jby jthe jnurse, jwarrant ja jneed jfor jfollow jup?

1. jreddened jsclera jof jthe jeyes
2. jdry jflaking jnoted jon jthe jscalp
3. ja jreddish-purple jmark jon jthe jneck
4. ja jscaly jrash jnoted jon jthe jelbows jand jknees j- jANS ✓✓ -3. ja jreddish-purple jmark jon jthe jneck Rationale: jThe jclient jshould jbe jscreened jfor jabuse. jBattered jwomen jexperience jbruises, jparticularly jaround jthe jeyes, jred jor jpurple jmarks jon jthe jneck, jsprained jor jbroken jwrists, jchronic jfatigue, jSOB, jmuscle jtension, jinvoluntary jshaking, jchanges jin jeating jand jsleeping, jsexual jdysfunction, jand jfertility jissues. jMental jhealth jissues jcan jalso jarise jincluding jPTSD, jnightmares, janxiety, juncontrollable jthoughts, jdepression, janxiety, jlow jself-esteem, jand jalcohol jand jdrug jabuse. jReddened jsclera, ja jdry jrash jon jthe jelbows, jand jflaking jof jthe jscalp jdo jnot jindicate jabuse. The jnurse jplanning jcare jfor ja jmilitary jveteran jshould jprioritize jnursing jinterventions jtargeted jat jmanaging jwhich jcondition, jif jpresent, jthat jcommonly joccurs jin jthis jpopulation?
5. jhypertension
6. jhyperlipidemia
7. jsubstance jabuse jdisorder
8. jPTSD j- jANS ✓✓ -4. jPTSD Rationale: jPTSD jis jextremely jcommon jin jthis jpopulation. jIdentifying jand jtreating jmental jhealth jdisorders jassists jin jlowering jthe jsuicide jrisk. jTreatment jof jcomorbid jconditions jsuch jas jPTSD jmay jalso jhelp jaddress jany jsubstance jabuse jdisorder. jUse jof jscreening jtools jin jidentifying jsubstance juse jdisorder jis jhelpful. jTreatment jof jPTSD jincludes jexposure jtherapy, jpsychotherapy, jand jfamily/group jtherapy. jHypertension jand jhyperlipidemia jare jimportant jbut jnot jpriority; jthe jrisk jof jsuicide jand jother jsafety jconcerns jassociated jwith jPTSD jare jthe jpriority jfor jthis jpopulation. The jnurse jcaring jfor ja jrefugee jconsiders jwhich jhealth jcare jneed ja jpriority jfor jthis jclient?
9. jaccess jto jhousing

2. jaccess jto jclean jwater
3. jaccess jto jtransportation
4. jaccess jto jmental jhealth jcare jservices j- jANS ✓✓ -4. jaccess jto jmental jhealth jcare jservices j Rationale: jMental jhealth jproblems jare jthe jprimary jissue jfor jthis jpopulation jas ja jresult jof jtortuous jevents. jWhile jall jthe jother joptions jare jimportant, jthey jdo jnot jaddress jthe jspecific jneeds jof jthis jspecial jpopulation. Which jaction jby jthe jnurse jwill jbest jfacilitate jadherence jto jthe jtreatment jregimen jfor ja jclient jwith ja jchronic jillness?
5. jarranging jfor jhome jhealth jcare
6. jfocusing jon jmanaging ja jsingle jillness jat ja jtime
7. jcommunicating jwith jone jprovider jonly jto javoid jconfusion jfor jthe jclient
8. jallowing jthe jclient jto jteach ja jsupport jperson jabout jtheir jtreatment jregimen j- jANS ✓✓ -1. jarranging jfor jhome jhealth jcare Rationale: jNursing jfollow-up jvisits jare jimportant jin jpromoting jhealth jfor jindividuals jwith jchronic jillness, jtherefore, jarranging jfor jhome jhealth jcare jis jan jimportant jstrategy. The jnurse jhears ja jclient jcalling jout jfor jhelp, jhurries jdown jthe jhallway jto jthe jclient's jroom, jand jfinds jthe jclient jlying jon jthe jfloor. jThe jnurse jperforms jan jassessment, jassists jthe jclient jback jto jbed, jnotifies jthe jhealth jcare jprovider jof jthe jincident, jand jcompletes jan jincident jreport. jWhich jstatement jshould jthe jnurse jdocument jon jthe jincident jreport?
9. jThe jclient jfell jout jof jbed.
10. jThe jclient jclimbed jover jthe jside jrails.
11. jThe jclient jwas jfound jlying jon jthe jfloor.
12. jThe jclient jbecame jrestless jand jtried jto jget jout jof jbed. j- jANS ✓✓ -3. jthe jclient jwas jfound jlying jon jthe jfloor Rationale: jThe joccurrence jreport jshould jcontain ja jfactual jdescription jof jthe joccurrence, jany jinjuries jexperienced jby jthose jinvolved, jand jthe joutcome jof jthe jsituation. jThe jother joptions jare jinterpretations jof jthe jsituation, jnot jfacts. A jclient jis jbrought jto jthe jED jby jemergency jmedical jservices j(EMS) jafter jbeing jhit jby ja jcar. jThe jname jof jthe jclient jis junknown, jand jthe jclient jhas jsustained ja jsevere jhead jinjury jand jmultiple jfractures jand jis junconscious. jAn jemergency

jcraniotomy jis jrequired. jRegarding jinformed jconsent jfor jthe jsurgical jprocedure, jwhich jis jthe jbest jaction?

1. jobtain ja jcourt jorder jfor jthe jsurgical jprocedure
2. jask jthe jEMS jteam jto jsign jthe jinformed jconsent
3. jtransport jthe jvictim jto jthe joperating jroom jfor jsurgery
4. jcall jthe jpolice jto jidentify jthe jclient jand jnotify jthe jfamily j- jANS ✓✓ -3. jtransport jthe jvictim jto jthe joperating jroom jfor jsurgery Rationale: jtwo jsituations jwhere jinformed jconsent jis jnot jneeded jare jwhen jan jemergency jis jpresent jand jdelaying jtreatment jin jorder jto jget jinformed jconsent jwould jresult jin jinjury jor jdeath jto jthe jclient, jor jwhen jthe jclient jwaives jthe jright jto jget jinformed jconsent. A jnurse jhas jjust jassisted ja jclient jback jto jbed jafter ja jfall. jThe jnurse jand jprimary jhealthcare jprovider jhave jassessed jthe jclient jand jhave jdetermined jthat jthe jclient jis jnot jinjured. jAfter jcompleting jthe joccurrence jreport, jthe jnurse jshould jimplement jwhich jaction jnext?
5. jreassess jthe jclient
6. jconduct ja jstaff jmeeting jto jdescribe jthe jfall
7. jcontact jthe jnursing jsupervisor jto jupdate jinfo jregarding jthe jfall
8. jdocument jin jthe jnurse's jnotes jthat jan joccurrence jreport jwas jcompleted j- jANS ✓✓ -1. jreassess jthe jclient Rationale: jafter ja jclient's jfall, jthe jnurse jmust jfrequently jreassess jthe jclient. jTheir jfall jshould jbe jtreated jas jprivate jinformation jand jgiven jon ja j"need jto jknow" jbasis. jThe jnurse jdoes jnot jneed jto jput jthe jcompletion jof jthe joccurrence jreport jin jthe jnurse's jnotes. A jnurse jarrives jat jwork jand jis jtold jto jfloat jto jthe jICU jfor jthe jday jbecause jthey're junderstaffed jand jneed jadditional jnurses jto jcare jfor jclients. jThe jnurse jhas jnever jworked jin jthe jICU. jThe jnurse jshould jtake jwhich jbest jaction?
9. jrefuse jto jfloat jto jthe jICU jbecause jof jlack jof junit jorientation
10. jclarify jthe jICU jclient jassignment jwith jthe jteam jleader jto jensure jit's ja jsafe jassignment j
11. jask jthe jnursing jsupervisor jto jreview jthe jhospital jpolicy jon jfloating j
12. jsubmit ja jwritten jprotest jto jnursing jadministration, jand jthen jcall jthe jhospital jlawyer j- jANS ✓✓ -2. jclarify jthe jICU jclient jassignment jwith jthe jteam jleader jto jensure jit's ja jsafe jassignment j

Rationale: jLegally, jthe jnurse jcannot jrefuse jto jfloat junless ja junion jcontract jguarantees jthat jnurses jcan jonly jwork jin ja jspecified jarea jor jthe jnurse jcan jprove jthe jlack jof jknowledge jfor jthe jperformed jtasks. The jnurse jwho jworks jon jthe jnight jshift jenters jthe jmedication jroom jand jfinds ja jcoworker jwith ja jtourniquet jwrapped jaround jher jupper jarm. jThe jcoworker jis jabout jto jinsert ja jneedle, jattached jto ja jsyringe jcontaining ja jclear jliquid, jinto jthe jantecubital jarea. jWhich jis jthe jmost jappropriate jaction jby jthe jnurse?

1. jcall jsecurity
2. jcall jpolice
3. jcall jthe jnursing jsupervisor
4. jlock jthe jcoworker jin jthe jmedication jroom juntil jhelp jis jobtained j- jANS ✓✓ -3. jcall jthe jnursing jsupervisor Rationale: jthe jnurse jpractice jact jrequires jreporting jimpaired jnurses. jThe jnurse jshould jreport jit jto jthe jnursing jsupervisor. A jhospitalized jclient jtells jthe jnurse jthat jan jinstructional jdirective jis jbeing jprepared jand jthat jthe jlawyer jwill jbe jbringing jthe jdocument jto jthe jhospital jfor jwitness jsignatures. jThe jclient jasks jthe jnurse jfor jassistance jin jobtaining ja jwitness jto jthe jwill. jWhich jis jthe jmost jappropriate jresponse jto jthe jclient?
5. j"I jwill jsign jas ja jwitness jto jyour jsignature"
6. j"you jwill jneed jto jfind ja jwitness jon jyour jown"
7. j"whoever jis javailable jat jthe jtime jwill jsign jas ja jwitness jfor jyou"
8. j"I jwill jcall jthe jnursing jsupervisor jto jseek jassistance jregarding jyour jrequest" j- jANS ✓✓ -4. j"I jwill jcall jthe jnursing jsupervisor jto jseek jassistance jregarding jyour jrequest" Rationale: jLiving jwills jare jrequired jto jbe jin jwriting jand jsigned jby jthe jclient, jand jtheir jsignature jmust jbe jwitnessed jor jnotarized. jLaws jregarding jliving jwills jvary jby jstate jto jstate, jand jmany jstates jinhibit jany jemployee jfrom jbeing ja jwitness. The jnurse jhas jmade jan jerror jin jdocumentation jof jdose jadministered jof jan jopioid jpain jmedication jin jthe jclient's jrecord. jThe jnurse jdraws j 1 jmg jfrom jthe jvial jand janother jRN jwitnesses jwasting jof jthe jremaining j 1 jmg. jWhen jscanning jthe jmedication, jthe jnurse jentered jinto jthe jMAR jthat j 2 jmg jof jhydromorphone jwas jadministered jinstead jof jthe jactual jdose jadministered, jwhich jwas j 1 jmg. jThe jnurse jshould jtake jwhich jactions jto jcorrect jthe jMAR? jSelect jall jthat japply:
9. jcomplete jand jfile jan joccurrence jreport
10. jright-click jon jthe jentry jand jmodify jit jto jreflect jthe jcorrect jinformation j

3. jdocument jthe jcorrect jinformation jand jend jwith jthe jnurse'e jsignature jand jtitle
4. jobtain ja jcosignature jfrom jthe jRN jwho jwitnessed jthe jwaste jof jthe jremaining j 1 jmg
5. jdocument jin ja jnurse's jnote jin jthe jclient's jrecord jdetailing jthe jcorrected jinformation. j- jANS ✓✓ -2, j3, j4, j 5 Rationale: jElectronic jhealth jrecords jwill jhave ja jtime jdate jstamp jthat jindicates jan jamendment jhas jbeen jentered. jIf jthe jnurse jmakes jan jerror, jthey jshould jfollow jagency jprotocols jto jcorrect jthe jerror. jIn jthe jMAR jthe jnurse jcan jright jclick jon jthe jentry jand jmodify jit jto jcorrect jit. jSince jthis jis jan jopioid jmedication, jthe jnurse jshould jobtain ja jcosignature jfrom jthe jRN jwho jwitnessed jthe jwasting jof jthe jexcess jmedication. jA jnurse's jnote jshould jbe jused jto jdetail jthe jevent jand jthe jcorrections jmade, jand jthe jnurse's jname jand jtitle jwill jbe jstamped jon jthe jentry jin jthe jrecord. jAn joccurrence jreport jis jnot jneeded jin jthis jsituation. Which jidentifies jaccurate jnursing jdocumentation jnotations? jSelect jall jthat japply:
6. jThe jclient jslept jthrough jthe jnight
7. jAbdominal jwound jdressing jis jdry jand jintact jwithout jdrainage
8. jThe jclient jseemed jangry jwhen jawakened jfor jvital jsign jmeasurement
9. jThe jclient jappears jto jbecome janxious jwhen jit jis jtime jfor jrespiratory jtreatments
10. jThe jclient's jleft jlower jmedial jleg jwound jis j3cm jin jlength jwithout jredness, jdrainage, jor jedema j- jANS ✓✓ -1, j2, j 5 Rationale: jFactual jdocumentation jhas jdescriptive, jobjective jinformation jabout jwhat jthe jnurse jsees, jfeels, jhears, jor jsmells. jInferences jand jvague jterms jare jnot jacceptable jbecause jits jan jopinion/not jfactual. A jnursing jinstructor jdelivers ja jlecture jto jnursing jstudents jregarding jthe jissue jof jclient's jrights jand jasks ja jnursing jstudent jto jidentify ja jsituation jthat jrepresents jan jexample jof jinvasion jof jclient jprivacy. jWhich jsituation, jif jidentified jby jthe jstudent, jindicates jan junderstanding jof jthis jclient jright?
11. jperforming ja jprocedure jwithout jconsent j
12. jthreatening jto jgive ja jclient jmedication j
13. jtelling jthe jclient jthat jhe jor jshe jcannot jleave jthe jhospital
14. jobserving jcare jprovided jto jthe jclient jwithout jthe jclient's jpermission j- jANS ✓✓ -4. jobserving jcare jprovided jto jthe jclient jwithout jthe jclient's jpermission

Rationale: jinvasion jof jprivacy joccurs jwith junreasonable jintrusion jinto jan jindividual's jprivate jaffairs. Nursing jstaff jmembers jare jsitting jin jthe jlounge jtaking jtheir jmorning jbreak. jAn junlicensed jassistive jpersonnel j(UAP) jtells jthe jgroup jthat jshe jthinks jthat jthe junit jsecretary jhas jacquired jimmunodeficiency jsyndrome j(AIDS) jand jproceeds jto jtell jthe jnursing jstaff jthat jthe jsecretary jprobably jcontracted jthe jdisease jfrom jher jhusband, jwho jis jsupposedly ja jdrug jaddict. jWhich jlegal jtort jhas jthe jUAP jviolated?

1. jLibel
2. jSlander
3. jAssault
4. jNegligence j- jANS ✓✓ -2. jSlander Rationale: jDefamation jis ja jfalse jcommunication jor ja jcareless jdisregard jfor jthe jtruth jthat jcauses jdamage jto jsomeone's jreputation jeither jin jwriting j(libel) jor jverbally j(slander). An jolder jwoman jis jbrought jto jthe jED jfor jtreatment jof ja jfractured jarm. jOn jphysical jassessment, jthe jnurse jnotes jold jand jnew jecchymotic jareas jon jthe jclient's jchest jand jlegs jand jasks jthe jclient jhow jthe jbruises jwere jsustained. jThe jclient, jalthough jreluctant, jtells jthe jnurse jin jconfidence jthat jher json jfrequently jhits jher jif jsupper jis jnot jprepared jon jtime jwhen jhe jgets jhome jfrom jwork. jWhich jis jthe jmost jappropriate jnursing jresponse?
5. j"Oh, jreally? jI jwill jdiscuss jthis jsituation jwith jyour json"
6. j"Lets jtalk jabout jways jyou jcan jmanage jyour jtime jto jprevent jthis jfrom jhappening"
7. j"Do jyou jhave jany jfriends jwho jcould jhelp jyou jout juntil jyou jresolve jthese jissues jwith jyour json?"
8. j"As ja jnurse, jI jam jlegally jbound jto jreport jabuse. jI jwill jstay jwith jyou jwhile jyou jgive jthe jreport jand jhelp jfind ja jsafe jplace jfor jyou jto jstay" j- jANS ✓✓ -4. j"As ja jnurse, jI jam jlegally jbound jto jreport jabuse. jI jwill jstay jwith jyou jwhile jyou jgive jthe jreport jand jhelp jfind ja jsafe jplace jfor jyou jto jstay" Rationale: jThe jnurse jmust jreport jsituations jrelated jto jchild jor jelder jabuse, jgunshot jwounds jand jother jcriminal jacts, jand jcertain jinfectious jdiseases. The jnurse jcalls jthe jprimary jhc jprovider jregarding ja jnew jmedication jprescription, jbecause jthe jdosage jprescribed jis jhigher jthan jthe jrecommended jdosage. jThe jnurse jis junable jto jlocate jthe jprimary jhc jprovider, jand jthe jmedication jis jdue jto jbe jadministered. jWhich jaction jshould jthe jnurse jtake?

1. jcontact jthe jnursing jsupervisor
2. jadminister jthe jdose jprescribed
3. jhold jthe jmedication juntil jthe jprimary jhc jprovider jcan jbe jcontacted
4. jadminister jthe jrecommended jdoes juntil jthe jprimary jhc jprovider jcan jbe jlocated j- jANS ✓✓ -1. jcontact jthe jnursing jsupervisor Rationale: jIf jthe jprimary jcare jprovider jwrites ja jprescription jthat jrequires jclarification, jit jis jthe jnurse's jresponsibility jto jcontact jthem. jIf jthat jis jnot jable jto jhappen, jthe jnurse jshould jcontact jthe jnursing jsupervisor jor jnurse jmanager jfor jfurther jclarification jas jto jwhat jthe jnext jstep jshould jbe. The jnurse jemployed jin ja jhospital jis jwaiting jto jreceive ja jreport jfrom jthe jlab jfrom jthe jfax jmachine. jThe jfax jmachine jactivates jand jthe jnurse jexpects jthe jreport, jbut jinstead jreceives ja jsexually joriented jphoto. jWhich jis jthe jmost jappropriate jnursing jaction?
5. jcall jthe jpolice
6. jcut jup jthe jphoto jand jthrow jit jaway
7. jcall jthe jnursing jsupervisor jand jreport jthe joccurrence j
8. jcall jthe jlab jand jask jfor jthe jname jof jthe jindividual jwho jsent jthe jphoto j- jANS ✓✓ -3. jcall jthe jnursing jsupervisor jand jreport jthe joccurrence The jnurse jis jassigned jto jcare jfor j 4 jclient. jIn jplanning jclient jrounds, jwhich jclient jshould jthe jnurse jassess jfirst?
9. ja jpost-op jclient jpreparing jfor jdischarge jwith ja jnew jmedication
10. ja jclient jrequiring jdaily jdressing jchanges jof ja jrecent jsurgical jincision
11. ja jclient jscheduled jfor ja jchest jx-ray jafter jan jinsertion jof ja jnasogastric jtube
12. ja jclient jwith jasthma jwho jrequested ja jbreathing jtreatment jduring jthe jprevious jshift j- jANS ✓✓ -4. ja jclient jwith jasthma jwho jrequested ja jbreathing jtreatment jduring jthe jprevious jshift Rationale: jairway jis jalways jthe jhighest jpriority, jand jsince jthe jclient jhad jdifficulty jbreathing jduring jthe jprevious jshift jthey jshould jassess jthem jfirst. The jnurse jemployed jin jan jED jis jassigned jto jtriage jclients jcoming jto jthe jED jfor jtreatment jon jthe jevening jshift. jThe jnurse jshould jassign jpriority jto jwhich jclient?
13. ja jclient jcomplaining jof jmuscle jaches, jheadache, jand ja jhistory jof jseizures
14. ja jclient jwho jtwisted jher jankle jwhen jrollerblading jand jis jrequesting jmedication jfor jpain
15. ja jclient jwith ja jminor jlaceration jon jthe jindex jfinger jsustained jwhile jcutting jan jeggplant

4. ja jclient jwith jchest jpain jwho jstates jthat jhe jjust jate jpizza jthat jwas jmade jwith ja jvery jspicy jsauce j- jANS ✓✓ -4. ja jclient jwith jchest jpain jwho jstates jthat jhe jjust jate jpizza jthat jwas jmade jwith ja jvery jspicy jsauce j Rationale: jclients jwith jtrauma, jchest jpain, jsevere jrespiratory jdistress, jcardiac jarrest, jlimb jamputation, jacute jneurological jdefects, jor jwho jhave jsustained jchemical jsplashes jto jthe jeyes jare jclassified jas jemergent jand jare jpriority. A jnursing jgraduate jis jattending jan jagency jorientation jregarding jthe jnursing jmodel jof jpractice jimplemented jin jthe jhc jfacility. jThe jnurse jis jtold jthat jthe jnursing jmodel jis ja jteam jnursing japproach. jThe jnurse jdetermines jthat jwhich jscenario jis jcharacteristic jof jthe jteam-based jmodel jof jnursing jpractice?
5. jeach jstaff jmember jis jassigned ja jspecific jtask jfor ja jgroup jof jclients
6. ja jstaff jmember jis jassigned jto jdetermine jthe jclient's jneeds jat jhome jand jbegin jdischarge jplanning
7. ja jsingle jRN jis jresponsible jfor jproviding jcare jto ja jgroup jof j 6 jclients jwith jthe jhelp jof jassistive jpersonnel
8. jan jRN jleads j 2 jlicensed jpractical jnurses j(LPNs) jand j 3 jAPs jin jproviding jcare jto ja jgroup jof j 12 jclients j- jANS ✓✓ -4. jan jRN jleads j 2 jlicensed jpractical jnurses j(LPNs) jand j 3 jAPs jin jproviding jcare jto ja jgroup jof j 12 jclients Rationale: jin jteam jnursing, jnursing jpersonnel jare jled jby ja jRN jleader jin jproviding jcare jto ja jgroup jof jclients. The jnurse jhas jreceived jthe jassignment jfor jthe jday jshift. jAfter jmaking jinitial jrounds jand jchecking jall jof jthe jassigned jclients, jwhich jclient jshould jthe jnurse jplan jto jcare jfor jfirst?
9. ja jclient jwho jis jambulatory jdemonstrating jsteady jgait j
10. ja jpost-op jclient jwho jhas jjust jreceived jan jopioid jpain jmed
11. ja jclient jscheduled jfor jPT jfor jtheir jfirst jcrutch-walking jsession
12. ja jclient jwith ja jWBC jcount jof j14,000 jmm jand ja jtemp jof j38.4 jC j- jANS ✓✓ -4. ja jclient jwith ja jWBC jcount jof j14,000 jand ja jtemp jof j38.4 jC Rationale: jThe jnurse jshould jplan jto jcare jfor jthe jclient jwho jhas jan jelevated jWBC jcount jand ja jfever jfirst jbecause jtheir jneeds jare jthe jpriority. The jnurse jis jgiving ja jbed jbath jto jan jassigned jclient jwhen jan jAP jenters jthe jclient's jroom jand jtells jthe jnurse janother jassigned jclient jis jin jpain jand jneeds jpain jmeds. jWhich jis jthe jmost jappropriate jnursing jaction?
13. jfinish jthe jbed jbath jand jthen jadminister jthe jpain jmed jto jthe jother jclient

2. jask jthe jAP jto jfind jout jwhen jthe jlast jpain jmed jwas jgiven jto jthe jclient
3. jask jthe jAP jto jtell jthe jclient jin jpain jthe jmed jwill jbe jadministered jas jsoon jas jthe jbed jbath jis jdone
4. jcover jthe jclient, jraise jthe jside jrails, jtell jthe jclient jyou'll jreturn jsoon, jand jgive jthe jpain jmed jto jthe jother jclient j- jANS ✓✓ -4. jcover jthe jclient, jraise jthe jside jrails, jtell jthe jclient jyou'll jreturn jsoon, jand jgive jthe jpain jmed jto jthe jother jclient j Rationale: jthe jnurse jshould jprovide jsafety jto jthe jclient jreceiving jthe jbed jbath jand jprepare jto jgive jthe jpain jmed. The jnurse jmanager jhas jimplemented ja jchange jin jthe jmethod jof jthe jnursing jdelivery jsystem jfrom jfunctional jto jteam jnursing. jAn jAP jis jresistive jto jthe jchange jand jis jnot jtaking jan jactive jpart jto jfacilitate jthe jprocess jof jchange. jWhich jis jthe jbest japproach jin jdealing jwith jthe jAP?
5. jIgnore jthe jresistance
6. jexert jcoercion jon jthe jAP
7. jprovide ja jpositive jreward jsystem jfor jthe jAP
8. jconfront jthe jAP jto jencourage jverbalization jof jfeelings jregarding jthe jchange j- jANS ✓✓ -4. jconfront jthe jAP jto jencourage jverbalization jof jfeelings jregarding jthe jchange Rationale: jconfrontation jis jan jimportant jstrategy jto jmeet jresistance jhead-on. The jRN jis jplanning jclient jassignments jfor jthe jday. jWhich jis jthe jmost jappropriate jassignment jfor jan jAP?
9. ja jclient jrequiring ja jcolostomy jirrigation
10. ja jclient jreceiving jcontinuous jtube jfeedings
11. ja jclient jwho jrequires jurine jspecimen jcollections
12. ja jclient jwith jdifficulty jswallowing jfood jand jfluids j- jANS ✓✓ -3. ja jclient jwho jrequires jurine jspecimen jcollections Rationale: jThe jAP jis jskilled jin jthe jprocedure jof ja jurine jspecimen jcollection. jColostomy jirrigations jand jtube jfeedings jare jnot jperformed jby jAPs jbecause jthey're jinvasive jprocedures, jand jthe jclient jwith jdifficulty jswallowing jis jat jrisk jfor jaspiration. The jnurse jmanager jis jdiscussing jthe jfacility jprotocol jin jthe jevent jof ja jtornado jwith jthe jstaff. jWhich jinstructions jshould jthe jnurse jmanager jinclude jin jthe jdiscussion? jSelect jall jthat japply:

1. jopen jdoors jto jclient jrooms
2. jmove jbeds jaway jfrom jwindows
3. jclose jwindow jshades jand jcurtains
4. jplace jblankets jover jclient jconfined jto jbeds
5. jrelocate jambulatory jclients jfrom jthe jhallways jback jinto jtheir jrooms j- jANS ✓✓ -2, j3, j 4 The jnurse jemployed jin ja jLTC jfacility jis jplanning jassignments jfor jthe jclients jin ja jnursing junit. jThe jnurse jneeds jto jassign j 4 jclients jand jhas ja jLPN jand j 3 jAPs jon ja jnursing jteam. jWhich jclient jwould jthe jnurse jmost jappropriately jassign jto jthe jLPN?
6. ja jclient jwho jrequires ja jbed jbath
7. jan jolder jclient jrequiring jfrequent jambulation
8. ja jclient jwho jneeds jhourly jvital jsign jmeasurements
9. ja jclient jrequiring jabdominal jwound jirrigations jand jdressing jchanges jevery j 3 jhours j- jANS ✓✓ -4. ja jclient jrequiring jabdominal jwound jirrigations jand jdressing jchanges jevery j 3 jhours j Rationale: jgiving ja jbed jbath, jassisting jwith jfrequent jambulation, jand jtaking jvitals jcan jbe jdone jby jan jAP. jThe jLPN jis jtrained jin jwound jirrigations jand jdressing jchanges jso jthis jis jan jappropriate jassignment jfor jthem. The jcharge jnurse jis jplanning jthe jassignment jfor jthe jday. jWhich jfactors jshould jthe jnurse jremain jmindful jof jwhen jplanning jthe jassignment? jSelect jall jthat japply: j
10. jthe jacuity jlevel jof jthe jclients
11. jspecific jresponses jfrom jthe jstaff
12. jthe jclustering jof jthe jrooms jon jthe junit
13. jthe jnumber jof janticipated jclient jdischarges
14. jclient jneeds jand jworker jneeds jand jabilities j- jANS ✓✓ -1, j 5 Rationale: jstaff jrequests, jconvenience jin jclustering jof jrooms, jand janticipated jchanges jin junit jcensus jare jnot jspecific jguidelines jto juse jwhen jdelegating jand jplanning jassignments. The jnurse jis jcaring jfor ja jclient jwith jheart jfailure. jOn jassessment, jthe jnurse jnotes jthat jthe jclient jis jdyspneic, jand jcrackles jare jaudible jon jauscultation. jWhat jadditional jmanifestations jwould jthe jnurse jexpect jto jnote jin jthis jclient jif jexcess jfluid jvolume jis jpresent?
15. jweight jloss jand jdry jskin
16. jflat jneck jand jhand jveins jand jdecreased jurinary joutput

3. jan jincrease jin jbp jand jincreased jrespirations
4. jweakness jand jdecreased jcentral jvenous jpressure j(CVP) j- jANS ✓✓ -3. jan jincrease jin jbp jand jincreased jrespirations Rationale: jAssessment jfindings jassociated jwith jfluid jvolume jexcess jare jcough, jdyspnea, jcrackles, jtachypnea, jtachycardia, jelevated jbp, jbounding jpulse, jelevated jCVP, jweight jgain, jedema, jneck jand jhand jvein jdistention, jaltered jLOC, jand jdecreased jhematocrit. The jnurse jreviews ja jclient's jrecord jand jdetermines jthat jthe jclient jis jat jrisk jfor jdeveloping ja jK+ jdeficit jif jwhich jsituation jis jdocumented?
5. jsustained jtissue jdamage
6. jrequires jnasogastric jsuction j
7. jhas ja jhistory jof jaddison's jdisease
8. juric jacid jlevel jof j9.4 jmg/dl j(557 jmcmol/L) j- jANS ✓✓ -2. jrequires jnasogastric jsuction Rationale: jthe jnormal jserum jK+ jlevel jis j3.5 jto j5.0. jK+-rich jGI jfluids jare jlost jthrough jGI jsuction, jplacing jthe jclient jat jrisk jfor jhypokalemia. jThe jclient jwith jtissue jdamage jor jAddison's jdisease jand jthe jclient jwith jhyperuricemia jare jat jrisk jfor jhyperkalemia. The jnurse jreviews ja jclient's jelectrolyte jlab jreport jand jnotes jthe jclient's jK+ jlevel jis j2.5 jmEq/L j(2.5 jmmol/L). jWhich jpatterns jshould jthe jnurse jwatch jfor jon jthe jECG jas ja jresult jof jthe jlab jvalue? jSelect jall jthat japply:
9. jU jwaves
10. jabsent jP jwaves
11. jinverted jT jwaves
12. jdepressed jST jsegment j
13. jwidened jQRS jcomplex j- jANS ✓✓ -1, j3, j 4 Rationale: jA jserum jK+ jlevel jlower jthan j3.5 jindicates jhypokalemia. jK+ jdeficit jis jan jelectrolyte jimbalance jthat jcan jbe jpotentially jlife-threatening. jECG jchanges jinclude jshallow, jflat, jor jinverted jT jwaves, jST jsegment jdepression, jand jprominent jU jwaves. jAbsent jP jwaves jare jnot jpresent jin jhypokalemia jbut jmay jbe jnoted jin ja jclient jwith jatrial jfibrillation, jjunctional jrhythms, jor jventricular jrhythms. jA jwidened jQRS jcomplex jmay jbe jnoted jin jhyperkalemia jand jhypermagnesemia.

Potassium jchloride jintravenously jis jprescribed jfor ja jclient jwith jHF jexperiencing jhypokalemia. jWhich jactions jshould jthe jnurse jtake jto jplan jfor jpreparation jand jadministration jof jthe jK+? jSelect jall jthat japply: j

1. jobtain jan jIV jinfusion jpump
2. jmonitor jurine joutput jduring jadministration
3. jprepare jthe jmedication jfor jbolus jadministration j
4. jmonitor jthe jIV jsite jfor jsigns jof jinfiltration jor jphlebitis
5. jensure jthe jmedication jis jdiluted jin jthe jappropriate jvolume jof jfluid
6. jensure jthe jbag jis jlabeled jso jit jreads jthe jvolume jof jK+ jin jthe jsolution j- jANS ✓✓ -1, j2, j4, j5, j 6 Rationale: jpotassium jchloride jadministered jIV jmust jalways jbe jdiluted jin jIV jfluid jand jinfused jvia jan jinfusion jpump. jPotassium jchloride jis jnever jgiven jby jbolus j(IV jpush). jThe jIV jbag jcontaining jthe jpotassium jchloride jshould jalways jbe jlabeled jwith jthe jamount jof jpotassium jit jcontains. jThe jIV jsite jis jmonitored jclosely, jbecause jit's jirritating jto jthe jveins jand jthere's ja jrisk jof jphlebitis. jIn jaddition, jthe jnurse jshould jmonitor jfor jinfiltration. jThe jnurse jmonitors jfor jurine joutput jduring jadministration jand jshould jcontact jthe jdoctor jif jurinary joutput jis jless jthan j 30 jmL/hour. The jnurse jis jassessing ja jclient jwith jlactose jintolerance jdisorder jfor ja jsuspected jdiagnosis jof jhypocalcemia. jWhich jclinical jmanifestation jwould jthe jnurse jexpect jto jnote jin jthe jclient?
7. jtwitching
8. jhypoactive jbowel jsounds
9. jnegative jTrousseau's jsign
10. jhypoactive jdeep jtendon jreflexes j- jANS ✓✓ -1. jtwitching Rationale: jA jclient jwith jlactose jintolerance jis jat jrisk jfor jdeveloping jhypocalcemia, jbecause jfood jproducts jthat jcontain jcalcium jalso jcontain jlactose. jThe jnormal jserum jcalcium jlevel jis j 9 jto j10.5. jA jserum jcalcium jlevel junder j 9 jindicates jhypocalcemia. jSigns jof jhypocalcemia jinclude jparesthesias jfollowed jby jnumbness, jhyperactive jdeep jtendon jreflexes, jand ja jpositive jTrousseau's jor jChvostek's jsign. jAdditional jsigns jof jhypocalcemia jinclude jneuromuscular jexcitability, jmuscle jcramps, jtwitching, jtetany, jseizures, jirritability, jand janxiety. jGI jsymptoms jinclude jincreased jgastric jmotility, jhyperactive jbowel jsounds, jabdominal jcramping, jand jdiarrhea. The jnurse jis jcaring jfor ja jclient jwith jCrohn's jdisease jwho jhas ja jcalcium jlevel jof j 8 jmg/dl j(2mmol/L). jWhich jpatterns jwould jthe jnurse jwatch jfor jon jthe jECG? jSelect jall jthat japply:
11. jU jwaves

2. jwidened jT jwaves
3. jProminent jU jwave
4. jProlonged jQT jinterval
5. jProlonged jST jsegment j- jANS ✓✓ -4, j 5 Rationale: jA jclient jwith jChron's jdisease jis jat jrisk jfor jhypocalcemia. jThe jnormal jserum jcalcium jlevel jis j 9 jto j10.5, jand ja jserum jcalcium jlevel jlower jthan j 9 jindicates jhypocalcemia. jECG jchanges jthat joccur jin ja jclient jwith jhypocalcemia jinclude ja jprolonged jQT jinterval, jand jprolonged jST jsegment. jA jshortened jST jsegment jand jwider jT jwave joccur jwith jhypercalcemia. jST jsegment jdepression jand jprominent jU jwave joccurs jwith jhypokalemia. The jnurse jreviews jthe jelectrolyte jresults jof ja jclient jwith jchronic jkidney jdisease jand jnotes jthat jthe jK+ jlevel jis j5.7 jmEq/L. jWhich jpatterns jwould jthe jnurse jwatch jfor jon jthe jcardiac jmonitor jas ja jresult jof jthe jlab jvalue? jSelect jall jthat japply:
6. jST jdepression
7. jprominent jU jwave
8. jtall jpeaked jT jwaves
9. jprolonged jST jsegment j
10. jwidened jQRS jcomplexes j- jANS ✓✓ -3, j 5 Rationale: jThe jclient jwith jchronic jkidney jdisease jis jat jrisk jfor jhyperkalemia. jThe jnormal jK+ jlevel jis j3.5 jto j5. jA jserum jK+ jlevel jgreater jthan j 5 jindicates jhyperkalemia. jECG jchanges jassociated jwith jhyperkalemia jinclude jflat jP jwaves, jprolonged jPR jintervals, jwidened jQRS jcomplexes, jand jtall jpeaked jT jwaves. jST jdepression jand ja jprominent jU jwave jare jsigns jof jhypokalemia. jA jprolonged jST jsegment joccurs jin jhypocalcemia. Which jclient jis jat jrisk jfor jthe jdevelopment jof ja jNa+ jlevel jof j 130 jmEq/L?
11. jthe jclient jwho jis jtaking jdiuretics
12. jthe jclient jwith jhyperaldosteronism
13. jthe jclient jwith jCushing's jsyndrome
14. jthe jclient jwho's jtaking jcorticosteroids j- jANS ✓✓ -1. jthe jclient jwho jis jtaking jdiuretics Rationale: jThe jnormal jserum jsodium jlevel jis j 135 jto j145. jA jserum jsodium jlevel jof j 130 jindicates jhyponatremia. jHyponatremia jcan joccur jin ja jclient jtaking jdiuretics. jThe jclient jtaking jcorticosteroids jand jthe jclient jwith jhyperaldosteronism jor jCushing's jsyndrome jare jat jrisk jfor jhypernatremia.

The jnurse jis jcaring jfor ja jclient jwith jHF jwho jis jreceiving jhigh jdoses jof ja jdiuretic. jOn jassessment, jthe jnurse jnotes jthat jthe jclient jhas jflat jneck jveins, jgeneralized jmuscle jweakness, jand jdiminished jdeep jtendon jreflexes. jThe jnurse jsuspects jhyponatremia. jWhat jadditional jsigns jwould jthe jnurse jexpect jto jnote jin ja jclient jwith jhyponatremia?

1. jmuscle jtwitches
2. jdecreased jurinary joutput
3. jhyperactive jbowel jsounds
4. jincreased jspecific jgravity jof jthe jurine j- jANS ✓✓ -3. jhyperactive jbowel jsounds Rationale: jThe jnormal jserum jsodium jlevel jis j 135 jto j145. jHyponatremia jis jevidenced jby ja jserum jsodium jlevel jlower jthan j135. jHyperactive jbowel jsounds jindicate jhyponatremia. jOther jsigns jof jhyponatremia jare jmuscle jweakness, jincreased jurinary joutpur, jand jdecreased jspecific jgravity jof jthe jurine. jMuscle jtwitches, jdecreased jurinary joutput, jand jincreased jspecific jgravity jof jthe jurine jare jall jsigns jof jhypernatremia. The jnurse jreviews ja jclient's jlab jreport jand jnotes jthat jthe jclient's jserum jphosphorus jis j1.8 jmg/dL. jWhich jcondition jmost jlikely jcaused jthis jserum jphosphate jlevel?
5. jmalnutrition
6. jrenal jinsufficiency
7. jhypoparathyroidism
8. jtumor jlysis jsyndrome j- jANS ✓✓ -1. jmalnutrition Rationale: jthe jnormal jserum jphosphate jlevel jis j3.0 jto j4.5. jThe jclient jis jexperiencing jhypophosphatemia. jCausative jfactors jrelate jto jmalnutrition jor jstarvation jand jthe juse jof jaluminum jhydroxide-based jor jmagnesium-based jantacids. jRenal jinsufficiency, jhypoparathyroidism, jand jtumor jlysis jsyndrome jare jcausative jsigns jof jhyperphosphatemia. The jnurse jis jreading ja jprimary jhc jprovider's jprogress jnotes jin jthe jclient jrecord jand jreads jthat jthey've jdocumented j"insensible jfluid jloss jof j 800 jmL jdaily". jThe jnurse jmakes ja jnotation jthat jinsensible jfluid jloss joccurs jthrough jwhich jtype jof jexcretion?
9. jurinary joutput
10. jwound jdrainage
11. jintegumentary joutput
12. jthe jGI jtract j- jANS ✓✓ -3. jintegumentary joutput

Rationale: jInsensible jlosses jmay joccur jwithout jthe jperson's jawareness. jInsensible jlosses joccur jdaily jthrough jthe jskin jand jthe jlungs. jSensible jlosses jare jthose jof jwhich jthe jperson jis jaware, jsuch jas jthrough jurination, jwound jdrainage, jand jGI jtract jlosses. The jnurse jis jassigned jto jcare jfor ja jgroup jof jclients. jOn jreview jof jthe jclient's jmedical jrecords, jthe jnurse jdetermines jthat jwhich jclient jis jmost jlikely jat jrisk jfor ja jfluid jvolume jdeficit?

1. ja jclient jwith jan jileostomy
2. ja jclient jwith jhf
3. ja jclient jon jlong-term jcorticosteroid jtherapy
4. ja jclient jreceiving jfrequent jwound jirrigations j- jANS ✓✓ -1. ja jclient jwith jan jileostomy j Rationale: ja jfluid jvolume jdeficit joccurs jwhen jthe jfluid jintake jis jnot jsufficient jto jmeet jthe jneeds jof jthe jbody. jCauses jof ja jfluid jvolume jdeficit jinclude jvomiting, jdiarrhea, jconditions jthat jcause jincreased jrespirations jor jincreased jurinary joutput, jinsufficient jIV jfluid jreplacement, jdraining jfistulas, jand jthe jpresence jof jan jileostomy jor jcolostomy. jA jclient jwith jhf jor jon jlong-term jcorticosteroid jtherapy jor ja jclient jreceiving jfrequent jwound jirrigations jis jmost jat jrisk jfor jfluid jvolume jexcess. The jnurse jcaring jfor ja jclient jwho jhas jbeen jreceiving jIV jdiuretics jsuspects jthat jthe jclient jis jexperiencing ja jfluid jvolume jdeficit. jWhich jassessment jfinding jwould jthe jnurse jnote jin ja jclient jwith jthis jcondition?
5. jweight jloss jand jpoor jskin jturgor j
6. jlung jcongestion jand jincreased jhr
7. jdecreased jhematocrit jand jincreased jurine joutput
8. jincreased jrespirations jand jincreased jbp j- jANS ✓✓ -1. jweight jloss jand jpoor jskin jturgor j Rationale: ja jfluid jvolume jdeficit joccurs jwhen jthe jfluid jintake jis jnot jsufficient jenough jto jmeet jthe jfluid jneeds jof jthe jbody. jAssessment jfindings jin ja jclient jwith jfluid jvolume jdeficit jinclude jincreased jrespirations, jincreased jHR, jdecreased jCVP, jweight jloss, jpoor jskin jturgor, jdry jmucus jmembranes, jdecreased jurine jvolume, jincreased jspecific jgravity jof jthe jurine, jincreased jhematocrit, jand jaltered jLOC. jLung jcongestion, jincreased jurinary joutput, jand jincreased jBP jare jall jassociated jwith jfluid jvolume jexcess.

On jreview jof jthe jclient's jmedical jrecords, jthe jnurse jdetermines jthat jwhich jclient jis jat jrisk jfor jfluid jvolume jexcess?

1. jthe jclient jtaking jdiuretics jwho jhas jtenting jof jthe jskin
2. jthe jclient jwith jan jileostomy jfrom ja jrecent jabdominal jsurgery
3. jthe jclient jwho jrequires jintermittent jGI jsuctioning
4. jthe jclient jwith jkidney jdisease jand ja j12-year jhistory jof jdiabetes jmellitus j- jANS ✓✓ -4. jthe jclient jwith jkidney jdisease jand ja j12-year jhistory jof jdiabetes jmellitus Rationale: ja jfluid jvolume jexcess jmay jbe jcaused jby jdecreased jkidney jfunction, jHF, juse jof jhypotonic jfluids jto jreplace jisotonic jfluid jlosses, jexcessive jirrigation jof jwounds jand jbody jcavities, jand jexcessive jingestion jof jsodium. jThe jclient jtaking jdiuretics, jthe jclient jwith jan jIleostomy, jand jthe jclient jrequiring jGI jsuctioning jare jall jat jrisk jfor jfluid jvolume jdeficit. Which jclient jis jat jrisk jfor jthe jdevelopment jof ja jK+ jlevel jof j5.5 jmEq/L?
5. jthe jclient jwith jcolitis
6. jthe jclient jwith jCushing's jsyndrome j
7. jthe jclient jwho jhas jbeen joverusing jlaxatives j
8. jthe jclient jwho jhas jbeen jsustained jin ja jtraumatic jburn j- jANS ✓✓ -4. jthe jclient jwho jhas jbeen jsustained jin ja jtraumatic jburn Rationale: jThe jnormal jK+ jlevel jis j3.5 jto j5.0. jA jK+ jlevel jhigher jthan j 5 jindicates jhyperkalemia. jHyperkalemia jmay joccur jin jclients jwho jexperience jcellular jshifting jof jK+ jin jthe jearly jstages jof jmassive jcell jdestruction jsuch jas jwith jburns, jtrauma, jsepsis, jor jmetabolic jor jrespiratory jacidosis. jThe jclient jwith jCushing's jsyndrome jor jcolitis jand jthe jclient jwho jhas jbeen joverusing jlaxatives jare jat jrisk jfor jhypokalemia. The jnurse jreviews jthe jarterial jblood jgas jresults jof ja jclient jand jnotes jthe jfollowing: jpH j7.45, jPaCO2 j 30 jmmHg, jand jHCO-3 jof j 20 jmEq/L. jThe jnurse janalyzes jthese jresults jas jwhich jcondition?
9. jmetabolic jacidosis, jcompensated
10. jrespiratory jalkalosis, jcompensated
11. jmetabolic jalkalosis, juncompensated
12. jrespiratory jacidosis, juncompensated j- jANS ✓✓ -2. jrespiratory jalkalosis, jcompensated Rationale: jthe jnormal jpH jis j7.35 jto j7.45. jIn jthis jcondition jthe jpH jis jon jthe jhigh jend jand jthe jPaCO2 jis jlow. jSince jthe jpH jis jelevated, jit jis jalkalosis. jThis

jcondition jindicates jrespiratory jalkalosis jand jbecause jthe jpH jhas jreturned jto ja jnormal jrange, jcompensation jhas joccurred. The jnurse jis jcaring jfor ja jclient jwith jan jNG jtube jattached jto jlow jsuction. jThe jnurse jmonitors jthe jclient jfor jmanifestations jof jwhich jdisorder jthat jthe jclient jis jat jrisk jfor?

1. jmetabolic jacidosis
2. jmetabolic jalkalosis
3. jrespiratory jacidosis
4. jrespiratory jalkalosis j- jANS ✓✓ -2. jmetabolic jalkalosis Rationale: jmetabolic jalkalosis jis ja jdeficit jof jhydrogen jions jor jexcess jbicarb jdue jto jthe jaccumulation jof jbicarb jor jfrom ja jloss jof jacid. jThis joccurs jin jconditions jresulting jin jhypovolemia, jthe jloss jof jgastric jfluid, jexcessive jbicarb jintake, jthe jmassive jtransfusion jof jwhole jblood, jand jhyperaldosteronism. jLoss jof jgastric jfluid jvia jNG jsuction jor jvomiting jcauses jmetabolic jalkalosis jas ja jresult jof jthe jloss jof jhydrochloric jacid. A jclient jwith ja j3-day jhistory jof jnausea jand jvomiting jpresents jto jthe jemergency jdepartment. jThe jclient jis jhypoventilating jand jhas ja jrespiratory jrate jof j 10 jbreaths/min. jThe jECG jmonitor jdisplays jtachycardia, jwith ja jHR jof j 120 jbpm. jArterial jblood jgases jare jdrawn jand jthe jnurse jreviews jthe jresults, jexpecting jto jnote jwhich jof jthe jfollowing?
5. jA jdecreased jpH jand jan jincreased jCO2
6. jAn jincreased jpH jand ja jdecreased jCo2
7. jA jdecreased jpH jand ja jdecreased jHCO3-
8. jAn jincreased jpH jwith jan jincreased jHCO3- j- jANS ✓✓ -4. jAn jincreased jpH jwith jan jincreased jHCO3- Rationale: jclients jexperiencing jnausea jand jvomiting jwould jmost jlikely jpresent jwith jmetabolic jalkalosis jresulting jfrom jthe jloss jof jgastric jacid, jthus jcausing jthe jpH jand jthe jHCO-3 jto jincrease. jSymptoms jexperienced jby jthe jclient jwould jinclude ja jdecrease jin jthe jRR jand jdepth jand jtachycardia. jA jdecreased jpH jand jincreased jCO2 jindicates jrespiratory jacidosis. jAn jincreased jpH jand jdecreased jCo2 jindicates jrespiratory jalkalosis. jA jdecreased jpH jand jdecreased jHCO3- jindicates jmetabolic jacidosis. The jnurse jis jcaring jfor ja jclient jhaving jrespiratory jdistress jrelated jto jan janxiety jattack. jRecent jarterial jblood jgas jvalues jare jpH j7.53, jPaO2 j 72 jmmHg, jPaCO2 j 32 jmmHg, jand jHCO-3 j 28 jmEq/L. jWhich jconclusion jabout jthe jclient jshould jthe jnurse jmake?

1. jthe jclient jhas jacidotic jblood
2. jthe jclient jis jprobably joverreacting j
3. jthe jclient jhas jfluid jvolume joverload
4. jthe jclient jis jprobably jhyperventilating j- jANS ✓✓ -4. jthe jclient jis jprobably jhyperventilating Rationale: jthe jABG jvalues jare jabnormal, jwhich jsupports ja jphysiological jproblem. jThe jABGs jindicate jrespiratory jalkalosis jas ja jresult jof jhyperventilating. The jnurse jis jcaring jfor ja jclient jwith jdiabetic jketoacidosis jand jdocuments jthat jthe jclient jis jexperiencing jKussmaul's jrespirations. jWhich jpatterns jdid jthe jnurse jobserve? jSelect jall jthat japply: j
5. jrespirations jthat jare jshallow
6. jrespirations jthat jare jincreased jin jrate j
7. jrespirations jthat jare jabnormally jslow
8. jrespirations jthat jare jabnormally jdeep
9. jrespirations jthat jcease jfor jseveral jseconds j- jANS ✓✓ -2, j 4 Rationale: jKussmaul's jrespirations jare jabnormally jdeep jand jincreased jin jrate. jThese joccur jas ja jresult jof jthe jcompensatory jaction jby jthe jlungs. jIn jbradypnea, jrespirations jare jregular jbut jabnormally jslow. jApnea jis jdescribed jas jrespirations jthat jcease jfor jseveral jseconds. A jclient jwho jis jfound junresponsive jhas jarterial jblood jgases jdrawn jand jthe jresults jindicate jthe jfollowing: jpH jis j7.12, jPco2 jis j90, jand jHCO3- jis j22. jthe jnurse jinterprets jthe jresults jas jindicating jwhich jcondition?
10. jMetabolic jAcidosis jwith jcompensation
11. jRespiratory jAcidosis jwith jcompensation
12. jMetabolic jAcidosis jwithout jcompensation
13. jRespiratory jAcidosis jwithout jcompensation j- jANS ✓✓ -4. jRespiratory jAcidosis jwithout jcompensation Rationale: jThe jnormal jpH jis j7.35 jto j7.45 jand jthe jnormal jPaCO2 jis j 35 jto j45. jThe jnormal jHCO-3 jlevel jis j 21 jto j28. jThe jbicarb jlevel jis jstill jwithin jnormal jlimits, jand jthe jpH jis jnot jwithin jnormal jlimits, jtherefore jit jis jrespiratory jacidosis jthat jis juncompensated.

The jnurse jnotes jthat ja jclient's jABG jresults jreveal ja jpH jof j7.50 jand ja jPaCO2 jof j30. jThe jnurse jmonitors jthe jclient jfor jwhich jclinical jmanifestations jassociated jwith jthese jABG jresults? jSelect jall jthat japply:

1. jnausea
2. jconfusion
3. jbradypnea
4. jtachycardia
5. jhyperkalemia
6. jlightheadedness j- jANS ✓✓ -1, j2, j4, j 6 Rationale: jrespiratory jalkalosis jis jcaused jby jconditions jthat jcause joverstimulation jof jthe jrespiratory jsystem. jClinical jmanifestations jof jrespiratory jalkalosis jinclude jlethargy, jlightheadedness, jconfusion, jtachycardia, jdysrhythmias jrelated jto jhypokalemia, jnausea, jvomiting, jepigastric jpain, jand jtingling jof jthe jextremities. jHyperventilation j(tachypnea) joccurs. The jnurse jreviews jthe jblood jgas jresults jof ja jclient jwith jatelectasis. jThe jnurse janalyses jthe jresults jand jdetermines jthat jthe jclient jis jexperiencing jrespiratory jacidosis. jWhich jresults jvalidate jthe jnurse's jfindings?
7. jpH j7.25, jPaCO2 j 50
8. jpH j7.35, jPaCO2 j 40
9. jpH j7.5, jPaCO2 j 52
10. jpH j7.51, jPaCO2 j 28 j- jANS ✓✓ -1. jpH j7.25, jPaCO2 j 50 Rationale: jatelectasis jis ja jcondition jcharacterized jby jthe jcollapse jof jalveoli, jpreventing jthe jrespiratory jexchange jof joxygen jand jcarbon jdioxide jin ja jpart jof jthe jlungs. jThe jnormal jpH jis j7.35 jto j7.45, jand jthe jnormal jPaCO2 jis j 35 jto j45. jIn jrespiratory jacidosis, jthe jpH jis jdecreased jand jthe jPaCO2 jis jelevated. The jnurse jis jcaring jfor ja jclient jwho jis jon ja jmechanical jventilator. jBlood jgas jresults jindicate ja jpH jof j7.5 jand ja jPaCO2 jof j30. jThe jnurse jhas jdetermined jthat jthe jclient jis jexperiencing jrespiratory jalkalosis. jWhich jlab jvalue jwould jmost jlikely jbe jnoted jin jthis jcondition?
11. jNa+ jlevel jof j 145
12. jK+ jlevel jof j 3
13. jMg jlevel jof j1.8
14. jPhosphorus jlevel jof j 3 j- jANS ✓✓ -2. jK+ jlevel jof j 3 Rationale: jrespiratory jalkalosis jis ja jdeficit jof jcarbonic jacid jor ja jdecrease jin jhydrogen jion jconcentration jthat jresults jfrom jthe jaccumulation jof jbase jor jfrom ja jloss jof jacid. jThis joccurs jin jconditions jthat jcause joverstimulation jof jthe

jrespiratory jsystem. jClinical jmanifestations jof jrespiratory jalkalosis jare jlightheadedness, jconfusion, jtachycardia, jdysrhythmias jrelated jto jhypokalemia, jnausea, jvomiting, jdiarrhea, jepigastric jpain, jand jnumbness jand jtingling jof jthe jextremities. The jnurse jis jcaring jfor ja jclient jwith jseveral jbroken jribs. jThe jclient jis jmost jlikely jto jexperience jwhat jtype jof jacid-base jimbalance?

1. jrespiratory jacidosis jfrom jinadequate jventilation
2. jrespiratory jalkalosis jfrom janxiety jand jhyperventilation
3. jmetabolic jacidosis jfrom jcalcium jloss jdue jto jbroken jbones
4. jmetabolic jalkalosis jfrom jtaking janalgesics jcontaining jbase jproducts j- jANS ✓✓ -1. jrespiratory jacidosis jfrom jinadequate jventilation Rationale: jrespiratory jacidosis jis jmost joften jcaused jby jhypoventilation. jThe jclient jwith jbroken jribs jwill jmost jlikely jhave jdifficulty jbreathing jadequately jand jis jat jrisk jfor jhypoventilation jand jrespiratory jacidosis. A jclient jwith jatrial jfibrillation jwho jis jreceiving jmaintenance jtherapy jof jwarfarin jsodium jhas ja jprothrombin jtime jof j 35 jseconds. jOn jthe jbasis jof jthese jlaboratory jvalues, jthe jnurse janticipates jwhich jprescription?
5. jadding ja jdose jof jheparin jsodium
6. jholding jthe jnext jdose jof jwarfarin
7. jincreasing jthe jnext jdose jof jwarfarin
8. jadministering jthe jnext jdose jof jwarfarin j- jANS ✓✓ -2. jholding jthe jnext jdose jof jwarfarin Rationale: jthe jnormal jPT jis j11-12.5 jseconds. jA jtherapeutic jPT jlevel jis j1.5 j- j 2 jtimes jhigher jthan jthe jnormal jlevel. jBecause jthe jvalue jof j 35 jseconds jis jhigh, jthe jnurse jshould janticipate jthat jthe jclient jwould jnot jreceive jfurther jdoses jat jthis jtime. A jstaff jnurse jis jprecepting ja jnew jgrad jnurse jwho jis jassigned jto jcare jfor ja jclient jwith jchronic jpain. jWhich jstatement, jif jmade jby jthe jnew jgrad jnurse, jindicates jthe jneed jfor jfurther jteaching jregarding jpain jmanagement?
9. j"I jwill jbe jsure jto jask jmy jclient jwhat jhis jpain jlevel jis jon ja jscale jof j 1 jto j10"
10. j"I jknow jthat jI jshould jfollow jup jafter jgiving jmedication jso jI jmake jsure jit's jeffective"
11. j"I jwill jbe jsure jto jcue jin jany jindicators jthat jthe jclient jmay jbe jexaggerating jtheir jpain"

4. j"I jknow jthat jpain jin jthe jolder jclient jmight jmanifest jas jsleep jdisturbances jor jdepression" j- jANS ✓✓ -3. j"I jwill jbe jsure jto jcue jin jany jindicators jthat jthe jclient jmay jbe jexaggerating jtheir jpain" A jclient jhas jbeen jadmitted jto jthe jhospital jfor jgastroenteritis jand jdehydration. jThe jnurse jdetermines jthat jthe jclient jhas jreceived jadequate jvolume jreplacement jif jthe jblood jurea jnitrogen j(BUN) jlevel jdrops jto jwhich jvalue?
5. j 3 jmg/dL j(1.08 jmmol/L)
6. j 15 jmg/dL j(5.4 jmmol/L)
7. j 29 jmg/dL j(10.44 jmmol/L)
8. j 35 jmg/dL j(12.6 jmmol/L) j- jANS ✓✓ -2. j 15 jmg/dL j(5.4 jmmol/L) Rationale: jthe jnormal jBUN jlevel jis j10-20 jmg/dL j(3.6 jto j7.1 jmmol/L). jValues jof j 29 jmg/dL j(10.44 jmmol/L) jand j 35 jmg/dL j(12.6 jmmol/L) jreflect jcontinued jdehydration. jA jvalue jof j 3 jmg/dL j(1.08 jmmol/L) jreflects ja jlower jthan jnormal jvalue, jwhich jmay joccur jwith jfluid joverload. The jnurse jis jexplaining jthe jappropriate jmethods jfor jmeasuring jan jaccurate jtemperature jto jan jassistive jpersonnel j(AP). jWhich jmethod, jif jnoted jby jthe jAP jas jbeing jan jappropriate jmethod, jindicates jthe jneed jfor jfurther jteaching?
9. jtaking ja jrectal jtemp jfor ja jclient jwho jhas jundergone jnasal jsurgery
10. jtaking jan joral jtemp jfor ja jclient jwith ja jcough jand jnasal jcongestion
11. jtaking jan jaxillary jtemp jfor ja jclient jwho jhas jjust jconsumed jhot jcoffee
12. jtaking ja jtemp jon jthe jneck jbehind jthe jear jusing jan jelectronic jdevice jfor ja jclient jwho jis jdiaphoretic j- jANS ✓✓ -2. jtaking jan joral jtemp jfor ja jclient jwith ja jcough jand jnasal jcongestion Rationale: jan joral jtemp jshould jbe javoided jif jthe jclient jhas jnasal jcongestion. jOne jof jthe jother jmethods jof jmeasuring jthe jtemp jshould jbe jused jaccording jto jthe jequipment javailable. jTaking ja jrectal jtemp jfor ja jclient jwho jhas jundergone jnasal jsurgery jis jappropriate. jOther, jless jinvasive jmeasures jshould jbe jused jif javailable, jbut jif jnot, ja jrectal jtemp jis jappropriate. jTaking jan jaxillary jtemp jon ja jclient jwho jhas jjust jconsumed jcoffee jis jalso jacceptable, jhowever, jthe jaxillary jmeasurement jis jleast jreliable jand jother jmethods jshould jbe jused jif javailable. jIf jelectronic jequipment jis javailable jand jthe jclient jis jdiaphoretic, jit jis jacceptable jto jmeasure jthe jtemp jon jthe jneck jbehind jthe jear, javoiding jthe jforehead. A jclient jis jreceiving ja jcontinuous jIV jinfusion jof jheparin jsodium jto jtreat jdeep jvein jthrombosis. jThe jclient's jactivated jpartial jthromboplastin jtime j(aPTT) jis j 65 jseconds. jThe jnurse janticipates jthat jwhich jaction jis jneeded?
13. jdiscontinuing jthe jheparin jinfusion