Nursing Concepts and Practices, Exams of Nursing

Download Nursing Concepts and Practices and more Exams Nursing in PDF only on Docsity! PN MEDICAL SERGICAL EXAM 2020 |LATEST VERSION| UPDATE 2024-2025| BEST STUDYING MATERIAL| ACCURATE QUESTIONS | VERIFIED ANSWERS| GUARANTEED PASS| GRADED A.| The nurse is discussing the post-operative period with a patient scheduled for a corneal transplant. Which statement indicates that the patient displays realistic expectations about vision improvement? A. "I will have my full vision restored within 48 to 72 hours." B. "It will take about 24 hours before I see improvement in my vision." C. "My vision will show improvement in about 2 weeks." D. "It may take about a month before my vision shows improvement." - Ans - Answer: C. "My vision will show improvement in about 2 weeks." The nurse is communicating with a patient who voices concern about an upcoming high-risk procedure. Which statement best demonstrates empathy? A. "Would you like to talk about your feelings regarding the procedure?" B. "My mother had the same procedure and did very well." C. I can't imagine how you feel." D. "It must be difficult preparing for the procedure; how are you feeling?" - Ans - Answer: D. "It must be difficult preparing for the procedure; how are you feeling?" The nurse caring for a patient with advanced AIDS. While collecting data, the nurse notes a weight loss of several pounds, poor food consumption, and complaint of no appetite. Based on these findings , the nurse should carefully monitor the patient for development of which problem? A. Lymphedema B. Hyperglycemia C. Hypertension D. Anasarca - Ans - Answer: D. Anasarca For which patient would the nurse question an order for isotretinoin (Accutane)? A. A 20-year-old epileptic man with nodular acne and epilepsy. B. A 22-year-old pregnant woman with severe acne. C. A 46-year-old woman on oral contraceptive pills with cystic acne. D. A 50-year-old hypertensive man with cystic acne. - Ans - Answer: B. A 22-year-old pregnant woman with severe acne. According to most state NPAs, the vocational nurse acting as charge nurse in a long- term care facility acts in which capacity? A. Working under direct supervision of an RN on the unit. B. Working with the RN in the building. C. Working under general supervision by the RN available on site or by phone. D. Working as an independent vocational nurse. - Ans - Answer: C. Working under general supervision by the RN available on site or by the phone. The nurse is caring for a patient with a deep vein thrombosis (DVT). Which medication would likely be used for initial inpatient treatment? A. Dabigatran (Pradaxa) B. Heparin C. Warfarin (Coumadin) D. Edoxaban (Lixiana) - Ans - Answer: C. Warfarin (Coumadin) The home health nurse is caring for a patient with congestive heart failure (CHF). Which assessment finding should the nurse report immediately to the physician? A. Moderate shortness of breath after walking down the hall. B. A 3 pound weight gain over the course of a week. C. Heart rate of 104 beats/min after ambulating to the bathroom. D. Increase urinary output to 50 mL in the last hour. - Ans - Answer: A. Shortness of breath after walking down the hall. The nurse is caring for a patient with C. difficile infection. Which action is most important for the nurse to take? A. Only use alcohol-based hand cleanser for hand hygiene. B. Always wear an impervious mask. C. Don proper eye protection before providing care. D. Put the patient on contact plus isolation. - Ans - Answer: D. Put the patient on contact plus isolation C. "How many years have you smoked? Nicotine will cause these changes in your skin." D. "These are just normal changes seen in most older people." - Ans - Answer: A. "The valves in the vessels in your legs aren't working as well as they used to, which causes the discoloration and thickening of your skin." The nurse is caring for a patient with anemia who has a medical history of diabetes, hypertension, chronic kidney disease, and acid reflux. The nurse is aware the patient's anemia is likely related to which condition? A. Diabetes B. Hypertension C. Chronic kidney disease D. Acid reflux - Ans - Answer: C. Chronic kidney disease The clinic nurse offers suggestions to a patient who is planning a trip to Mexico that will help prevent a protozoan infection. Which suggestion is most helpful? A. "Ask the doctor for a prophylactic prescription for an antiviral drug." B. "Broad-spectrum antibiotics will be most helpful if you contract a protozoan infection." C. "Be sure to practice good hand hygiene while on your trip." D. "It would be best if you drank bottled water while on your trip." - Ans - Answer: D. "It would be best if you drank bottled water while on your trip." The patient refuses to take off her diamond wedding band prior to going to the operating room. What action should the nurse take first? A. Document the patient's refusal to remove the jewelry. B. Tape the ring to the finger, covering the ring. C. Request the patient sign a waiver to release the hospital from responsibility. D. Alert the surgery team to the presence of the jewelry. - Ans - Answer: B. Tape the ring to the finger, covering the ring. The nurse reading a tuberculin skin test (PPD) on a new employee who lives in the Midwest, is 20-years-old, and has no known history of contact with any people with tuberculosis (TB). The nurse should interpret the reading as positive if the area around the injection site has an induration of how many millimeters? A. 0 mm B. 5 mm C. 10 mm D. 15 mm - Ans - Answer: D. 15 mm The nurse is caring for a patient with suspected macular degeneration. During the assessment the patient is asked to focus on an image. Which finding supports the diagnosis? A. The patient only sees disconnected pieces of the image. B. The patient sees a dark spot in the center of what is viewed. C. The patient sees nothing in the peripheral vision. D. The patient sees wavy lines and bright flashing lights. - Ans - Answer: B. The patient sees a dark spot in the center of what is viewed. The nurse is explaining the difference between exertional angina and unstable angina. Which statement about unstable angina is accurate? A. Unstable angina occurs with moderate exercise. B. Unstable angina occurs when blood pressure increases sharply. C. Unstable angina occurs when the body reacts to high stress levels. D. Unstable angina occurs unpredictably, even in sleep. - Ans - Answer: D The nurse is caring for a 20-year-old patient who . Unstable angina occurs unpredictably, even in sleep. recently underwent a tonsillectomy. The patient is fully awake and clearing his throat frequently but denies pain. Which action is most important for the nurse to take first? A. Place the patient in a side-lying position. B. Look in the patient's mouth. C. Offer the patient a grape popsicle. D. Remove the straw from the patient's tray. - Ans - Answer: D. Remove the straw from the patient's tray. A 75-year-old patient questions the nurse about vaccination to prevent shingles. What response is most appropriate? A. "The incidence of shingles in people your age is not overly common, so vaccination is unnecessary." B. "The vaccination has not yet been approved for use in the older adult." C. "Because of the incidence of shingles in your age group, you should consider taking the vaccination." D. "The vaccination is expensive but will provide lifelong immunity." - Ans - Answer: C. "Because of the incidence of shingles in your age group, you should consider taking the vaccination." A 65-year-old patient complains of leg pain that disappears at rest after having walked a short distance. The nurse recognizes the patient's symptoms are consistent with which problem? A. Muscle spasm B. Deep venous thrombosis C. Claudication D. Angiospasm - Ans - Answer: C. Claudication The patient with angina asks the nurse how a daily dose of 81 mg of aspirin is helpful. Which reply is best? A. Low-dose aspirin helps reduce clotting. B. Low-dose aspirin helps dilate coronary vessels. C. Low-dose aspirin helps alleviate pain associated with angina. D. Low-dose aspirin helps lower cholesterol. - Ans - Answer: A. Low-dose aspirin helps reduce clotting. Which manifestation is the classic early warning symptom of a detached retina? A. Tearing and swelling of the eye. B. Flashing colored lights in the eye. C. Bleeding into the anterior chamber. D. Intense brow pain. - Ans - Answer: B. Flashing colored lights in the eye Which foundational behavior is necessary for effective critical thinking? A. Unshakable beliefs and values B. An open attitude C. An ability to disregard evidence inconsistent with set goals D. An ability to recognize the perfect solution - Ans - Answer: B. An open attitude The post-operative patient complains of pain only 1 hour after having been medicated with an opioid, which cannot be repeated for 3 more hours. What action should the nurse take? C. "I should wash my hands before preparing my food." D. "It is important that I take my antibiotic until my symptoms have completely resolved." - Ans - Answer: D: "It is important that I take my antibiotic until my symptoms have completely resolved." The nurse is teaching a patient who takes warfarin (Coumadin) about a coagulation monitoring device. Which blood clotting time should the device monitor? A. PT B. PTT C. INR D. ACT - Ans - Answer: C. INR The LPN/LVN is in the patient's room while the charge nurse is obtaining the patient's signature on the surgical consent form. The patient states, "I didn't really understand what my surgeon explained, but I trust him completely." How should the nurse respond? A. "I need to contact your surgeon so your questions can be answered." B. "I can answer any questions that you might have regarding your surgery." C. "As long as you are comfortable, then you may sign the consent form." D. "Maybe we should call your surgeon to be sure it is okay to sign the consent." - Ans - Answer: A. "I need to contact your surgeon so your questions can be answered." The nurse is caring for a patient following abdominal surgery. The patient asks the nurse when he will be able to eat a normal diet. Which response is best? A. "It will depend on how well you tolerate advancing from a clear liquid diet." B. "We will have to wait until your surgeon orders a regular diet for you." C. "Most patients are able to eat regular foods within 2-3 days following abdominal surgery." D. "Once you have bowel sounds and are passing gas, you may have clear liquids, and your diet will be advanced based upon your tolerance." - Ans - Answer: D. "Once you have bowel sounds and are passing gas, you may have clear liquids, and your diet will be advanced based upon your tolerance." The nurse is caring for a patient who has a new prescription for a loop diuretic. Which nutritional intervention is most important for the nurse to add to the care plan? A. Increase intake of leafy green vegetables. B. Increase intake of bananas and potatoes. C. Avoid foods like canned soups and hot dogs. D. Limit caffeine intake. - Ans - Answer: B. Increase intake of bananas and potatoes The nurse is educating a patient with psoriasis. Which information is most important for the nurse to include in the teaching plan? A. Liberally apply a lubricating cream 3 times daily. B. Use a humidifier at night. C. Use an alcohol-based cleanser in the morning. D. Take hot baths to reduce skin discomfort. - Ans - Answer: B. Use a humidifier at night. The nurse is caring for a patient during the immediate post-operative period following a rhinoplasty. Which finding is most concerning to the nurse? A. The patient complains of being cold and chilled. B. The patient complains of nausea. C. The nurse notices the patient is swallowing frequently. D. The nurse notices drainage on the nasal drip pad. - Ans - Answer: C. The nurse notices the patient is swallowing frequently. The nurse is caring for a burn patient. Which action best prevents contractures? A. Assist the patient with ambulation as soon as fluid shifts stabilize. B. Medicate the patient approximately 30 minutes prior to dressing changes. C. Ensure adequate hydration. D. Ensure adequate nutritional intake. - Ans - Answer: A. Assist the patient with ambulation as soon as fluid shifts stabilize. When the nurse notes a rise in the eosinophil count, which problem does she suspect? A. Bacterial infection B. Allergy C. Viral infection D. Blood dyscrasia - Ans - Answer: B. Allergy The nurse is performing deep tracheal suctioning of a patient with a respiratory disorder. Which action demonstrates appropriate technique? A. The nurse maintains clean technique. B. The nurse places the patient in a side-lying position. C. The nurse suctions the patient for 10 to 15 seconds. D. The nurse reassures the patient that he will feel no discomfort. - Ans - Answer: C. The nurse suctions the patient for 10 to 15 seconds. A patient who presented to the emergency room with a myocardial infarction (MI) becomes pale, diaphoretic, and hypotensive. What action should the nurse take first? A. Notify the physician immediately. B. Ensure the patient has patent IV access. C. Request assistance from respiratory therapy. D. Inform the patient's family of the change in status. - Ans - Answer: A. Notify the physician immediately The nurse is caring for a patient with a compression dressing. Which action indicates appropriate wound care? A. The nurse changes the compression dressing daily. B. The nurse uses an alcohol-based cleanser before applying the compression dressing. C. The nurse places a compression dressing over the wound dressing. D. The nurse dons a face mask before applying a compression dressing. - Ans - Answer: C. The nurse places a compression dressing over the wound dressing. The home health nurse is educating the family of a child with head lice. Which instructions are most important for the nurse to include? A. Lice cannot be transmitted to pets. B. Insects must be moving across the scalp to confirm diagnosis of head lice. C. Wash and dry all linens on the hottest setting. D. Apply a dime-sized amount of alcohol-based lotion to hair. - Ans - Answer: C. Wash and dry all linens on the hottest setting. The drug Alteplase (t-PA) is given to the patient with a myocardial infarction (MI). Which statement accurately describes the purpose of this medication? A. "Alteplase (t-PA) dissolves the obstruction in the coronary artery." B. "Alteplase (t-PA) dilates vessels to relieve pain." C. "Alteplase (t-PA) strengthens cardiac contraction." D. "Alteplase (t-PA) increases cardiac output." - Ans - Answer: A. Monitor respiratory status B. Raise the bed rails C. Elevate the head of the bed 30 degrees D. Take seizure precautions - Ans - Answer: B. Raise the bed rails What is the average life span of a platelet cell? A. 10 days B. 14 days C. 30 days D. 45 days - Ans - Answer: A. 10 days The nurse is caring for a patient with Meniere disease. Which action is most important for the nurse to take? A. Speak loudly and clearly into the affected ear. B. Restrict sodium intake. C. Encourage frequent ambulation. D. Encourage fluid intake. - Ans - Answer: B. Restrict sodium intake The nurse carefully applies suction prior to deflating the cuff on a cuffed tracheostomy in order to prevent which complication? A. Bleeding B. Excessive negative pressure C. Accidental dislodgement of the tube D. Aspiration - Ans - Answer: D. Aspiration The nurse discusses and demonstrates proper hand hygiene to an immunocompromised patient and his wife. Which statement indicates a need for additional teaching? A. "It's okay for my wife to wear artificial nails as long as she washes her hands properly." B. "I should always wash my hands before I eat." C. "Hand gels work as well as handwashing under most circumstances." D. "I should use friction and wash my hands for about 20 seconds if I am using soap and water." - Ans - Answer: A. "It's okay for my wife to wear artificial nails as long as she washes her hands properly." The home health nurse is caring for a patient with a blood pressure reading of 200/160. The patient denies any discomfort. The nurse should immediately contact the health care provider to report that the patient is experiencing which problem? A. Primary hypertension B. Hypertensive crisis C. Essential hypertension D. Secondary hypertension - Ans - Answer: B. Hypertension crisis The nurse is caring for multiple patients. After reviewing the patients' histories, the nurse determines that which patient possesses the highest risk of throat cancer? A. A male patient who drink four cups of coffee per day. B. A female patient who smokes a pack of cigarettes weekly. C. A female patient who drinks three carbonated drinks per day. D. A male patient who drinks four vodka tonics per day. - Ans - Answer: D. A male patient who drinks four vodka tonics per day. The nurse is caring for a patient with sickle cell anemia. Which intervention may best help to prevent sickle cell crisis? A. Taking iron supplements daily B. Maintaining adequate fluid intake C. Engaging in daily exercise D. Eating leafy green vegetables - Ans - Answer: B. Maintaining adequate fluid intake When the nurse places the diaphragm of the stethoscope over one of the main bronchi, which expected normal breath sound should the nurse hear? A. Bronchovesicular sounds B. Bronchial sounds C. Sonorous sounds D. Vesicular sounds - Ans - Answer: A. Bronchovesicular sounds Which example shows the nursing student demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPAA)? A. The student uses the patient's full name only on clinical assignments submitted to the instructor. B. The student uses a facility printer to copy laboratory reports on an assigned patient. C. The student shreds any documents that contain identifying patient information before leaving the clinical facility. D. The student asks the patient for permission to copy laboratory and diagnostic reports for educational purposes. - Ans - Answer: C. The student shreds any documents that contain identifying patient information before leaving the clinical facility. The nurse is caring for a patient with a history of hypertension. Which information is most important for the nurse to obtain? A. "Do you take a multivitamin?" B. "Do you use over-the-counter decongestants or diet pills?" C. "How often do you use laxatives?" D. "How often do you use antacids?" - Ans - Answer: B. "Do you use over-the-counter decongestants or diet pills?" A 75-year-old patient presents to the emergency department with shortness of breath, fatigue, and a dry cough. What information leads the nurse to suspect this patient should undergo a workup for histoplasmosis? A. The patient reports drinking pond water. B. The patient lives on a farm and raises chickens. C. The patient recently went hunting in a wooded area. D. The patient owns a landscaping company. - Ans - Answer: B. The patient lives on a farm and raises chickens. Which assessment finding on a patient who had a right total knee replacement this morning should be reported to the charge nurse immediately? A. Pain level of 8/10 at operative site. B. Capillary refill of right toe of 7 seconds C. Right foot warm to the touch D. Swelling right knee - Ans - Answer: B. Capillary refill of right toe of 7 seconds A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan? a) Apply foam handles to the client's eating utensils. b) Obtain a referral for physical therapy. c) Have an assistive personnel feed the client. d) Ask the provider for a prescription for a pureed diet. - Ans - A. Apply foam handles to the client's eating utensils. Rationale: To help a client with chronic arthritis who experiences difficulty eating, applying foam handles to the eating utensils can provide a larger, more comfortable grip and reduce strain on the joints. Asking for a puree diet may not be necessary unless swallowing difficulties are present. Having an assistive personnel feed the client may not promote independence. While obtaining a referral for physical therapy may be beneficial for overall mobility, it does not directly address the client's difficulty with eating. A nurse is providing directions to an assistive personnel about moving a client up in bed. a. "Place a pillow under the client's head prior to repositioning." b. "Keep your feet close together while moving the client" c "Face in the direction of the client's movement" d. "Move the client's arms to his sides prior to repositioning." - Ans - C. "Face in the direction of the client's movement." Rational: When moving a client up in bed, it is important for the nurse to face in the direction of the client's movement to maintain proper body mechanics and ensure safe transfer. 1)Adjust the head of the bed to a flat position. 2)Remove all pillows from under the client. 3)Position the UAP on the side opposite the nurse. 4)Place a friction-reducing sheet under the client. 5)Ask the client to bend the legs and place the chin on the chest. 6)Grasp the sheet and move the client on the count of three. A nurse is obtaining a medication history from a client who is to start taking nitroglycerin for chest discomfort with activity. Which of the following medications should the nurse instruct the client to avoid taking within 24 hrs of using nitroglycerin? a) Atorvastatin b) Metformin c) Sildenafil d) Omeprazole - Ans - C. Sildenafil Rationale: Sildenafil treats PAH (pulmonary arterial hypertension) by relaxing the blood vessels in the lungs to allow blood to flow easily. Same as, nitroglycerin is a vaso-dilator which is primarily to treat anginal chest pain and thereby it reduces blood pressure. Remaining drugs like omeprazole and atorvastatin can be given for patients with in 24hrs of nitroglycerin administration. A nurse is caring for a client who has a new prescription for nitroglycerin. The nurse should monitor for which of the following adverse effects of the medication? Nocturia Increased saliva production Flushing Fever - Ans - Flushing Rationale: nitroglycerin is a vaso-dilator. When vaso-dilators too well, fluid start sipping out and causing flushing A nurse is preparing to obtain a postprandial blood glucose level from a client who has diabetes mellitus. Which of the following actions should the nurse take? a) Apply the first drop of blood to the test strip. b) Clean the client's finger with hexachlorophene. c) Prick the central tip of the client's finger. d) Hold the client's finger in a dependent position. - Ans - D. Hold the client's finger in a dependent position. Rationale: The nurse should clean the client's finger with an alcohol swab and prick the side of the finger, not the central tip, to obtain a postprandial blood glucose level. The nurse should not apply the first drop of blood to the test strip since the alcohol could cause false reading. Hexachlorophene is not recommended for cleaning the client's finger as it can cause tissue damage. TEST A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching? a) "It is common for one breast to be larger than the other." b) "It is common for the skin on my breasts to dimple." c) "I will perform breast exams the day my period begins." d) "I will perform breast exams every other month." - Ans - A. "It is common for one breast to be larger than the other." Rationale: It is normal to have asymmetrical breasts, usually, the left breast is bigger than the right. This is because of the difference in the percentage of breast tissues and fatty tissues, that's why they react differently to hormonal changes. "Dimpling on the skin on breasts is NOT common" Physician consultation should be taken regarding this as it can be a sign of breast cancer. "Self-breast exams are recommended to be performed after a week when the period starts." The rest of the month breasts reamain tender due to hormone fluctuation. "Self-Breast exams should be performed every month." For women in reproductive age usually after a week when the period starts and at the same day of every month for women who have attained menopause. A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following statements by the client indicates an understanding of the teaching? a) "I will need to empty the bag every 4 to 6 hours." b) "I will use moisturizing soap to clean around the stoma before applying the bag." c) "I will use a skin sealant before I apply the bag." d) "I will cut the wafer opening one-fourth of an inch larger than the stoma." - Ans - C. "I will use a skin sealant before I apply the bag." Rationale: An ileostomy is an opening in the belly that's made during surgery to allow waste to pass out of the body. It requires special care to keep the skin around it clean and prevent infection. A skin sealant can protect the skin from irritation and help the bag stick better. The other statements are incorrect because: a) You may need to empty the bag more often than every 4 to 6 hours, depending on how much waste you produce. c) Heat food before serving. d) Provide three large meals daily. - Ans - C. Heat food before serving. Rationale: Radiation therapy can inhibit the salivary glands and taste buds. This is why the patient is experiencing a change in taste. Option B it can help food taste better, but it is likely that taste is still impaired as taste buds are affected in radiation therapy. Option D can cause nausea and vomiting especially in patients undergoing radiation therapy. TEST A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take? a) Raise all four side rails while the client is in bed. b) Apply a motion sensor mat to the client's bed. c) Leave the television on in the client's room. d) Move the overbed table away from the bed. - Ans - B. Apply a motion sensor mat to the client's bed. Rationale: The nurse should apply a motion sensor mat to the client's bed. This will alert the nurse if the client tries to get out of bed and will help prevent falls. Option A raising all four side rails while the client is in bed is not recommended because it can be considered a restraint and can lead to injury or death. Option C leaving the television on in the client's room is not recommended because it can be overstimulating and can interfere with sleep. Option D moving the overbed table away from the bed is not recommended because it can increase the risk of falls. TEST A nurse is reinforcing teaching with a client about increasing her intake of fiber. Which of the following foods should the nurse encourage the client to eat? a) Cheese b) Pears c) Yogurt d) Eggs - Ans - B. Pears Rationale: Only pear has fiber out of 4 choices. TEST A nurse is reviewing the medical record of a client who reports his urine is red-orange. The nurse should identify which of the following medications can cause this adverse effect? a) Isoniazid b) Metoprolol c) Furosemide d) Rifampin - Ans - D. Rifampin Rationale: associated with Red Man syndrome (bodily fluids like urine appear red-orange in color) A nurse is collecting data from a client who is taking metoprolol. Which of the following findings should the nurse expect? Increased blood pressure Decreased heart rate Decreased Bronchospasm Increased blood glucose level - Ans - Decreased heart rate Rationale: Metoprolol blocks stimulation to beta1-adrenergic receptors without usually affecting beta2-adrenergic receptors. Decrease effects of the sympathetic nervous system: decreases speed of conduction which slows heart rate and decreases contraction force causing less cardiac output and decreased BP. TEST A nurse is caring for a client in hospice care who is dying. The client's partner expresses concern that the client is sleeping more than in the previous week. Which of the following is an appropriate response by the nurse? a) "Encourage your partner to wake up to interact with family members." b) "Sitting quietly near the bedside can provide comfort and support." c) "I will call the provider to discuss your concerns." d) "I can ask the provider to prescribe a medication that will minimize drowsiness." - Ans - B. "Sitting quietly near the bedside can provide comfort and support." Rationale: This action shows therapeutic technique of offering self which can be verbal and non- verbal. Just being with the patient's side having your presence shows comfort and support specially as the patient is nearing its death. TEST A nurse is reinforcing teaching with a client who is postoperative following a tympanoplasty. Which of the following information should the nurse include? a) Drink fluids through a straw. b) Plan to shampoo hair in 1 week. c) Resume exercising in 10 days. d) Close mouth when sneezing. - Ans - B. Plan to shampoo hair in 1 week. Plan to shampoo hair in 1 week: The client should avoid getting water in the ear for at least one week after surgery. This includes avoiding washing hair, swimming, or taking baths. After one week, the client can resume normal hair care activities. Resume exercising in 10 days: The client should avoid strenuous exercise or heavy lifting for at least two weeks after surgery. After two weeks, the client can gradually resume normal activities. Close mouth when sneezing: The client should avoid blowing the nose or sneezing with the mouth open for at least two weeks after surgery. This can help prevent pressure changes in the ear that may interfere with healing A nurse is reinforcing discharge teaching about dietary changes with a client who has a new colostomy. Which of the following foods should the nurse recommend? a) Asparagus b) Bananas c) Grapes d) Broccoli - Ans - B. Bananas Rationale: other options are high in fiber A nurse is caring for a client who has diabetes mellitus. Which of the following laboratory results should the nurse report to the provider? a) Glycosylated hemoglobin 5.2% b) Urine positive for ketones c) Urine negative for bilirubin A nurse is assisting with the plan of care for a client who requires contact precautions. Which of the following interventions should the nurse include in the plan? a) Keep a stethoscope at the client's bedside for the duration of her hospital stay. b) Wear an N95 mask when entering the room. c) Use an alcohol swab to clean the temperature probe before removing it from the room. d) Remove personal protective equipment immediately after leaving the client's room. - Ans - A. Keep a stethoscope at the client's bedside for the duration of her hospital stay. Rationale: contact precaution! TEST A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the following actions should the nurse take? a) Request a dosage increase of the apical heart rate is less than 60/min. b) Administer the medication with an antacid. c) Instruct the client to expect increased hair growth. d) Withhold the medication if the systolic blood pressure is less than 90 mm Hg. - Ans - D. Withhold the medication if the systolic blood pressure is less than 90 mm Hg. Rationale: propranolol is a beta block. It is usually prescribed for high blood pressure and other heart problems. Depend on your facility, you will need to withhold the medication when the patient BP or P is at a certain low threshold. Antacids, although are considered harmless, can affect negatively with Propranolol. They, just like Omeprazole, can interfere with the usual absorption of Propranolol in your body. Magnesium antacids may not affect the absorption that much, much aluminium containing antacids should be avoided while you're being treated with Propranolol. A nurse is reinforcing teaching about dietary modifications to help control blood pressure with a client who has hypertension. Which of the following food choices by the client indicates an understanding of the teaching? a) A ham sandwich on rye bread b) Broiled cod with broccoli c) Beef bouillon with crackers d) Pork sausage with sauteed peppers - Ans - B. Broiled cod with broccoli Rationale: What can I say? It is fish and vegi A nurse is reinforcing teaching with a client about heart disease prevention, which of the following client statements indicates an understanding of the teaching? a) "I will increase my dairy intake by drinking whole milk every meal." b) "I will exercise by walking twice a week for 25 minutes." c) "I will try to maintain my blood pressure around 116/72." d) "I will improve my LDL cholesterol by raising it from 100 to 130." - Ans - C. "I will try to maintain my blood pressure around 116/72." TEST A nurse is reinforcing teaching about a transcutaneous electrical nerve stimulation (TENS) unit for a client who has a herniated intervertebral disk. Which of the following statements by the client indicates an understanding of the teaching? a) "I will need to charge the TENS unit for 2 hours each day." b) "The TENS unit administers a continuous dose of pain medication." c) "I should adjust the TENS unit until I feel a tingling sensation." d) "The TENS unit should be applied at least 6 inched from the actual site of my pain." - Ans - C. "I should adjust the TENS unit until I feel a tingling sensation. Rationale: A TENS unit is a device that delivers mild electrical current to the affected area of the back using small transcutaneous electrode pads. It can be used to relieve lower back pain and improve posture in those with herniated discs and lower back conditions. It can also help to reduce swelling and stiffness in the lower back. This can help to improve your mobility and overall range of motion. TEST The nurse is reinforcing teaching about a Transcutaneous Electrical Nerve Stimulation (TENS). Which of the following statements by the nurse is accurate? a) "This form of pain management involves tiny needles inserted into the skin and subcutaneous tissues." b) "This form of pain management focused on a pleasant thought to divert focus." c) "This form of pain management involves meditation, yoga, and progressive muscle relaxation." d) "This form of pain management involves mild electrical stimulus applied to the area of pain." - Ans - D. This form of pain management involves mild electrical stimulus applied to the area of pain. Rationale: This nonpharmacological technique is known as TENS. Option A this nonpharmacological technique is known as acupuncture. Option B this nonpharmacological technique is known as Imagery. Option C this nonpharmacological technique is known as Relaxation. TEST A nurse is reviewing a client's medical record. Which of the following findings is the priority for the nurse to report? a) Urine output 200 mL/8 hrs b) A client's rating of ear pain as 5 on a scale from 0 to 10 c) Potassium level 6.2 mEq/L d) Abnormal hepatoiminodiacetic acid (HIDA) scan - Ans - C. Potassium level 6.2 mEq/L Rational: Among the options, the elevated potassium level of 6.2 mEq/L is the most critical finding that should be reported to the provider. Hyperkalemia can lead to serious cardiac complications and requires immediate attention. The other options, including an abnormal hepatoiminodiacetic acid (HIDA) scan, a client's rating of ear pain, and urine output of 200 mL/8 hr, are important but not as high a priority as the elevated potassium level. A nurse is reinforcing teaching about decreasing the risk of osteoporosis to a client who is postmenopausal. Which of the following instructions should the nurse include? regimen to decrease my risk for a stroke." c) "My risk for a stroke increases if my HbA1c level is 6 percent or less." d) "I can decrease my risk for a stroke by losing excess weight." - Ans - D. "I can decrease my risk for a stroke by losing excess weight." Rationale: obesity and stroke always go hand in hand. A nurse is monitoring a client who has a nasogastric (NG) tube set to intermittent suction to manage a mechanical intestinal obstruction. Which of the following findings should the nurse report? a) Potassium 4.2 mEq/L b) BUN 16 mg/dL c) Abdominal distention d) Bile-colored drainage from the NG tube - Ans - C. Abdominal distention A nurse is reinforcing teaching about the use of an insulin pen with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? *I will shake the pen before injecting the insulin." "I will apply a disposable needle on the cartridge." "I will hold the pen upside-down to select the appropriate dose." "I will aspirate before injecting the insulin." - Ans - "I will hold the pen upside-down to select the appropriate dose." TEST A nurse working in a provider's office is caring for a client who received penicillin G potassium 15 min ago to treat strep throat. Which of the following is the priority finding the nurse should report to the provider? a) Nausea b) Hypotension c) Abdominal pain d) Arthralgia - Ans - B. Hypotension Rationale: Hypotension is a manifestation of anaphylaxis. TEST A nurse is collecting data from a client who began taking captopril 2 days ago. Which of the following findings should the nurse report to the provider immediately? a) Lip swelling b) Dizziness c) Joint aches d) Metallic taste - Ans - A. Lip swelling Rational: According to the information I found, lip swelling is a rare but serious side effect of captopril that should be reported to the provider immediately. It may indicate an allergic reaction or angioedema, which can be life-threatening if it affects the airway. The other options are less serious or common side effects that may not require immediate attention. TEST A nurse is caring for a client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take when assisting the client with feeding? a) Offer the client sticky foods such as peanut butter. b) Instruct the client to place their chin to their chest when swallowing. c) Place food on the affected side of the client's mouth. d) Position the client upright for 5 min after eating. - Ans - B. Instruct the client to place their chin to their chest when swallowing. Rationale: When assisting a client with dysphagia and left-sided weakness following a stroke, the nurse should take the following actions when feeding the client: The chin tuck is a swallowing technique that can help people with dysphagia. It involves placing the chin down towards the chest while swallowing. This technique can help to close off the airway and protect the lungs from food or liquid entering them. However, it is important to note that this technique may not be suitable for everyone with dysphagia. Offer the client food on the unaffected side of their mouth. This will help prevent aspiration and choking. Position the client upright for 30-60 minutes after eating. This will help prevent aspiration and reflux. It is important to note that sticky foods such as peanut butter should be avoided as they can be difficult to swallow and may cause choking. A nurse is reinforcing teaching with a client who has ovarian cancer and will receive chemotherapy through a peripherally inserted central catheter (PICC) line. Which of the following statements by the client indicates an understanding of the teaching? a) "I will wear an arm immobilizer to prevent dislodgement of this device." b) "I will monitor my temperature for fever while I have this device." c) "It's okay to get the device wet when I shower." d) "I should pull the dressing away from the insertion site when I change it." - Ans - B. "I will monitor my temperature for fever while I have this device." A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take? a) Replace the unit when the drainage chamber is full. b) Clamp the tube for 30 min every 8 hr. c) Pin the tubing to the client's bed sheets. d) Monitor for at least 150 mL of drainage every hour. - Ans - A. Replace the unit when the drainage chamber is full. Rationale: Pinning the tube can cause tension or pulling, which can lead to dislodgement of the tube or tension pneumothorax Clamping the tube for 30 mins every 8 hrs can lead to build up pressure in the pleural space, which can cause lung collapse or tension pneumothorax Monitor for at least 150 mL is incorrect because the nurse should monitor for the amount and character of drainage, but there is no specific amount that must be monitor hourly. A nurse is collecting data from a client who is 2 days postoperative following a colon restriction. Which of the following indicates the need for nursing intervention? a) Mild abdominal pain when coughing 30 min after receiving pain medication b) Dark brown drainage in the NG tube c) Serosanguineous drainage on the wound dressing d) Oxygen saturation 95% - Ans - B. Dark brown drainage in the NG tube Rationale: Dark brown drainage in the NG tube can be an indication of old blood in the stomach or upper intestine. This tube will be set to suction and will drain out brownish colored stomach acid. When it runs from brown to light green to clear, this is an indication that things are moving through the stomach and feedings may be possible. TEST A nurse is receiving a change-of-shift report about the care of four clients. Which of the following clients should the nurse see first? a) A client who displays increased confusion over the past 4 hr b) A client who has a blood glucose level of 128 mg/dL c) A client who has a blood pressure of 138/88 mm Hg d) A client who reports a pain level of 4 on a scale of 0 to 10 - Ans - A. A client who displays increased confusion over the past 4 hr Rationale: A nurse is receiving a change-of-shift report about the care of four clients. The nurse should see the client who displays increased confusion over the past 4 hours first. This could be indicative of a serious medical condition, such as a stroke or hypoglycemia1. The nurse should assess the client's vital signs, blood glucose level, and neurological status to determine the cause of the confusion and initiate appropriate interventions. The other clients also require attention, but their conditions are not as urgent as that of the client with increased confusion. The client with a blood glucose level of 128 mg/dL may require insulin administration or dietary modifications. The client with a blood pressure of 138/88 mm Hg may require antihypertensive medication or lifestyle modifications. The client who reports a pain level of 4 on a scale of 0 to 10 may require pain management interventions. A nurse is assisting care of a client whose cardiac monitor suddenly displays ventricular tachycardia. Which of the following is the priority nursing action? a) Determine palpable pulse. b) Begin chest compressions. c) Perform immediate defibrillation. d) Provide pulmonary ventilation. - Ans - A. Determine palpable pulse. Rationale: Assess first to know what the cause of ventricular tachycardia was. Can't start doing intervention without knowing the cause. A nurse is collecting data from a client who underwent a thyroidectomy 4 hrs ago. Which of the following client findings indicates a complication of the procedure? a) Tingling of the fingers b) Report of sore throat c) Serosanguineous drainage on the dressing d) Soreness at the incision site - Ans - A. Tingling of the fingers Rationale: Tingling of the fingers, numbness, twitching of the face and hands or positive Trousseau sign indicates hypocalcemia which is a serious and common complication post thyroidectomy A nurse is reinforcing discharge teaching with a client who had an excisional biopsy of the left breast. Which of the following instructions should the nurse include? a) Refrain from wearing a bra for 10 days after surgery. b) Apply an ice pack to the incision site to treat discomfort. c) Expect numbness to last for up to 4 months. d) Use bandages to absorb bleeding at the incision site. - Ans - B. Apply an ice pack to the incision site to treat discomfort. Rationale: Post excision biopsy small rim of redness and swelling around the incision site is present. Applying an ice pack for 10-15 minutes several times within 24-48 hours post procedure helps reduce pain, bleeding, swelling, discomfort. A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect? a) Peripheral edema b) Decreased respirations c) Absent bowel sounds d) Polyuria - Ans - C. Absent bowel sounds Rationale: Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs. The nurse should expect absent bowel sounds in a client who has peritonitis. Other symptoms of peritonitis include abdominal pain or tenderness, bloating, fever and chills, nausea and vomiting, loss of appetite, diarrhea, increased thirst, passing significantly less urine, inability to pass stool or gas, fatigue A nurse is reinforcing teaching with a client about menopause. Which of the following statements by the client indicates an understanding of the teaching? a) "I will need hormone replacement therapy for the rest of my life." b) "I should expect to have an increased risk for breast cancer." c) "The use of black cohosh will decrease vaginal bleeding." d) "I should use a vaginal douche to prevent dryness." - Ans - B. "I should expect to have an increased risk for breast cancer." A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease. Which of the following dietary instructions should the nurse include? a) Chew food thoroughly. b) Use a straw when drinking liquids. c) Drink carbonated beverages with meals. d) Limit meals to three per day with no snacking in between. - Ans - A. Chew food thoroughly TEST A nurse is preparing a client for a colposcopy following an abnormal Papanicolaous (Pap) test. Which of the following actions should the nurse take? a) Place the client in the Sims' position. b) Reinforce teaching that the procedure involves dilation of the cervix. c) Insert a tampon following the procedure. d) Instruct the client to avoid sexual intercourse until the cervix is healed. - Ans - D. Instruct the client to avoid sexual intercourse until the cervix is healed. Rationale: A colposcopy is a procedure to examine your cervix, vagina and vulva for signs of disease using a special instrument called a colposcope. For this procedure, you will be asked to lie on your back, legs in stirrups, and buttocks at the lower edge of the table (a position known as the dorsal lithotomy position). A speculum will be placed in your vagina to open it and allow the colposcope to get close to your cervix. The other options are incorrect because: The procedure does not involve dilation of the cervix. A tampon should not be used after the procedure because it can cause infection or bleeding. Rationale: When applying a sequential compression device (SCD), the nurse should ensure that two fingers fit between the leg and the sleeve. This ensures that the device is not too tight, which could cause discomfort or impede circulation. The nurse should not wrap excess tubing to the side of each leg as this could cause the tubing to become tangled or twisted, which could impede the effectiveness of the device. The nurse should also not ensure pressure of the device is at 25 mmHg as this is not a standard pressure setting for SCDs. The pressure setting for SCDs is typically prescribed by a physician and varies depending on the patient's condition. The correct action for the nurse to take when applying an SCD is to place each sleeve under each leg with the opening at the calf. This ensures that the device is properly positioned and will be effective in promoting blood flow. NGN-QUESTION A nurse is caring for a client who has bladder cancer and is 1 day postoperative following placement of an ileal conduit. Which of the following information should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.") a) Platelet count b) Stoma color c) Bowel sounds d) Urine output - Ans - B. Stoma color TEST A nurse is collecting data about immunizations for a 65-year-old client who has no identified risk factors for disease. The nurse should identify the client's need for which of the following immunizations? a) Inactivated polio virus b) Herpes zoster c) Human papilloma virus d) Measles, mumps, and rubella - Ans - B. Herpes zoster Rationale: Measles, mumps, rubella and inactivated polio vaccines are given to children during routine immunization of less than 2yrs of age however according to studies this can only be given at maximum age of 12yrs old. HPV or human papilloma virus vaccine is given to girls at 9 yrs old until there reproductive age only. Herpes zoster on the other hand, a single dose should be given to 60 years old and older with no contraindication condition present as per CDC. A nurse is caring for a client who is to receive zoster vaccine live due to the risk for herpes zoster. Which of the following is an appropriate action by the nurse? a. Withhold an immunization if the white blood cell count is less than 5,000/mm3 b. Administer the immunization IM c. Repeat the immunization three months after the initial injection d. Administer Diphenhydramine stat if erythema develops at the site - Ans - A. Withhold an immunization if the white blood cell count is less than 5,000/mm3. Rationale: Zoster vaccine live, used for herpes zoster prevention, should be withheld if the client's white blood cell count is less than 5,000/mm3 due to the risk of disseminated vaccine- related infection. A nurse is reinforcing teaching with a client about colorectal cancer. Which of the following risk factors should the nurse include? a) Biliary colic b) Duodenal ulcer c) Chronic constipation d) Ulcerative colitis - Ans - D. Ulcerative colitis Rationale: Ulcerative colitis is an inflammatory bowel disease that causes inflammation and ulcers in your digestive tract. Risk factors for colorectal cancer includes history of inflammatory bowel disease. A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation? (Select all that apply.) a) Primary health problem b) Scheduled times for dressing changes c) Current medication prescriptions d) Number of family members who have visited e) Admission vital signs from 1 week ago - Ans - A. Primary health problem B. Scheduled times for dressing changes C. Current medication prescriptions TEST A nurse is collecting data from a client prior to administering hydrochlorothiazide for mild hypertension. Which of the following findings should the nurse identify as a contraindication to administering the medication? a) 2+ pedal edema b) Potassium 2.8 mEq/L c) Allergy to shellfish d) History of GERD - Ans - B. Potassium 2.8 mEq/L Rationale: HCTZ or hydrochlorothiazide is a diuretic medication also used in treating high blood pressure. It is non-selective diuretic therefore it also flushes out electrolytes such as potassium. Normal potassium range is 3.5-5.0mEq/L, therefore a value of 2.8mEq/L is contraindicated because it can lead further to hypokalemia. A nurse is caring for a client who has a terminal illness and is in the active phase of dying. The client refuses further hydration and nourishment. Which of the following actions should the nurse take? a) Request a prescription for IV fluids. b) Ask the client's health care surrogate for permission to withhold nourishment. c) Provide regular oral care for the client with a moist swab. d) Explain the importance of oral hydration to the chest. - Ans - C. Provide regular oral care for the client with a moist swab. A nurse is caring for a client who has returned to the unit following a cardiac catheterization using a femoral approach. Which of the following methods should the nurse use to monitor for complications? a) Check the client's blood pressure while the client lies supine, sits, and stands. b) Palpate the client's brachial pulses and compare bilaterally. c) Check for jugular vein distention while the client is supine. d) Palpate the client's pedal pulses and compare bilaterally. - Ans - D. Palpate the client's pedal pulses and compare bilaterally. Rationale: Rationale: Covering the pad before use prevents it from any damage prior to usage. Aquathermia pad uses distilled water. It should be place in the body part for 30 minutes. Using it 40 minutes or more could lead to burn. Do not put pin to secure the pad in place for it can cause burn and injury. A nurse is reinforcing teaching about risk factors for colorectal cancer with a client. Which of the following risk factors should the nurse include in the teaching? (Select all that apply.) a) High-fiber diet b) Physical inactivity c) History of diabetes mellitus d) Family history of colorectal cancer e) Age over 50 years - Ans - B. Physical inactivity C. History of diabetes mellitus D. Family history of colorectal cancer E. Age over 50 years Rationale: the risk factors for colorectal cancer. According to the CDC, some of the risk factors include: Age over 50 years Physical inactivity A low-fiber and high-fat diet, or a diet high in processed meats Family history of colorectal cancer or colorectal polyps History of inflammatory bowel diseases such as Crohn's disease or ulcerative colitis A nurse is caring for an older adult client who has stomatitis due to poorly fitting dentures. Which of the following actions should the nurse take? a) Rinse the client's mouth twice daily with an alcohol-based mouthwash. b) Increase the client's fluid intake to 2,000 mL daily. c) Offer the client hot beverages to drink. d) Provide the client with a high-protein diet. - Ans - D. Provide the client with a high- protein diet. Rational: high-protein diet can help healing. The nurse should also encourage the client to rinse their mouth with a non-alcohol-based mouthwash or warm salt water. Offering hot beverages to drink is not recommended as it can irritate the oral mucosa. A nurse is caring for a client who is in skin traction. Which of the following actions should the nurse take? a) Loosen the ropes of the pulleys when repositioning the client in bed. b) Inspect the client's skin every 12 hr for signs of breakdown. c) Ensure the weights hang freely from the client's bed. d) Maintain 6.8 kg (15 lb) of weight for the client's skin traction. - Ans - C. Ensure the weights hang freely from the client's bed. Rationale: Nursing responsibility for a patient having skin traction is to make sure that the traction weight bag is hanging freely and not rested on the bed or the floor to ensure proper traction and preventing misalignment. TEST A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection? a) WBC count 9,000/mm3 b) Changed mental status c) Temperature 37.3C (99.1F) d) Diminished reflexes - Ans - B. Changed mental status. Rationale: Untreated bladder infection or UTI among older adults can make the infection cause a drop in there blood pressure which could result in dizziness, fatigue and muscle weakness. WBC count given in the choices is within normal range. 37.3C temperature can still be considered normal. A nurse is preparing to assist with the administration of peritoneal dialysis to a client. In which order should the nurse take the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) a) Record the client's vital signs. b) Measure the client's abdominal girth. c) Prime the client's catheter tubing with dialysate solution. d) Infuse dialysate solution into the client's peritoneal cavity. e) Open the client's drainage tubing after 10 min of dwell time. - Ans - A. Record the client's vital signs. B. Measure the client's abdominal girth. C. Prime the client's catheter tubing with dialysate solution. D. Infuse dialysate solution into the client's peritoneal cavity. E. Open the client's drainage tubing after 10 min of dwell time. A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first? a) Administer a glycerin suppository. b) Ambulate the client in the hallway. c) Offer an analgesic medication. d) Request the client to be NPO. - Ans - B. Ambulate the client in the hallway Rationale: Cramping and hypoactive bowel sound is common post operative for patient having abdominal surgery that can last until 5 days. This can be due to the gas introduced in the abdomen during surgery. Walking can encourage peristaltic bowel movement relieving gas and constipation. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? a) Empty urine from the drainage bag every 12 hrs. b) Secure the catheter tubing to the client's thigh. c) Apply topical antimicrobial ointment to the client's urinary meatus following catheter care. d) Use clean technique to collect urine specimens from the drainage system. - Ans - B. Secure the catheter tubing to the client's thigh. Rationale: TEST A nurse is caring for a client who is postoperative following an appendectomy. Which of the following information should the nurse include when documenting in the electronic medical record? a) Incision healing well b) Client status unchanged throughout shift c) Abdominal wound dry, without redness d) Client received an adequate amount of fluid - Ans - C. Abdominal wound dry, without redness Rationale: According to the ANA's Principles for Nursing Documentation, documentation should be accurate, timely, complete, factual, organized and compliant. It should also reflect the nursing process and the full extent of a nurse's professional capabilities. Some of the information that should be included when documenting in the electronic medical record are: The patient's status, needs, problems, goals, interventions and outcomes The time and date of each entry The medication administered, the route, the dosage, and the patient's response. The precautions or preventive measures used, such as bed rails. The patient's refusal of treatment or medication, and the actions taken3 Any phone calls to the physician, including the message and response. The incision site, its appearance, any drainage, dressing changes, and signs of infection. TEST A nurse is caring for a client who is 24 hrs postoperative following abdominal surgery. The client received an opioid analgesic 1 hr ago and now reports a pain level of 2 on a scale of 0 to 10. Which of the following actions should the nurse take? a) Reposition the client. b) Administer an additional dose of pain medication. c) Maintain the client on bed rest. d) Apply a warm, moist compress to the incision area. - Ans - A. Reposition the client. Rationale: Since the patient had analgesic 1 hr ago and report pain only at 2 out of 10. Reposition the patient can alleviate that pain. TEST A nurse is reinforcing teaching about immunizations with an older adult client. Which of the following instructions should the nurse include? a) "You should receive the live, attenuated influenza vaccine every other year." b) "You should receive the hepatitis A vaccine every 10 years." c) "You should receive the human papillomavirus vaccine." d) "You should receive one dose of the pneumococcal vaccine." - Ans - D. "You should receive one dose of the pneumococcal vaccine." Rationale: One dose Pneumococcal vaccine is given to elderly 65 yrs old above. Influenza vaccine is given annually to this age group. HPV is given to women in reproductive age. TEST A nurse is monitoring a client who is receiving a transfusion of packed RBCs. Which of the following findings should the nurse identify as an indication that the client should receive diphenhydramine? a) Pulmonary congestion b) Urticaria c) Vomiting d) Jugular vein distention - Ans - B. Urticaria Rationale: Acute hypersensitivity reaction following blood transfusion includes symptoms of localized pruritus and urticaria unrelated to infusion site. Diphenhydramine is an antihistamine use to treat hypersensitivity or allergic reaction. TEST A nurse is caring for a client who is expecting a generalized tonic-clonic seizure. Which of the following actions should the nurse take? a) Apply restraints to the client. b) Insert a tongue blade into the client's mouth. c) Administer an IV bolus of lorazepam. d) Place the client in the prone position. - Ans - c) Administer an IV bolus of lorazepam Rationale: Administering an IV bolus of lorazepam is the appropriate action for a patient who is expecting a generalized tonic-clonic seizure, as it can help prevent or reduce the severity of the seizure. TEST A nurse is prioritizing care for four clients following a change-of-shift report. Which of the following clients should the nurse attend to first? a) A client who has diverticulitis and a temperature of 38.3C (100.9F) b) A client who has a prescription for a sputum specimen to be obtained before breakfast c) A client who sustained a head injury 2 days ago and has a decreased level of consciousness d) A client who has Alzheimer's disease and requires assistance to the bathroom - Ans - C. A client who sustained a head injury 2 days ago and has a decreased level of consciousness. Rationale: The decrease level of consciousness needs immediate action and monitoring. This could lead to deficit level of brain functioning that may lead to shock thus needing intensive care. Having a febrile client as what option 1 presents also needs attention however fever is also included in the symptoms of infected/inflamed diverticula. Though significant but the value given is manageable range. A nurse in a long-term care unit is assisting in the care of a client who has Alzheimer's disease. Which of the following actions should the nurse take? A. Alternate the client's daily routine B. Keep the lights dimmed. C. Raise the four side rails on the client's bed. D. Participate in reminiscence therapy with the client. - Ans - D. Participate in reminiscence therapy with the client. TEST A nurse is reinforcing teaching with a client who is taking oxybutynin. The nurse should tell the client that the medication will have which of the following effects? a) Relaxes the muscles of the bladder b) Increases venous return to the heart c) Relaxes the muscles of the colon d) Increases tissue perfusion in the lungs - Ans - A. Relaxes the muscles of the bladder. a) Suction the client for 20 seconds with each pass. b) Apply suction pressure while inserting the catheter into the trachea. c) Sanitize around the stoma with povidone-iodine. d) Allow space for one finger to be placed under the tube ties. - Ans - D. Allow space for one finger to be placed under the tube ties. Rationale: The nurse should suction the client for no more than 10-15 seconds with each pass. The nurse should also not apply suction pressure while inserting the catheter into the trachea. The nurse should sanitize around the stoma with normal saline. A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take? Instill saline into the tubing Perform suctioning Check the cuff pressure. Increase the humidification - Ans - Perform suctioning Rationale: The correct intervention for a client who has a tracheostomy tube and shows signs of respiratory distress is to perform suctioning. Suctioning helps to clear the airway of secretions and improve gas exchange. The other interventions are not appropriate for this situation. Instilling saline into the tubing may cause bronchospasm or infection. Checking the cuff pressure or increasing the humidification may not address the immediate problem of airway obstruction A nurse is collecting data from a client who has gastroenteritis with diarrhea and vomiting. Which of the following laboratory values should alert the nurse that the client is at risk for fluid volume deficit? a) Hematocrit 56 mg/dL b) Creatinine 1.1 mg/dL c) Sodium 140 mEq/L d) Potassium 4.5 mEq/L - Ans - A. Hematocrit 56 mg/dL TEST A nurse is reviewing the results for a client's facial occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result? a) The client consumed citrus juice 3 days before the test. b) The client has a history of breast cancer. c) The client takes ibuprofen for headaches. d) The client had a hemorrhoidectomy 1 year ago. - Ans - C. The client takes ibuprofen for headaches. Rationale: All med that falls under NSAIDs category like ibuprofen increase the risk of bleeding -> this can lead to a false-positive result in fecal occult blood test result. TEST A nurse is reinforcing discharge teaching with the partner of a client who requires tracheal suctioning. Which of the following statements by the partner indicates an understanding of the teaching? a) "I will suction the mouth before inserting the suction catheter into the tracheostomy." b) "I will suction for less than 15 seconds while inserting the suction catheter." c) "I will set the suction pressure dial between 80 and 120." d) "I will wrap the suction catheters in a clean towel to be used again at a later time." - Ans - C. "I will set the suction pressure dial between 80 and 120." Rationale: The usual suction pressure is 80-120 and must not exceed 120 to prevent tracheal suction damage. Option A tracheostomy must be suctioned before the mouth. Option B you should not suction while inserting. It must be inserted first, and suctioning must be applied while pulling the catheter out. Option D suction catheters are a one-time use only and must be sterile to prevent instillation of pathogens into the respiratory tract. TEST A nurse is caring for a client who has Parkinson's disease. The client displays difficulty using utensils while eating at mealtime. For which of the following interdisciplinary team members should the nurse recommend a referral? a) Recreational therapist b) Occupational therapist c) Physical therapist d) Speech therapist - Ans - B. Occupational therapist TEST A nurse is preparing to administer diphenhydramine 25 mg PO every 6 hr to an older adult client who has rhinitis. The amount available is diphenhydramine syrup 12.5 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - Ans - 10 mL TEST A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion? a) Hypertension b) Vomiting c) Distended neck veins d) Polyuria - Ans - B. Vomiting Rationale: A septic reaction to a blood transfusion is a rare but serious complication that occurs when the donor blood is contaminated with bacteria. The symptoms may include vomiting, fever, chills, and hypotension. A nurse is reinforcing teaching about environmental modifications in the home with a family member of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching? a) Leave the television on. b) Install locks at the top of doors. c) Schedule alternate caregivers. d) Place throw rugs on the floor. - Ans - B. Install locks at top of doors. Rationale: Putting locks on top of the doors which is out of reach by the patient prevents everyone from being lock out as the patient tends to forget as they wander which is typical in its condition. Option A keeping the television ON will attract attention of the patient however excessive noise and exceedingly brightly lights could disturb the patient. Option C will make the patient confused. In assigning a care giver to patient with this condition, consistency and familiarity is essential eliminating confusion. Option D puts patients at risk for fall and injury. Remember patient with Alzheimer tends to wander around. A nurse is reinforcing teaching about the care of a client who has tinea corporis with a newly licensed nurse. Which of the following should the nurse include in the teaching? a. "You can expect your leg muscles to look a little swollen." b. "You should avoid elevating your leg while sitting." c. "You should hold still to prevent injury to your skin." d. "You can expect to feel pressure when we cut the cast." - Ans - d. "You can expect to feel pressure when we cut the cast." A nurse reinforcing discharge teaching with the client who had an abdominal hysterectomy 2 days ago. Which of the following instructions should the nurse include in the teaching a. "Douche with warm water to remove vaginal discharge." b. "Take a shower rather than a bath." c. "Avoid climbing stairs for 8 week." d. "Expect bright red vaginal bleeding for 1 week following surgery." - Ans - B. "Take a shower rather than a bath." Rationale: Following an abdominal hysterectomy, the client should avoid taking baths and instead take showers to reduce the risk of infection. Douching is generally not recommended as it can disrupt the natural flora of the female reproductive part. Climbing stairs may be restricted initially but not for 8 weeks. Expecting bright red reproductive part bleeding for 1 week following surgery is not accurate information as bleeding should gradually decrease. TEST Patient has a new placement of colostomy, which of the following indicate that the colostomy is functioning properly? - Ans - Red beefy after surgery, moist, shiny TEST Patient is post-op and has DVT, nurse should? - Ans - Maintain patient on bed rest. Rationale:: Deep vein thrombosis (DVT) is a condition where a blood clot forms in one or more of the deep veins in the body, usually in the legs. It can cause leg pain, swelling, or no symptoms at all. It can also lead to serious complications like pulmonary embolism (PE) if the clot breaks loose and travels to the lungs. Nursing interventions for DVT include: Assessing the patient's history and symptoms, such as risk factors, signs of inflammation, and pain level. Administering anticoagulant medications, such as heparin, warfarin, or direct oral anticoagulants (DOACs), to prevent clot growth and recurrence. Managing pain with analgesics, elevation of the affected limb, and warm compresses. Immobilizing the patient and initiating bed rest to reduce the risk of clot mobilization (clot mobilization could travel to lungs and lead to pulmonary embolism). Promoting circulation with compression therapy, such as stockings or devices, and encouraging activity as tolerated. Educating the patient about DVT, self-care measures, medication adherence, and signs of complications. Providing psychosocial support and addressing any fears or concerns. Collaborating with the healthcare team and monitoring the patient's condition closely. TEST A nurse is caring for a client who has deep-vein thrombosis. Which of the following interventions should the nurse plan to take? a) Measure the calf of the affected extremity each shift. b) Place the client's bed in reverse Trendelenburg position. c) Apply cold compresses to the affected extremity. d) Massage the affected extremity every 4 hr. - Ans - A. Measure the calf of the affected extremity each shift Rationale: The nursing care plan for the client with deep vein thrombosis include: providing information regarding disease condition, treatment, and prevention; assessing and monitoring anticoagulant therapy; providing comfort measures; positioning the body and encouraging exercise; maintaining adequate tissue perfusion; and preventing complications. Therefore, the nurse should measure the calf of the affected extremity each shift to assess for any changes in size. The nurse should also place the client's bed in a position that promotes venous return, such as elevating the affected extremity above the level of the heart. Applying cold compresses to the affected extremity is not recommended as it can cause vasoconstriction and reduce blood flow. Massage is contraindicated in clients with deep vein thrombosis as it can dislodge clots and cause pulmonary embolism. TEST A nurse is contributing to the plan of care for a client who has developed an infectious wound would foul-smelling drainage. Which of the following actions should the nurse include in the plan of care? a. Minister antibiotic therapy before culturing the client's wound. b. discard soiled wound care supplies in a trash receptacle outside the client's room. c. Place the client in a private room with a private bathroom. d. Instruct visitors to perform hand hygiene four five seconds after leaving the client's room. - Ans - C. Put patient in a private room with a private bathroom Rationale: (contact precaution) TEST A nurse in a long-term care facility is reinforcing teaching about pain control with a client who has terminal cancer. Which of the following information should the nurse include? A. "We will use intramuscular medications to control your pain." B. "Pain patches are applied each morning and removed at bedtime." C. "Analgesia should be used around the clock to promote pain control." D. "A medication dose must be decreased if you develop tolerance." - Ans - C. "Analgesia should be used around the clock to promote pain control." Rationale: This is very effective in managing pain as intermittent administration of medication might not provide. Option A usually IV medications is given Option B transdermal patches could be used to manage pain in terminally ill patients, but they must be applied for 24 hours to achieve therapeutic effect and not applied in the morning and removed at night. Option D the dose must be increased to have desired therapeutic effect. TEST Manifestation of opioid toxicity? - Ans - Hypotension Rationale Opioids exhibit a myriad of cardiovascular complications including hypotension, bradycardia, peripheral vasodilatory flushing, and syncope. By contrast, opioid withdrawal triggers hypertension, tachycardia, stress cardiomyopathy, and potentially ACS. Feel your breasts while standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover the entire breast from top to bottom, side to side — from your collarbone to the top of your abdomen, and from your armpit to your cleavage. Look for any signs of fluid coming out of one or both nipples (this could be a watery, milky, or yellow fluid or blood). If you notice any changes or lumps in your breasts, you should report them to your doctor as soon as possible. However, most breast changes are not cancerous, so don't panic if you find something suspicious. BSE is not a substitute for other screening methods such as mammograms or clinical breast exams by a doctor. It is best to combine BSE with other screening tools for early detection of breast cancer. TEST Patient is 24 hrs post-op following a total hip arthroplasty, which of the following actions the nurse should include in the care plan? - Ans - "Performing range of motion by adducting" Rationale: some of the actions that the nurse should include in the care plan for a patient who is 24 hours post-op following a total hip arthroplasty are: Encourage the patient to do gentle exercises in bed, such as ankle pumps, quadriceps and gluteal contractions, to facilitate blood flow and prevent stiffness. Assist the patient to stand up and walk with the aid of a physical therapist and/or a walker, as weight-bearing can help with recovery and prevent complications. Follow the surgeon's instructions on how much weight can be put on the new hip, as this may vary depending on the type of surgery and prosthesis used. Monitor the patient's pain level and administer pain medication as prescribed. Prevent infection by changing dressings, keeping the surgical site clean and dry, and administering antibiotics as prescribed. Educate the patient on how to care for the new hip at home, such as avoiding certain movements that may cause dislocation, using assistive devices, and following up with physical therapy. TEST A nurse is assisting in the care of a client who has a pulmonary embolism and is experiencing dyspnea. Which of the following actions should the nurse take first? A. Obtain the client's vital signs. B. Administer heparin to the client. C. Encourage the client to cough and deep breathe. D. Place the client in high Fowler's position. - Ans - D. Place the client in high Fowler's position. Rationale: the first action the nurse should take is place the client in high Fowler's position. This can help improve gas exchange and reduce dyspnea. The other actions are also important, but not the priority. TEST A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take? A. Apply petroleum jelly to the client's nares. B. Maintain the client in a supine position. C. Implement t contact precautions D. Initiate fall precautions - Ans - D. Initiate fall precautions Rationale: Patient is in the condition of hypoxia so their is increased risk of irritability of brain due to lack of oxygen. Level of alertness and physical activity also Decreases. In this condition chances of fall are higher so fall precautions should be initiated. Other options are incorrect. Supine position is not safe after aspiration pneumonia. Semi fowler position should be provided. Petroleum jelly can increase risk of aspiration. Contact precautions is not necessary because aspiration pneumonia is not contagious. It occurs due to aspiration of food particles , liquid or foreign particles. TEST Pt received penicillin 30 mins ago and began to develop hives and itching. Which of the following is the nurse's highest priority question? - Ans - "Are you having any difficulty breathing?" Rationale: This question to rule out whether the patient is experiencing anaphylaxis. TEST A nurse is assisting with the care plan for a client who has osteoarthritis. The client reports knee stiffness upon ambulation. Which of the following interventions should the nurse include in the plan of care? a.) Apply moist heat prior to ambulation. b.) Rest in a soft chair. c.) Use a continuous passive motion machine. d.) Delay ambulation until the next day. - Ans - A. Apply moist heat prior to ambulation. Rationale: Heat therapy can alleviate knee osteoarthritis pain and stiffness in two ways. First, the sensation of heat provides relief by overpowering the nerves that send pain signals to your brain. This is why you'll often feel the warmth of your heating pad over the discomfort. Second, heat improves blood flow in the area. As such, moist heat is a much better choice for OA instead of ice because the warmth dilates blood vessels (larger diameter) around the knee, improves circulation, loosens up muscles and helps to alleviate joint stiffness. Applying moist heat prior to ambulation can help reduce knee stiffness and improve mobility for clients with osteoarthritis. TEST Reinforcing teaching for pt has just returned home following a total hip arthroplasty, what should the nurse include in teaching? - Ans - Place electrical cords against the wall Rationale: This action is to eliminate fall risk factors for patient with impair ambulation. TEST Pt has an order of intermittent enteral feeding through an NGT, what is the nurse priority before feeding? - Ans - Keep the head of the bed at 30-degree angle. Rationale: The nurse's priority before feeding a patient with intermittent enteral feeding through an NGT is to check the position of the tube and ensure that it is located in the stomach. This can be done by aspirating gastric contents and measuring the pH (lower than 5), or "I will not eat any solid food the day before the exam." "I will drink plenty of clear liquids but avoid red ones." "I will take the laxative as instructed by my doctor." "I will arrange for someone to drive me home after the exam." TEST A nurse is caring for a client who is postoperative following right total knee arthroplasty. Which of the following actions should the nurse take when applying the continuous passive motion (ICP) device? a. Ensure the hip is in full abduction when applying CPM device. b. Elevate the head of the bed 30 degrees before starting the CPM device c. Apply the CPM device over the knee immobilizer d. Ensure the knee joint is positioned over the CPM device frame joint. - Ans - D. Ensure the knee joint is positioned over the CPM device frame joint. another form of answer will be "Align patient joint with joint on the frame." Rationale: When applying a continuous passive motion (CPM) device for a client who underwent a total knee arthroplasty, it is important to ensure that the knee joint is positioned over the CPM device frame joint. This helps to provide proper alignment and maximize the benefits of the device. The hip does not need to be in full abduction. Elevating the head of the bed is not necessary for applying the CPM device. Applying the CPM device over the knee immobilizer is not appropriate. TEST Nurse is reinforcing teaching about low fat diet for pt with CAD (coronary artery disease), which of the following statements indicate understanding teaching? a. "I will increase butter in my diet." b. "I will use coconut oil in my diet." c. "I will eat fish 3 times per week." d. "I will add 2% milk in my diet." - Ans - c. "I will eat fish 3 times per week." Rationale A low-fat diet for coronary artery disease (CAD) should include foods that are high in soluble fiber and low in saturated and trans fats, such as oats, nuts, beans, fatty fish, and olive and canola oils. It should also include plenty of fresh fruits and vegetables, whole grains, lean protein, low-fat dairy products, and monounsaturated fats from nuts, avocados, and olives. A diet for CAD should avoid foods that are rich in saturated fat, such as red meat, coconut oil, butter, cheese, whole and 2% milk. It should also limit sugar, salt, refined carbs, fried foods, processed foods, egg yolks, organ meats, and foods cooked in butter, cheese, or cream sauce. Based on this information, the statement that indicates understanding of the teaching is c. "I will eat fish 3 times per week." This is because fish is a good source of omega-3 fatty acids, which can lower LDL cholesterol and blood pressure. The other statements are incorrect because they suggest increasing or adding foods that are high in saturated fat or cholesterol, which can worsen CAD. TEST Cheilosis location - Ans - Swelling and fissuring of the lips Rationale: Angular cheilitis (AC) is inflammation of one or both corners of the mouth. Often the corners are red with skin breakdown and crusting. It can also be itchy or painful. The condition can last for days to years. Angular cheilitis is a type of cheilitis (inflammation of the lips). Angular cheilitis can be caused by infection, irritation, or allergies. Infections include by fungi such as Candida albicans and bacteria such as Staph. aureus. Irritants include poorly fitting dentures, licking the lips or drooling, mouth breathing resulting in a dry mouth, sun exposure, overclosure of the mouth, smoking, and minor trauma. Allergies may include substances like toothpaste, makeup, and food. Often a number of factors are involved. Other factors may include poor nutrition or poor immune function. Diagnosis may be helped by testing for infections and patch testing for allergies. TEST Pt is receiving treatment for cancer and developing stomatitis, which of the following actions the nurse should implement to help manage stomatitis? - Ans - Encourage pt to consume cold items. Rationale: Stomatitis is a common side effect of cancer treatment that causes swelling and redness of the mouth lining and painful sores. To help manage stomatitis, some possible actions the nurse can implement are: Encourage good mouth care and mouth rinses with baking soda, salt water, or saline. Use a soft toothbrush or foam swab and avoid dental floss if it causes bleeding. Avoid alcohol, tobacco, spicy, acidic, or dry foods that can irritate the mouth. Apply ice or cold foods to the mouth to reduce pain and inflammation. Give pain medicines or mouth rinses prescribed by the doctor, such as antiviral or anti- inflammatory agents. Monitor the mouth for signs of infection, such as white or yellow patches, pus, or increased pain. TEST A nurse is caring for a client who is receiving treatment for cancer and has stomatitis. Which of the following actions should the nurse take? (SATA) a.) Limit the client's fluid intake to 1,000 mL daily. b.) Rinse the client's toothbrush with hydrogen peroxide after the use. c.) Instruct the client how to use artificial saliva. d.) Give the client tooth sponges to brush her teeth. e.) Include OJ in the client's daily diet. - Ans - c.) Instruct the client how to use artificial saliva products to rinse mouth., d.) Give the client tooth sponges to brush her teeth. Rationale: Stomatitis is the inflammation of the oral mucosa, which can be caused by cancer treatment such as chemotherapy and radiation. The client with stomatitis may experience painful sores that can make it hard to eat, drink, or swallow. Here are the nursing interventions that should be taken care of: Instruct the client how to use artificial saliva. Artificial saliva can help to keep the mouth moist and relieve dryness. Give the client tooth sponges to brush her teeth. Tooth sponges are soft and gentle on the gums and teeth, which can help to prevent further irritation. DO NOT include OJ in the client's daily diet. OJ is acidic and can cause further irritation to the mouth sores. DO NOT limit the client's fluid intake to 1,000 mL daily. Adequate hydration is important for clients with stomatitis. DO NOT rinse the client's toothbrush with hydrogen peroxide after use. Hydrogen peroxide can cause further irritation to the mouth sores TEST Place in order for Z-track technique after the nurse has already performed hand hygiene and identify pt. - Ans - - Put on clean gloves and cleanse the site with alcohol - Pull the skin and the SQ away from the infection site Recent onset of confusion can be an indicator of dehydration in older adults. Dehydration can affect cognitive function and lead to confusion or delirium. It is important for the nurse to recognize this symptom and assess the client's hydration status. There are several possible signs of dehydration in older adults, such as: Decreased urination or low urine output Urine that's a darker color than normal Dry mouth Sunken eyes or cheeks Muscle cramping Feeling dizzy or lightheaded TEST A nurse is caring for a client who has diabetes mellitus. Which of the following laboratory findings indicates the client has maintained control of his blood glucose levels for the past 3 months? A. Fasting blood glucose 100 mg/dL B. HbA1c 12.5% C. Fasting blood glucose 70 mg/dL D. HbA1c 6.5% - Ans - D. HbA1c 6.5% Rationale: HbA1c is the best indicator for blood sugar control in the past 3 months. For DM pt, HbA1c should be kept below 7% TEST A nurse is reviewing the ABG values of a client who has pneumonia. Which of the following findings indicates the client is developing respiratory acidosis? PaO2; 85 mm Hg PaCO2; 55 mm Hg pH 7.47 HCO, 25 mEQ/L - Ans - PaCO2 55 mmHg Rationale: normal value is 35 - 45 TEST Pt just had coronary angiography, which lab should be reported? - Ans - BUN 30 mg/dL Rationale: Normal range is 10 to 20 mg/dL TEST Pt has leukemia, which of the following findings is the highest priority? - Ans - Elevated temperature (indicate infection) TEST The nurse is reviewing the lab result on a patient with severe dispnea, which of the following labs indicate pt is experiencing heart failure (HF)? - Ans - Brain natriuretic peptide (BNP) 275 (BNP < 100 indicate no HF, more than 100 suspect HF, more than 400 ensure than pt is having HF) TEST Point of maximum impulse - Ans - Point of maximum impulse = Apical pulse = 5th intercostal midclavicular line TEST The nurse is collecting data on a patient 1 month following the surgery of a new colostomy. Which statement indicates pt is in the acceptance stage? - Ans - "I have purchased stoma cap to use as needed" TEST A nurse is reinforcing teaching with a client who has psoriasis. Which of the following treatment options should the nurse include in the teaching? a. Phototherapy b. Dermabrasion c. Oil-based ointment d. Benzoyl peroxide - Ans - A. Phototherapy Rationale: Phototherapy, specifically ultraviolet (UV) light therapy, is a common treatment option for psoriasis. It helps to slow down the rapid skin cell growth and reduce inflammation. Dermabrasion is a procedure used for scar revision, oil-based ointments are not typically recommended for psoriasis, and benzoyl peroxide is used for acne treatment. TEST Alendronate teaching - Ans - Sit upright 30 to 60 mins after taking medication Rationale: Alendronate is a medication used to prevent and treat bone loss (osteoporosis) in adults. It belongs to a class of drugs called bisphosphonates. It works by slowing down the breakdown of bone and increasing bone density. Here are some important points to remember when taking alendronate: Take it on an empty stomach, as soon as you get up in the morning, and at least 30 minutes before any food, drink, or other medication. Swallow the tablet whole with a full glass of plain water. Do not chew, suck, or crush it. Stay upright (sitting, standing, or walking) for at least 30 minutes after taking it. Do not lie down until after your first food of the day. Avoid taking calcium, iron, antacids, vitamins, or other supplements within 30 minutes of taking alendronate. They can interfere with its absorption. Tell your doctor and dentist that you are taking alendronate. You may need to stop it before certain dental procedures or surgeries. Report any side effects to your doctor, such as heartburn, chest pain, difficulty swallowing, jaw pain, muscle or joint pain, or signs of low calcium levels. TEST Pt has peripheral IV infusion, the nurse notes edematous, cool, and tender at the injection site. What should the nurse expect? - Ans - Infiltration Rationale: The nurse should expect that the patient has an infiltration or extravasation of the IV fluid or medication into the surrounding tissue. This can cause inflammation, pain, and possible tissue damage. The nurse should stop the infusion, remove the IV, and notify the doctor. The nurse should also mark and photograph the affected area TEST Pt is 8 hr abdominal post-op, BP is 94/56, which action should the nurse take first? - Ans - Compare the reading to the preoperative value. TEST A nurse is preparing to perform a sterile dressing change for a client who has a stage III pressure ulcer. Which of the following actions should the nurse plan to take? A. Prepare the sterile dressing supplies 30 min before the dressing change B. offer the client pain medication before the procedure Pt has a new order of digoxin, which of the following indicate understanding the teaching? - Ans - "I will have potassium level check periodically" Rational: The most common trigger of digoxin toxicity is hypokalemia, which may occur as a result of diuretic therapy. Dosing errors are also a common cause of toxicity in the younger population. TEST Pt has chronic venous insufficiency, which of the following image demonstrate venous stasis ulcer - Ans - TEST A nurse is assisting with the care of a client who has a seizure disorder. Which of the following supplies should the nurse have at the client's bedside at all times? a.) Wrist restraints. b.) Suction equipment. c.) Backboard. d.) Padded tongue blade. - Ans - b. Suction equipment Rationale: Suction equipment to help clear the patient airway TEST SLE skin care (SATA), got this one wrong, options area. a. Pat skin dry gently b. Lotion to skin twice per day c. Cleanse the area with astringent- Astringent is to remove oil from the skin d. Put on sunscreen with SPF 30 before doing gardening e. Limit to only 10 mins on bed tanning - Ans - a. Pat skin dry gently b. Lotion to skin twice per day d. Put on sunscreen with SPF 30 before doing gardening. TEST Reinforcing teaching about breast health, what should the nurse include to decrease chances of developing breast cancer? - Ans - Consume diet high in antioxidant. Rationale According to some sources, consuming a diet high in antioxidants may help decrease the chances of developing breast cancer by offsetting the toxins and carcinogens that can trigger it. Some foods that are rich in antioxidants include broccoli, berries, grapes, and herbs and spices. TEST A nurse is collecting data from a female client during an initial health assessment. Which of the following findings should the nurse identify as a risk factor for osteoporosis? A. Applies an estrogen vaginal cream daily. B. includes canned sardines in her diet. C. Walks 30 min per day D. Uses a beclomethasone inhaler. - Ans - D. Use beclomethasone inhalers Rationale: Chronic corticosteroid therapy by any route is the most common cause of medication- induced osteoporosis (Beclomethasone "-sone" belongs to steroids, one of steroids' adverse effects is osteoporosis) Option A estrogen therapy even helps prevent osteoporosis. Option B canned sardines are high in calcium, helping prevent or decrease risk of osteoporosis. Option C exercise decreases risk of osteoporosis. A nurse is collecting data from a female client who is postmenopausal. Which of the following findings should the nurse identify as a risk factor for the development of osteoporosis? A. Long-term use of prednisone B. Monthly vitamin B12 injections C. History of kidney stones D. Congenital heart murmur - Ans - Long-term use of prednisone TEST The nurse is reviewing the change-of-shift report, which of the following pt should the nurse see first? - Ans - Pt who reports pain on L calf and respiratory rate of 32/min Rationale: Pain on L calf is an indication of manifestation of DVT and tachypnea is an indication of pulmonary embolism which caused by the dislodged blood clog traveled to the lungs. TEST Which of the following solutions can be infused together with pack of RBCs - Ans - 0.9% normal saline Rationale: this solution will not cause clump or clothing of the RBCs TEST A nurse is caring for a client who has a closed head injury. In which of the following positions should the nurse place the client? A. Modified Trendelenburg B. Sims C. Semi-Fowler's D. Prone - Ans - C. Semi-Fowler position Rationale: To decrease intracranial pressure TEST The nurse is reviewing the change-of-shift report, which of the following pt should the nurse see first? - Ans - Pt with an indwelling catheter and has urine output 80 mL over the past 8h Rationale: normal urine output should be 30 mL/hr TEST The nurse is teaching about saturated fat, which of the following cooking oil should the nurse recommend? a. Coconut oil b. Vegetable shortening c. Palm oil d. canola oil - Ans - D. Canola oil Rationale: The nurse should recommend canola oil as it is low in saturated fat and high in unsaturated fat. Coconut oil, vegetable shortening, and palm oil are high in saturated fat which can increase the risk of heart disease TEST The nurse is collecting data following thoracentesis procedure, what should the nurse report - Ans - RR of 26/min Rational: TEST A nurse is reinforcing teaching with a client who is scheduled for a bronchoscopy. Which of the following statements should the nurse include in the teaching? A. "You will be placed on your left side during the procedure." B. "You will be able to eat as soon as the procedure is finished." C. "You should not eat or drink for 2 hours before the scheduled time of the procedure." D. "Your vital signs will be checked frequently for the first 2 hours after the procedure." - Ans - D. "Your vital signs will be checked frequently for the first 2 hours after the procedure." Rationale: Frequent monitoring is done to the patient post-procedure to check for any complications and adverse effects of sedative or anesthetics given and also for bleeds related to procedure. Option A patient is positioned supine. Option B patient is placed on NPO (nothing by mouth) status post procedure until gag reflexes have returned. Option C must be 6 hrs prior. TEST Pt has dementia, and is experiencing confusion, what should the nurse do? - Ans - Use holiday decoration to provide orientation of time TEST Pt has pertussis, what should the nurse do? - Ans - Wear simple surgical mask when caring for pt Rationale: (Pertussis belongs to droplet precaution) Droplet precautions require: -A private room or a room with other clients who have the same infectious disease. Ensure that clients have their own equipment. -Masks for providers and visitors. -Clients who have a droplet infection should wear a mask while outside of the room/home. A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions in preparation for the procedure should the nurse take? A. Shave the client from axillae to groin. B. Administer a cleansing enema. C. Ensure the signed consent is in the medical record. D. Have the client drink contrast medium. - Ans - C. Ensure that the signed consent form is in patient medical record. Rationale: Proper documents especially the signed consent must be properly placed in the medical records. Option A no catheter is inserted into femoral artery, thus shaving axilla to groin is not necessary. Option B is not necessary as a colonoscopy is not done. A cleansing enema is not needed in esophagogastroduodenoscopy. Option D the patient does not need to drink contrast media in esophagogastroduodenoscopy. An IV of the contrast media will be administered A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include? a. Administer enemas 2 days before the procedure. b. Do not eat or drink anything except water for 12 hrs before the procedure. c. Restrict the diet to clear liquids for 1 to 3 days before the procedure. d. Expect the provider to schedule another procedure to remove any polyps. - Ans - C. Restrict the diet to clear liquids for 1 to 3 days before the procedure. Rationale: Before a colonoscopy, it is important to restrict the diet to clear liquids for 1 to 3 days prior to the procedure. This allows for adequate visualization of the colon during the procedure. Administering enemas 2 days before the procedure is not a standard preparation. Complete fasting (except water) for 12 hours before the procedure is not necessary. The provider may remove polyps during the colonoscopy if found, but scheduling another procedure is not necessarily routine. A nurse is reinforcing teaching about foods containing potassium with a client who has a new prescription for hydrochlorothiazide, what food is the best source of potassium? a. ½ cup of cucumber slices (only 80 mg) b. 1 cup of apricot slices c. ½ cup of okra d. 1 cup of pineapple chunks (200 mg) - Ans - B. 1 cup of apricot slices. Rationale: Among the options, 1 cup of apricot slices is the best source of potassium. Apricots are rich in potassium, with approximately 450 mg per cup. Cucumber slices, okra, and pineapple chunks contain lower amounts of potassium compared to apricots. TEST The nurse is reinforcing teaching about applying antiembolic stock, which statement should be included? - Ans - Reapply before getting out of bed. Rationale: Some other possible statements to include in the teaching about applying antiembolic stockings are: Antiembolic stockings are tight fitting stockings that help prevent blood clots in your legs by promoting blood return to the heart. You should wear them as much as possible, except when you shower or clean your legs. You should make sure the stockings fit properly, are not too tight or too loose, and do not have any wrinkles or rolls. You should check your toes and feet regularly for any signs of poor circulation, such as coldness, paleness, numbness, or pain. You should follow the instructions on how to wash and dry the stockings. TEST Pt had a TB test 72 hours ago, which of the following findings indicate that pt needs further tests? - Ans - Palpable area larger than 10 mm in diameter TEST A nurse is interpreting the results of a tuberculin skin test for a group of clients who received the test 48 hr ago. Which of the following clients should the nurse identifies as having a positive test result? A client whose injection site has an elevated area measuring 15 mm A client whose injection site is ecchymotic A client whose injection site is scabbed A client whose injection site is firm and measures 3 mm - Ans - A client whose injection site has an elevated area measuring 15 mm TEST electrodes is vital in obtaining accurate information about the electrical activity of the heart. TEST A nurse is caring for an older adult client immediately following a bronchoscopy with biopsy. Which of the following is the priority action the nurse should take? -Document sputum color and consistency. -Check for a gag reflex. -Offer ice chips. -Instruct the client to gargle with warm saline. - Ans - Check for gag reflex. Rationale: The priority action the nurse should take immediately following a bronchoscopy with biopsy is to check for a gag reflex. The nurse should also monitor the client's respiratory status and maintain a viable airway. Documenting sputum color and consistency is important but not the priority action. Offering ice chips or instructing the client to gargle with warm saline are not appropriate actions after a bronchoscopy with biopsy. TEST A nurse on a medical-surgical unit is caring for an older adult client who has developed sepsis due to a urinary tract infection. A member of the client's family tells the nurse not to perform any "heroic measures" to keep the client alive. Which of the following responses by the nurse is appropriate? "The client's condition is not critical enough to discuss these issues." "Let me check the client's medical record for advance directives." "You should contact the client's attorney to document your wishes legally." "Why do you believe treatment would not benefit the client?" - Ans - "Let me check the client's medical record for advance directives." A nurse is monitoring a client who is receiving intravenous fluids. Which of the following findings indicates a fluid volume excess? (Select all that apply) A. Bradycardia B. Flat neck veins C. Weight gain D. Hypertension D. Dyspnea - Ans - Weight gain Hypertension Dyspnea Rationale: Fluid volume excess is a condition where the body retains too much fluid1. The following findings indicate fluid volume excess: Weight gain: This is a common sign of fluid volume excess. It occurs when the body retains more fluid than it excretes. Hypertension: Fluid volume excess can cause an increase in blood pressure. Dyspnea: This is a feeling of shortness of breath or difficulty breathing. It can occur when there is too much fluid in the lungs. Bradycardia and flat neck veins are not associated with fluid volume excess. A nurse is reinforcing teaching about a heart-healthy diet with a client. Which of the following statements by the client indicates that the teaching was effective? A. "I will increase my intake of lean red meat." B. "I will eat chicken as my source of fiber." C. "I will use skim milk as my source of dairy." D. "I will increase my servings of canned vegetables." - Ans - C. "I will increase my intake of lean red meat." Rational: STEAK! A nurse is caring for a client who has chronic kidney disease. Which of the following interventions is appropriate? A. Offer the client a high-protein diet. B. Administer NSAIDs for discomfort. C. Monitor the client for hypokalemia. D. Obtain the client's daily weight. - Ans - C. Monitor the client for hypokalemia. A nurse is reinforcing discharge teaching with a client regarding self-administration of regular insulin. Which of the following instructions should the nurse include? A. Store opened insulin vials at room temperature for up to 4 weeks. B. Warm the insulin vial to dissolve any crystals that develop. C. Plan to eat a snack 6 hrs after insulin administration. D. Keep unopened insulin vials in the freezer. - Ans - A. Store opened insulin vials at room temperature for up to 4 weeks. Rationale: Most insulin manufacturers recommend storing unopened insulin in the fridge. But many insulin products can be unrefrigerated for up to 28 days. There are a few exceptions. Avoid exposing your insulin to extreme hot or cold temperatures. Always read the manufacturer's instructions for storing your particular type of insulin. A nurse is preparing to enter the room of a client who has tuberculosis. Which of the following personal protective equipment should the nurse wear? A. Venturi mask B. surgical mask C. Respirator mask D. Nonrebreather mask - Ans - C. Respirator mask A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan? A. Initiate protective isolation for the client. B. Administer Ibuprofen for mild headache. C. Check the client for ecchymosis. D. Instruct the client to shave with a disposable razor. - Ans - C. Check the client for ecchymosis. Rationale: Thrombocytopenia is a medical condition characterized by low levels of platelets in the blood. It can cause nosebleeds, bleeding gums, blood in urine, heavy menstrual periods, and bruising. The priority goals of nursing care for a client with thrombocytopenia include prevention and early detection of bleeding, as well as intervening when bleeding occurs. Therefore, the nurse should include checking the client for ecchymosis in the plan of care. Ecchymosis is a medical term for a bruise, which is a common symptom of thrombocytopenia. The nurse should also instruct the client to avoid activities that may cause injury or bleeding, such as shaving with a disposable razor. Administering Ibuprofen for mild headache is not recommended as it can thin the blood and increase the risk of bleeding. Initiating protective isolation for the client is not necessary as thrombocytopenia is not contagious. A nurse is assisting with the care of a client who is postoperative and has received fentanyl for pain management. In the event the client develops respiratory depression, the nurse should make sure that which of the following medications is available to administer? A. Naloxone B. Atropine C. Fumazenit D. Acetylcysteine - Ans - Naloxone