NCLEX LVN Exam Questions and Answers 2024 Update | Graded A+, Exams of Nursing

Download NCLEX LVN Exam Questions and Answers 2024 Update | Graded A+ and more Exams Nursing in PDF only on Docsity! NCLEX LVN Exam Questions and Answers 2024 Update | Graded A+ Which of the following assessment findings could the nurse see in a patient with parkinsonism? (Select all that apply.) a. An abrupt onset of symptoms b. Muscle rigidity c. Involuntary tremors d. Bradykinesia e. Bilateral muscle weakness - Correct answer-b. Muscle rigidity c. Involuntary tremors d. Bradykinesia A patient is receiving carbidopa-levodopa for parkinsonism. What should the nurse know about this drug? a. Carbidopa-levodopa may lead to hypertension. b. Carbidopa-levodopa may lead to excessive salivation. c. Dopaminergic and anticholinergic therapy may lead to drowsiness and sedation. d. Dopaminergics and anticholinergics are contraindicated in patients with glaucoma. - Correct answer- d. Dopaminergics and anticholinergics are contraindicated in patients with glaucoma. The nurse has initiated teaching for a family member of a patient with Alzheimer's disease. The nurse realizes more teaching is needed if the family member makes which statement? a. As the disease gets worse, the memory loss will get worse. b. There are several theories about the cause of the disease. c. Personality changes and hostility may occur. d. It may take several medications to cure the disease. - Correct answer-d. It may take several medications to cure the disease. A patient is taking rivastigmine (Exelon). The nurse should teach the patient and family which information about rivastigmine? a. That hepatotoxicity may occur b. That the initial dose is 6 mg t.i.d. c. That GI distress is a common side effect d. That weight gain may be a side effect - Correct answer-c. That GI distress is a common side effect 5.Which is a nursing intervention for a patient taking carbidopa-levodopa for parkinsonism? a. Encourage the patient to adhere to a high-protein diet. b. Inform the patient that perspiration may be dark and stain clothing. c. Advise the patient that glucose levels should be checked with urine testing. d. Warn the patient that it may take 4 to 5 days before symptoms are controlled. - Correct answer-b. Inform the patient that perspiration may be dark and stain clothing. What would the nurse teach a patient who is taking anticholinergic therapy for parkinsonism? (Select all that apply.) a. Avoid alcohol, cigarettes, and caffeine. d. A response to any demand made upon the individual - Correct answer-d. A response to any demand made upon the individual The nurse is caring for a patient who is currently voicing feelings of anxiety. The nurse correctly recognizes what as the best description of the feelings that the patient is experiencing? a. A vague feeling of apprehension b. Feelings of paranoia c. Concerns about the impressions others have for her d. Emotional stability - Correct answer-a. A vague feeling of apprehension An assembly line manager in a factory was told that he would be laid off if his line did not meet the hourly quote. He promptly went to his workers and threatened to fire anyone who was found taking even 1 minute extra on a break. What is the manager displaying? a. Denial b. Regression c. Displacement d. Identification - Correct answer-c. Displacement Punishment and abandonment were how mentally ill people were treated in medieval times. These practices continued until the 17th and 18th centuries. Which care practice that is still being used today did Dr. Phillipe Pinel of France advocate? a. Electroshock therapy for melancholy b. Humane care with record keeping of behaviors c. Psychoanalysis d. Home care in the community - Correct answer-b. Humane care with record keeping of behaviors The student nurse is working on a presentation regarding OBRA. What was the result of this landmark legislation? a. Deinstitutionalization b. Approved surgical treatment for schizophrenia c. Prohibition of electroshock therapy d. Increased construction of state facilities for residential mental health care - Correct answer-a. Deinstitutionalization A 52-year old patient experienced cardiac arrest from a myocardial infarction. During his acute care stay in the hospital, the patient flirts with all female nurses. When he is asked to stop, he withdraws and later complains of chest heaviness. What is a possible explanation for the patient's behavior? a. Boredom from restricted activity b. Lack of motivation to recover c. Frustration from illness d. Threatened self-concept - Correct answer-d. Threatened self-concept A 14-year-old tells the school nurse that she is self-conscious about her recent breast development. She reports that the boys in her class are teasing her. What is the first step for the nurse to take? a. Call her parents b. Have her describe what happened c. Ask who her friends are d. Provide her with a pamphlet outlining the changes associated with puberty - Correct answer-b. Have her describe what happened Your patient with heart failure has been responding well to treatments that include medications such as ACE inhibitors and a loop diuretic. Today, the client is complaining about leg weakness and is refusing to ambulate. What is most likely occurring with this client? a. Hyperkalemia b. Hyponatremia c. Hypokalemia d. Hypernatremia - Correct answer-c. Hypokalemia Hypokalemia, or low potassium, often occurs as the result of treatments with loop diuretics like furosemide (Lasix). The signs and symptoms of hypokalemia include muscular weakness, pain and cramping, as well as serious cardiac dysrhythmias. Clients taking loop diuretics should be closely monitored for hypokalemia and also given potassium supplementation when indicated. Which of the following assistive techniques should the be used to transfer a patient who can bear weight from the bed to the chair? a. mechanical lift b. slide transfer c. pivot transfer d. assisted transfer - Correct answer-c. pivot transfer Your client is to have an NG tube inserted. To mark the tube prior to insertion, you should: a. place the tip of the tube at the corner of the patient's eye and extend the tip to the earlobe, and then to the tip of the xiphoid process. b. place the tip of the tube at the corner of the mouth and extend the tip to the top of the patient's ear, and then to the umbilicus. c. place the tip of the tube at the patient's nostril and extend the tip of the earlobe, and then to the tip of the xiphoid process. d. place the tip of the tube at the patient's nostril , extend it to the tip of the earlobe, and then to the base of the ribcage. - Correct answer-c. place the tip of the tube at the patient's nostril and extend the tip of the earlobe, and then to the tip of the xiphoid process. A patient with a history of alcohol abuse is arrested for driving under the influence. His wife bails him out of jail for the third time. His wife's response is an example of: a. attachement disorder c) Breach of duty, damages, and causation d) Duty, breach of duty, damages, and causation - Correct answer-d) Duty, breach of duty, damages, and causation Reason: Any professional negligence action must meet certain demands in order to be considered negligence and result in legal action. They're commonly known as the four D's: duty of the health care professional to provide care to the person making the claim, a dereliction (breach) of that duty, damages resulting from that breach of duty, and evidence that damages were directly due to negligence (causation) The infection control nurse is making rounds to ensure that airborne precautions are being observed while caring for clients with tuberculosis. Which action by the staff nurse requires further education? a) The nurse double-bags respiratory secretions. b) The nurse dons a surgical isolation mask when entering the client's room. c) The client's meals are served on disposable trays. d) The nurse gathers disposable client care items. - Correct answer-b) The nurse dons a surgical isolation mask when entering the client's room. Reason: When entering the room of a client with tuberculosis, the nurse should wear an N95 particulate respirator mask because surgical isolation masks allow turbide bacilli to pass through. All trash and waste should be disposed of as infectious waste. All client care items and meal trays should be disposable The nurse is caring for a client who underwent internal fixation of the right hip. Before administering the client's warfarin, the nurse checks the laboratory report for the client's International Normalized Ratio (INR) results. Which of the following indicates the therapeutic range for this client? a) 1.0 to 2.0 b) 2.0 to 3.0 c) 1.5 to 2.0 d) 3.0 to 4.0 - Correct answer-b) 2.0 to 3.0 Reason: Recent guidelines recommend an INR of 2.0 to 3.0 for clients without mechanical prosthetic heart valves who are receiving warfarin therapy. For clients with mechanical prosthetic heart valves, an INR of 2.5 to 3.5 is suggested. An INR below 2.0 is subtherapeutic with warfarin therapy. An INR above 3.0 in a client without a prosthetic valve indicates the need to reduce the warfarin dose . A nurse is caring for a client with multiple myeloma. What is a sign that a client with multiple myeloma isn't coping well with his prognosis? a) He shows concern about his family during his treatment. b) He avoids any conversation concerning his health. c) He becomes tearful when discussing his condition. d) He asks questions about his prognosis. - Correct answer-b) He avoids any conversation concerning his health. Reason: A client with multiple myeloma who avoids conversation may be denying his condition, which can interfere with treatment. Crying is a normal response to his disease. Asking questions about his prognosis is a normal coping response, as is showing concern for his family. The nurse educator is presenting an in-service on pediatric assessments. Why should the educator instruct nursing staff to inspect first and then auscultate when collecting data on a pediatric clients? a) Because the nurse's touch may frighten the child b) Because the nurse's hand or stethoscope may feel cold, making the child recoil c) Because the child may cry as data collection proceeds, making auscultation difficult d) Because the nurse's touch may calm the child - Correct answer-c) Because the child may cry as data collection proceeds, making auscultation difficult Reason: Because other data collection procedures may make the child cry, the nurse should auscultate the child's lungs immediately after inspection. Crying increases the respiratory rate and creates noise that interferes with clear auscultation The nurse is trying to establish rapport with a newly admitted client. Which statements will facilitate effective communication? Select all that apply. a) "Why are you crying?" b) "Tell me about your treatment so far." c) "What did your physician tell you about your need for hospitalization?" d) "Everything will be all right." e) "Did you take your medicine yesterday?" - Correct answer-c) "What did your physician tell you about your need for hospitalization?" b) "Tell me about your treatment so far Reason: Giving advice, providing false reassurance, and asking the client why he or she is crying is judgmental, all of which block rather than promote effective communication with a client. Asking open- ended questions and using leading questions promote effective communication A first-term nursing student is preparing to use a stethoscope to auscultate a client's chest. The nursing instructor asks the student to explain the working of the stethoscope. Which statement, provided by the student, about a stethoscope with a bell and diaphragm is true? a) "The diaphragm detects low-pitched sounds best." b) "The bell detects high-pitched sounds best." c) "The bell detects thrills best." d) "The diaphragm detects high-pitched sounds best." - Correct answer-d) "The diaphragm detects high- pitched sounds best." Reason: The diaphragm of a stethoscope detects high-pitched sounds best; the bell detects low-pitched sounds best. Palpation detects thrills best. A nurse is caring for a client who was admitted to the emergency department after a motor vehicle collision. Under the law, informed consent before treatment must be obtained unless which circumstance exists? a) The client asks the nurse to give substituted consent. b) The client refuses to give informed consent. c) "I'll watch for and report signs of hypercalcemia." d) "I'll eat such foods as apricots, dates, and citrus fruits." - Correct answer-d) "I'll eat such foods as apricots, dates, and citrus fruits." Reason: Because furosemide is a potassium-wasting diuretic, the client should eat potassium-rich foods, such as apricots, dates, and citrus fruits, to prevent potassium depletion. The client may also consume magnesium-rich foods as desired. The client should watch for signs of adverse reactions to furosemide, such as hypocalcemia (not hypercalcemia). If furosemide is prescribed once daily, it should be taken in the morning; taking the medication at night causes frequent awakening because of the need to urinate The nurse is collecting data on a client who appears to miss portions of what is being asked by the nurse. The client's family member tells the nurse that the client has a hearing aid, but will not wear it. The client states, "It worked when I first got it, but now it's a nuisance because I can't hear anything with it." The nurse asks which question to gain a better understanding of the client's concern? a) "Have you notified the medical equipment place where you got the hearing aid?" b) "Let's look at having your hearing aid refitted." c) "You have not given it a chance to work. You must wear it all the time." d) "Have you checked the battery to make sure it works?" - Correct answer-d) "Have you checked the battery to make sure it works?" Reason: The client stated the hearing aid no longer works, so the nurse needs to determine if there is a problem; asking about the battery is appropriate. Before contacting the medical equipment company, the client should check the battery first. Even if the hearing aid is ill -fitted, it still should work, so the battery needs to be checked. The hearing aid was working, so the client did give it an opportunity to work. A student nurse is preparing a care plan using the nursing diagnosis: risk for situational low self-esteem related to intervention by social services as evidenced by poor eye contact, flat affect, and beh avioral changes for a child entering the foster care system. Which action(s) by the foster parents indicate that the teaching interventions to improve self-esteem were successful? Select all that apply. a) The parents established a critical environment for behavior to enhance situational understanding. b) The parents sought opportunities to provide honest praise. c) The parents used physical discipline when necessary to reinforce rules. d) The parents developed a written plan describing consistent limits on good and bad behavior. e) The parents maintained inconsistent boundaries to challenge decision-making. - Correct answer-b) The parents sought opportunities to provide honest praise. d) The parents developed a written plan describing consistent limits on good and bad behavior. Reason: Teaching interventions are successful as demonstrated by the following answer choices: a structured lifestyle with consistent limits demonstrates acceptance and caring and provides a sense of security, and honest praise for good behavior promotes self -esteem. On the other hand, a critical environment erodes a person's esteem; inconsistent boundaries lead to feelings of insecurity and lack of concern; and physical discipline and false praise can decrease one's self-esteem. A 57-year-old client reports experiencing leg pain whenever he walks several blocks. The client has type 1 diabetes and has smoked two packs of cigarettes per day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide which instruction about long-term care to the client? a) "See the physician if the symptoms bother you." b) "Consider cutting down on your smoking." c) "Reduce your exercise level." d) "Practice meticulous foot care." - Correct answer-d) "Practice meticulous foot care." Reason: Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing; therefore, meticulous foot care is essential. The nurse should teach the client to bathe his feet in warm water, dry them thoroughly, cut his toenails straight across, wear well-fitting shoes, and avoid taking medication unless cleared by the physician. The client should stop smoking, not just cut down, because nicotine is a vasoconstrictor. Daily walking benefits the client with intermittent claudication. The client should see the physician regularly, not just when he's bothered by symptoms A geriatric client has experienced several adverse drug reactions. What does the nurse recognize that this client may benefit from? a) Increased drug doses at longer intervals b) Frequent visits to the physician c) Reduced drug dosages d) Nursing home placement - Correct answer-c) Reduced drug dosages Reason: Older clients commonly have diminished hepatic and renal function that reduces drug metabolism and excretion. Adverse reactions tend to be related to blood level; therefore, the client may benefit from reduced drug dosages. Adverse drug reactions aren't a cause for nursing home placement. Increased drug doses at longer intervals may increase adverse reactions rather than decrease them. Although frequent visits to the physician may benefit the client, the visits themselves won't alter how the drug reacts in the client's body. For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These findings indicate which nursing diagnosis? - Correct answer-Deficient fluid volume Reason: Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to fluid volume deficit, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema A nurse is caring for a terminally ill client. Place the following five stages of death and dying described by Elisabeth Kübler-Ross in the order in which they occur - Correct answer-Denial and isolation Anger Bargaining Depression Acceptance The nurse is preparing to boost a client up in bed. She instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner? - Correct answer-Shearing forces Reason: Using a trapeze reduces shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis), which increase the Reason: Theoretical and conceptual models of nursing provide the foundation for all nursing knowledge. They also direct nursing practice based on the concepts of health, person, environment, and nursing. Scientific breakthroughs, technological advances, and medical practices may affect nursing but aren't frameworks for nursing education and practice The nurse is reviewing the medication administration record (MAR) in preparation for medication administration. Which of the following orders should the nurse question? - Correct answer- acetaminophen 650 mg PO as needed Reason: The acetaminophen order does not have a time frame and therefore is not safe. The way th e order is written can cause a client to overdose. All the other prescriptions have all the required information for accurate medication administration. Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should: - Correct answer-keep the client warm Reason: The nurse should keep the client covered and expose only the portion of the client's body that is being assessed. The nurse should also keep the client warm by maintaining the room temperature between 68° F and 74° F (20° to 23.3° C). Extreme temperatures aren't good for clients with PVD because the valves in their arteries and veins are already insufficient and exposing them to vast changes in temperature could influence the client's response. A room temperature of 78° F may be too warm for some clients and too cool for others. Keeping the client uncovered would lead to chilling. Matching the room temperature with the client's body temperature is inappropriate A client who suffered a head injury is in a rehabilitation center receiving 30 mL of aluminum hydroxide through a nasogastric tube every 4 hours because of his increased risk for a stress ulcer. Which potential adverse effect should the nurse monitor for with this client? - Correct answer-Constipation Reason: Constipation is a potential adverse effect of antacids that contain aluminum. Urine retention, nausea, and vomiting aren't adverse effects of aluminum hydroxide. Diarrhea occurs with the use of magnesium-containing antacids The nurse distinguishes that which assessment data will most influence a client in crisis? - Correct answer-Previous coping skills Reason: Coping is the process by which a person deals with probl ems using cognitive and noncognitive components. Cognitive responses come from learned skills noncognitive responses are automatic and focus on relieving discomfort. Previous coping skills are cognitive and include the thought and learning necessary to identify the source of stress in a crisis situation. Therefore, option 2 is the best answer. Age could have either a positive or negative effect during crisis, depending on previous experiences. Although sometimes useful, noncognitive measures, such as self-esteem, may prevent the person from learning more about the crisis as well as a better solution to the problem. The person involved could have correct or incorrect perception of the problem that could have either a positive or negative outcome. - Correct answer- A licensed practical nurse (LPN/LVN) is working with the RN in verifying a heparin IV i nfusion rate. The prescribed dose is 400 units of heparin per hour. The heparin is in a solution of 5,000 units/100 mL NS. How many milliliters per hour should the pump be set? - Correct answer-8 ml/hr A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis? - Correct answer-"Before discharge, the client correctly identifies three potassium-rich food sources." Reason: A client outcome must be measurable, objective, concise, realistic for the client, and attainable through nursing management. For each client outcome, the nurse should include only one client behavior, should express that behavior in terms of client expectations, and should indicate a time frame. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in potassium aren't measurable. Understanding all complications isn't measurable or specific to the nursing diagnosis listed The nurse is caring for a 40-year-old client admitted with an acute myocardial infarction. Which behavior by the client indicates adult cognitive development? - Correct answer-Generates new levels of awareness Reason: Adults ages 31 to 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development — not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults ages 20 to 30 The physician prescribes acetaminophen 650 mg by mouth every 4 hours for a client with a temperature of 102°F (38.8°C) who has a feeding tube in place. The nurse has acetaminophen solution on hand containing 160 mg/5 mL. How many milliliters of solution should the nurse administer? Record your answer using one decimal place. - Correct answer-20.3 ml Which aspect of drug therapy is most important when planning nursing care for an elderly client? - Correct answer-Noncompliance Reason: Noncompliance in older clients is so prevalent that most nurses consider it a top priority when planning nursing care. An undesired drug action is a factor that can make it harder for the client to remain compliant, but the issue of compliance is a higher priority overall. Elderly clients commonly require reduced drug dosages however, noncompliance may cause the physician to increase dosages if the client's symptoms appear not to resolve with current dosages. - Correct answer- A nurse is caring for a client with advanced cancer. After reading the nursing note below, determine the nurse's next intervention. Progress notes: 1/7/10, 1545 Pt. states, "The doctor says my chemotherapy isn't working anymore. They can only treat my symptoms now. I don't want to die in the hospital, I want to be in my own bed." R. Daly, RN a) Tell the client that only in the hospital can he receive adequate pain relief. b) Reread the Patient's Bill of Rights to the client. c) Call the client's spouse to discuss the client's statements. d) Explain the use of an advance directive to express the client's wishes. - Correct answer-d) Explain the use of an advance directive to express the client's wishes. Reason: An advance directive is a legal document used as a guideline for life-sustaining medical care of a client with an advanced disease or disability who can no longer indicate his own wishes. This document can include a living will, which instructs the health care provider to administer no life -sustaining treatment, and a durable power of attorney for health care, which names another person to act on the Reason: The rationale for using TENS for pain relief is to block painful stimuli traveling over small nerve fibers. Massage is used to relax tense muscles. Range-of-motion exercises are used to prevent stiffness and further loss of mobility. Elevation and repositioning are used to reduce swelling and inflammation. The licensed practical nurse is admitting a client to the medical -surgical floor. She asks the client if he has an advance directive. The client responds by saying, "I don't know what you mean." How should the nurse respond? - Correct answer-"An advance directive is a document that states your wishes about health care." Reason: An advance directive is a written document that states a client's health care wishes should certain conditions occur. The document includes wishes regarding withdrawing treatment, resuscitation measures, life support, and end-of-life care. The other answer options might be included in a last will and testament these wishes aren't included in an advance directive - Correct answer- The nurse is examining a client with suspected peritonitis. What nursing intervention does the nurse use to elicit rebound tenderness? - Correct answer-Press the affected area firmly with one hand, release pressure quickly, and note any tenderness on release Reason: The nurse elicits rebound tenderness by pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release. The other options aren't used to elicit rebound tenderness The physician orders an intramuscular (I.M.) injection for a client. The nurse knows which factor may affect the drug absorption rate from an I.M. injection site? - Correct answer-Blood flow to the injection site Reason: Blood flow to the I.M. injection site affects the drug absorption rate. Muscle tone and strength have no effect on drug absorption. The amount of body fat at the injection site may help determine the size of the needle and the technique used to localize the site however, it doesn't affect drug absorption (unless the nurse inadvertently injects the medication into the subcutaneous tissue instead of the muscle) - Correct answer- A nurse is caring for a client with otosclerosis who's scheduled for stapedectomy. The client asks the nurse when his hearing will improve. Which response by the nurse is most appropriate? - Correct answer-"It might take as long as 6 weeks for your hearing to improve." Reason: After stapedectomy, hearing improvement can take as long as 6 weeks to occur. Hearing might initially worsen after surgery because of swelling and fluid accumulation in the ear. The client might not notice any improvement in the first 2 weeks after surgery A 2-year-old male child is admitted through the emergency department with a suspected diagnosis of Hirschsprung disease (aganglionic megacolon). The child's mother asks about treatment of the disease. What would be an appropriate response from the nurse? - Correct answer-"He'll have a temporary colostomy 'pull-through' surgery will be done in the future." Reason: Repair of aganglionic megacolon in a child with a suspected diagnosis of Hirschsprung disease requires dissection of the aganglionic segment and anastomosis with the unaffected intestine. It's usually done in a two-stage operation. The first surgery creates a colostomy to evacuate the bowel of stool and rest the distended portion of the bowel. The second surgery, done several months later, involves colostomy closure and a rectal "pull-through." The colostomy isn't permanent. Only a two-stage operation is required. Chemotherapy and radiation therapy aren't required for this condition - Correct answer- it isn't cancer. - Correct answer- A client has a prescription for a low-fat diet. When reviewing the client's food diary, which food items would the nurse suggest the client to eliminate from the diet? Select all that apply. a) Milk chocolate b) cream cheese c) broiled haddock d) beef sausage e) broccoli - Correct answer-a) Milk chocolate b) Cream cheese d) Beef sausage Reason: Creamed cheese, processed meats (beef sausage), and chocolate are high in fats. Fruits and vegetables (broccoli) and broiled haddock are low in fats. An adult client who is receiving warfarin asks the nurse if there is anything to worry about while on this medication. What are the nurse's best responses? Select all that apply. - Correct answer-• Do not increase your intake of green leafy vegetables. • Use a soft toothbrush for cleaning your teeth. • You will need to have your blood drawn for laboratory examination frequently. Reason: Green leafy vegetables contain vitamin K, which can act as an antidote for warfarin. A soft toothbrush will not injure the gums and lead to bleeding. Aspirin will increase the risk of bleeding and should not be used with warfarin. Blood work is needed frequently to monitor the PT level and to titrate warfarin to prevent bleeding. An antibiotic may be needed for dental work, but this has nothing to do with warfarin. A client on warfarin who needs dental work must notify the dentist and may need to st op the medication before dental surgery A nurse is explaining how to measure blood pressure in a client who has lymphedema in both arms and requires blood pressure measurement using a thigh cuff. In reference to the client's baseline arm blood pressure, what information would the nurse expect to find when utilizing the thigh? - Correct answer- Higher systolic blood pressure reading Reason: Systolic readings in the thigh may be 10 to 40 mm Hg higher than in the arm. Diastolic readings are the same in the arm and thigh. A client who sustained a head injury in a motor vehicle accident is prescribed phenytoin liquid to prevent seizures. The client is unable to take anything by mouth and has a feeding tube in place for enteral feedings. Which intervention by the nurse is most appropriate when administering phenytoin to this client? - Correct answer-Administering the phenytoin 2 hours before or 2 hours after beginning the tube feedings Reason: Enteral nutrition therapy may reduce orally administered phenytoin concentrations. Therefore, the nurse should give phenytoin 2 hours before starting enteral feeding or 2 hours after stopping enteral feeding. It isn't necessary to have the dose administered I.V. Bleeding complications can occur if the Reason: The nurse must first explore her own personal beliefs and feelings about contraception to detect biases if biases exist, the nurse must refer the client to another health care professional. Only after exploring personal beliefs and feelings does the nurse obtain a thorough health history, perform a complete physical assessment, and help determine the most appropriate contraceptive method. - Correct answer- A client is prescribed acetaminophen by mouth every 4 hours as needed for headache. Which factor in the client's medical history would cause the nurse to question this order? a) Bleeding disorder b) Allergy to salicylates c) Duodenal ulcer d) Cirrhosis - Correct answer-d) Cirrhosis Reason: Acetaminophen can cause liver failure, so the nurse should question its use in a client with a history of cirrhosis. An order for aspirin should be questioned in a client with a history of duodenal ulcer, salicylate allergy, or bleeding disorder A newly hired nurse is reviewing a health care practitioner's orders. Which of the following would the nurse expect that must be included in a medication order? Select all that apply. a) Client's allergies b) Possible adverse reactions c) Drug class d) Client's full name e) Physician's signature - Correct answer-d) Client's full name e) Physician's signature Reason: The physician's signature must be included in a medication order. Other components of a medication order include the client's full name, drug name, dosage form, dose amount, administration route, time schedule, and the date and time of the order. The drug class and possible adverse reactions aren't components of a medication order. Client allergies should be recorded in the client's chart, not on the medication order A client with type 1 diabetes who's in the second trimester of pregnancy is consuming a 2,400-calorie American Diabetes Association diet divided into three meals and several snacks. Her breakfast meal plan consists of these exchanges: 3 breads, 1 meat, 1 fruit, 1 milk, and 2 fats. Which menu would best comply with the meal plan? a) 2 bagels (½ bagel per exchange), 1 cup cooked grits, 3 eggs, 1 banana, 1 cup whole milk, 3 tsp margarine b) 3 breadsticks, 2 oz ham, 30 grapes (15 grapes per exchange), and 2 tsp margarine c) 4 breadsticks, 1 oz ham, 1 small apple, 2 bacon slices, and 1 cup low-fat yogurt d) 1 English muffin, ½ cup cooked grits, 1 egg, ½ banana, 1 cup skim milk, and 2 tsp margarine - Correct answer-d) 1 English muffin, ½ cup cooked grits, 1 egg, ½ banana, 1 cup skim milk, and 2 tsp margarine Reason: The first menu is best for the pregnant client with type 1 diabetes and includes the following exchanges: 3 breads (2 halves of the English muffin plus ½ cup cooked grits), 1 meat (1 egg), 1 fruit (½ banana), 1 milk (1 cup skim milk), and 2 fats (2 tsp margarine). The second menu exceeds the bread, meat, and fat exchanges. The third menu exceeds the bread exchanges. The fourth menu exceeds the meat and fruit exchanges. A client is prescribed misoprostol (Cytotec) for treatment of a gastric ulcer. The nurse should be alert for which common dose-related adverse reaction? a) Nausea b) Diarrhea c) Bloating d) Vomiting - Correct answer-b) Diarrhea Reason: Misoprostol commonly causes diarrhea. This reaction is usually dose-related. Nausea and vomiting are adverse reactions that might be associated with misoprostol administration, but they're uncommon. Bloating isn't an adverse reaction to misoprostol . The nurse is preparing a client who has been newly diagnosed with asthma for discharge. As part of his discharge orders, the client is prescribed albuterol via nebulizer every 8 hours for 3 days, followed by one dose daily thereafter. Which instruction should the nurse include when teaching the client about nebulizer use? a) "If you feel short of breath you can use your nebulizer more frequently than prescribed." b) "You should take your pulse before and after treatment - Correct answer- if your pulse rate increases by more than 30 beats/minute you should notify your physician." c) "You might develop nervousness and palpitations during your treatment - Correct answer- this is normal and will subside." d) "You can be flexible with scheduling your albuterol treatments." - Correct answer-b) "You should take your pulse before and after treatment if your pulse rate increases by more than 30 beats/minute you should notify your physician." Reason: The nurse should show the client how to check his pulse rate. The client should be instructed to check his pulse rate before and after using his nebulizer and to call the physician if his pulse rate increases by more than 30 beats/minute. The nurse should instruct the client to use his nebulizer exactly as prescribed. Using the nebulizer more often than prescribed can cause the drug to lose effectiveness, or to produce uncomfortable adverse effects. The client should also be instructed to notify his physician if his shortness of breath worsens, the drug becomes less effective, or he develops palpitations, nervousness, or a hypersensitivity reaction such as a rash. - Correct answer- The nurse is administering two drugs concomitantly to a client. Which interaction, recognized by the nurse, occurs when two drugs with the same qualitative effects produce a response when given together that is greater than the response either drug produces when given alone? a) Hyporeactivity b) Tolerance c) Synergism d) Antagonism - Correct answer-c) Synergism d) A history of diabetes - Correct answer-a) Recent pelvic surgery Reason: The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease A client with heart failure develops pink, frothy sputum - Correct answer- coarse crackles - Correct answer- and restlessness. Which action should the nurse take first? a) Calculate the client's fluid balance. b) Place the client in high Fowler position. c) Notify the physician. d) Check the client's blood pressure. - Correct answer-b) Place the client in high Fowler position. Reason: High Fowler position position can help reduce venous return to the heart and also decrease lung congestion. Checking the client's blood pressure is important but doesn't take top priority. Calculating the client's fluid balance wouldn't be an immediate priority in an emergency. The physician should be notified after the client has been repositioned and evaluated Which term describes a clinical judgment that an individual, family, or community is more vulnerable to develop a certain problem than others in the same or similar situation? a) Actual nursing diagnosis b) Syndrome nursing diagnosis c) Risk nursing diagnosis d) Health promotion nursing diagnosis - Correct answer-c) Risk nursing diagnosis Reason: Risk nursing diagnosis refers to the vulnerability of a client, family, or community to health problems. An actual nursing diagnosis describes a human response to a health problem being manifested. Syndrome nursing diagnosis describes a cluster of nursing diagnoses that are addressed together through similar interventions. A health promotion nursing diagnosis is a diagnostic statement describing the human response to levels of wellness in an individual, family, or community that have a potential for enhancement to a higher state. Which statement is correct about the diagnosis of somatoform disorders? a) The somatic complaints are limited to one organ system. b) They're physical conditions with organic pathologic causes. c) The event preceding the physical illness occurred recently. d) They're disorders that occur in the absence of organic findings. - Correct answer-d) They're disorders that occur in the absence of organic findings. Reason: The essential feature of somatoform disorders is a physical or somatic complaint without any demonstrable organic findings to account for the complaint. There are no known physiological mechanisms to explain the findings. Somatic complaints aren't limited to one organ system. The diagnostic criteria for somatoform disorders state that the client has a history of many physical complaints beginning before age 30 that occur over several years The nurse is collecting data on a 47-year-old client who has come to the physician's office for his annual physical. The nurse should keep in mind that one of the first physical signs of aging is: a) failing eyesight, especially close vision. b) having more frequent aches and pains. c) accepting limitations while developing assets. d) increasing loss of muscle tone. - Correct answer-a) failing eyesight, especially close vision. Reason: Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Increasing loss of muscle tone occurs in later years (ages 80 and older). Accepting limitations while developing assets is an example of socialization development that occurs in adulthood (ages 31 to 45) A nurse works in a mental health facility that uses a therapeutic community (milieu) approach to client care. Which statement describes the nurse's role in this facility? a) Distinctly separate from the psychiatrist b) Supervisor more than counselor c) Primary caregiver d) Member of the milieu - Correct answer-d) Member of the milieu Reason: In a therapeutic community, everything focuses on the client's treatment. Staff and clients work together as a team or member of the milieu. The nurse wouldn't be a primary caregiver, but would work with the psychiatrist. The nurse's role could be that of supervisor as well as counselor. Which of the following outcome criteria would be most appropriate for the client with a nursing diagnosis of Ineffective airway clearance? a) Presence of congestion on X-ray b) Continued use of oxygen when necessary c) Breath sounds clear on auscultation d) Respiratory rate of 24 breaths/minute - Correct answer-c) Breath sounds clear on auscultation Reason: The expected outcome for a client with Ineffective airway clearance is for the lungs to sound clear on auscultation. Congestion on X-ray, continued use of and need for oxygen, and a respiratory rate of 24 breaths/minute indicate that the client is still experiencing airway problems A nurse is caring for a mother whose infant has died. The mother tells the nurse that she's angry at God for taking away her child. She has vowed never again to go to church or pray. Which nursing diagnosis is most appropriate? a) Powerlessness b) Spiritual distress c) Ineffective coping Reason: The aim is to get the liquid to spread over the entire inside surface of the nose, including the upper surface. To install, have the client lay on a bed with his or her head tipped back do not touch the nose with the tip of the dropper or bottle while installing the drops in the nares. Have the client stay in that position for 2 minutes before getting up so the liquid does not immediately run out of the client's nose or down the back of the throat. Do not instill nose drops by t ilting the head back when the client is standing or sitting. The upper surface inside of the nose will not be covered by the liquid. - Correct answer- A client is admitted to the hospital with an exacerbation of chronic systemic lupus erythematosus (SLE). The client gets angry when the call bell isn't immediately answered. What would be the most appropriate response for the nurse? a) "You seem angry." b) "Calm down. You know that stress can make your symptoms worse." c) "Would you like to talk about the problem with the nursing supervisor?" d) "I can see you're angry. I'll come back when you've calmed down." - Correct answer-a) "You seem angry." Reason: Verbalizing the observed behavior is a therapeutic communication technique in which the nurse acknowledges what the client is feeling. Although stress can exacerbate the symptoms of SLE, telling the client to calm down doesn't acknowledge his feelings. Offering to get the nursing supervisor doesn't acknowledge the client's feelings either. Leaving the client implies that the nurse has no interest in what the client has said A client with coronary artery disease reports intermittent chest pain that occurs with exertion. The physician prescribes sublingual nitroglycerin. When teaching the client about nitroglycerin administration, the nurse should include which instruction? a) "Make sure you replace your nitroglycerin tablets every 6 months to ensure potency." b) "Leave two nitroglycerin tablets on the bedside table to take if chest pain occurs at night." c) "When you experience chest pain, take one tablet every 30 minutes until the pain is relieved." d) "Take nitroglycerin with caution because it may cause dizziness." - Correct answer-d) "Take nitroglycerin with caution because it may cause dizziness." Reason: The client should use caution when taking nitroglycerin because it commonly causes orthostatic hypotension and dizziness. To ensure potency, the client should store nitroglycerin in a tightly closed container in a cool, dark place. The client shouldn't leave nitroglycerin tablets open on the bedside table. The client should replace the tablets every 3 months. The client should take a sublingual nitroglycerin tablet at the onset of chest pain and repeat the dose every 5 to 10 minutes, for up to three doses. If this doesn't relieve chest pain, the client should seek immediate medical attention. An unlicensed assistive personnel (UAP) is observed leaving the room of a client in isolation. The nurse recognizes the UAP is following proper technique when he or she removes which protective equipment first? a) Mask b) Cap c) Gown d) Gloves - Correct answer-d) Gloves Reason: When leaving an isolation room, the health care practitioner should remove the gloves first because they're considered the most contaminated. Removing other protective equipment before removing the gloves and washing hands could cause contamination of the hair and uniform and promote pathogen transmission Before preparing a client for surgery, a nurse assists in developing a teaching plan. What's the primary purpose of preoperative teaching? a) To explain the risks and obtain informed consent b) To reduce the risk of postoperative complications c) To determine if the client is psychologically ready for surgery d) To express concerns to the client about the surgery - Correct answer-b) To reduce the risk of postoperative complications Reason: Preoperative teaching helps reduce the risk of postoperative complications by telling the client what to expect and providing an opportunity to practice before surgery any postoperative activities that may be required, such as breathing and leg exercises. The physician, not the nurse, is responsible for determining the client's psychological readiness. It's inappropriate for the nurse to express personal concerns about surgery to a client. The physician should describe alternative treatments and explain the risks of surgery to the client when obtaining informed consent A school nurse is examining a student at an elementary school. Which finding would lead the nurse to suspect impetigo? a) Red spots with a blue base found on the buccal membranes b) Small, red lesions on the trunk and in the skinfolds c) A discrete, pink-red, maculopapular rash that starts on the head and progresses down the body d) Vesicular lesions that ooze, forming crusts on the face and extremities - Correct answer-d) Vesicular lesions that ooze, forming crusts on the face and extremities Reason: Impetigo starts as papulovesicular lesions surrounded by redness. The lesions become purulent and begin to ooze, forming crusts. Impetigo occurs most often on the face and extremities. Small, red lesions on the trunk and in the skinfolds are characteristic of scarlet fever. A discrete, pink -red, maculopapular rash that starts on the face and progresses down to the trunk and extremities is characteristic of rubella (German measles). Red spots with a blue base found on the buccal membranes, known as Koplik spots, are characteristic of measles (rubeola). A nurse is teaching a client how to use transcutaneous electrical nerve stimulation (TENS) to manage pain. Which client statement indicates an accurate understanding of its use? a) "It's okay to increase the unit's amplitude as rapidly as needed." b) "I'll leave the TENS unit on while I take a shower." c) "If I have a headache, nausea, or unpleasant sensations, I'll use my troubleshooting techniques." d) "I should clean the unit every 24 hours by soaking it in water for 5 to 10 minutes." - Correct answer-c) "If I have a headache, nausea, or unpleasant sensations, I'll use my troubleshooting techniques." Reason: By identifying symptoms that require troubleshooting, the client demonstrates that teaching has been effective. The client should remove the TENS unit before bathing or showering to prevent b) It can cause orthostatic hypotension. c) It can cause rectal tears. d) It can cause hypersensitivity to the drug. - Correct answer-a) It can result in incomplete drug absorption. Reason: Incomplete drug absorption is a disadvantage of rectal drug administration. The drug itself, not the way in which it is administered, may cause orthostatic hypotension or hypersensitivity reactions. If inserted properly, drugs won't cause rectal tears A LPN/LVN working in a community health center is reinforcing family needs during a disaster planning drill. What should be included in the family preparedness drill? Select all that apply. a) Prepare a package of vital records b) Plan where to park the family c) Establish a place to meet in an emergency d) Plan to transport pets to the shelter e) Have extra medications and food items for dietary requirements - Correct answer-a) Prepare a package of vital records c) Establish a place to meet in an emergency e) Have extra medications and food items for dietary requirements Reason: A plan for parking the vehicle is not a concern during disaster rather, the vehicle should have enough fuel to transport the family to safety. Vital records that contain immunization records, insurance policies, deeds, and cash should be prepared ahead of a disaster. Necessary medications and food items for a dietary requirement, especially packaged or canned foods, should be prepared ahead of a disaster. Establishing a place to meet outside of the home in emergencies will help account for all members of the family. Pets are not allowed in most shelters. Preparation for pets should include leaving food and water and attaching proper identification - Correct answer- A client comes to the emergency department with the complaint of chest pain. After an electrocardiogram shows an irregular heart rate of 166 beats/minute, the client is admitted to the intensive care unit. Which nursing diagnosis is the priority? a) Anxiety related to the fear death b) Impaired physical mobility related to complete bed rest c) Social isolation related to restricted family visits d) Deficient knowledge related to emergency interventions - Correct answer-a) Anxiety related to the fear death Reason: Anxiety related to the fear of death is a priority nursing diagnosis. Anxiety can adversely affect the client's heart rate and rhythm by stimulating the autonomic nervous system. The threat of death is an immediate and real concern for the client. The other nursing diagnoses are valid, but they aren't the priority in this situation A nurse is caring for a client who had a stroke. Which nursing intervention can help prevent contractures in the client's lower legs? a) Apply slippers to the feet. b) Keep the heels off the mattress. c) Turn the client every 2 hours. d) Attach braces or splints to each foot and leg. - Correct answer-d) Attach braces or splints to each foot and leg. Reason: Attaching a brace or a splint to each foot and leg prevents footdrop (a lower leg contracture) by supporting the feet in proper alignment in the client who has had a stroke. Slippers can't prevent footdrop because they're too soft to support the ankle joints. Turning the client every 2 hours and keeping the heels off the mattress prevent skin breakdown, not contractures. The home health nurse is completing the admission paperwork for a new client diagnosed with osteomyelitits who will be receiving home service intravenous therapy for the next month. The client is 32 years old and happily married. Which of the following findings will warrant further investigation? Select all that apply. a) The client voices concerns about recovering quickly so that she might return back to work in the next month. b) The client is talkative about her spouse and children. c) The client reports having many hobbies and interests outside of the home. d) The client spends a great deal of time reflecting back on her teen years. e) The client talks repeatedly about her death. - Correct answer-e) The client talks repeatedly about her death. d) The client spends a great deal of time reflecting back on her teen years. Reason: At age 32, the client is in the middle adult stage of life. Her repeated discussions about death and reflections back on life aren't appropriate or expected for this stage of development and should be investigated further. An interest in civic responsibilities and the establishment of hobbies is expected. During this developmental period, the greatest concern typically relates to establishing gainful employment and significant relationships. This is being demonstrated by the client's willingness to discuss her spouse and children A 2-year-old returns from surgery after a bowel resection as a result of Hirschsprung disease. A temporary colostomy is in place. Which immediate postoperative nursing intervention would have priority? a) Suction the nasopharynx frequently to remove secretions. b) Auscultate lung sounds. c) Irrigate the colostomy with 100 mL of normal saline solution. d) Change the surgical dressing. - Correct answer-b) Auscultate lung sounds. Reason: The immediate nursing intervention after bowel resection surgery is to evaluate pulmonary function. The surgical dressing shouldn't require changing right away. Suctioning should be performed only if the client can't maintain a patent airway. Colostomy irrigation isn't warranted. When attempting to dislodge a foreign object from an infant's airway, the rescuer should initiate five back blows followed by what intervention? a) A blind sweep of the airway Hyperglycemia, not hypoglycemia, is a complication secondary to carbohydrate load of enteral feeding solutions. Constipation is a problem, but it usually isn't a serious one. The client would most likely experience diarrhea A nurse is teaching a client with pernicious anemia who requires vitamin B12 replacement therapy. Which statement indicates that the client understands the treatment program? a) "I'll need only daily injections of vitamin B12 until my blood count improves." b) "I'll take a vitamin B12 tablet once each month for life." c) "I'll take one vitamin B12 tablet every morning for 2 weeks." d) "I'll need an injection of vitamin B12 every month for life." - Correct answer-d) I'll need an injection of vitamin B12 every month for life." Reason: In pernicious anemia, the gastric mucosa doesn't secrete intrinsic factor, a protein necessary for vitamin B12 absorption. Without intrinsic factor, vitamin B12 replacements taken orally aren't absorbed therefore, vitamin B12 must be administered through the I.M. or deep subcutaneous route. The client must have vitamin B12 injections each day for 2 weeks initially, then weekly for several months, and then once each month for life - Correct answer- While providing care to a married female client, the nurse notes multiple blue, purple, and yellow ecchymotic areas on her arms and trunk. When the nurse asks how she got these bruises, the client responds, "I tripped." What actions should the nurse take? Select all that apply. a) Provide the client with telephone numbers of local shelters and safe houses. b) Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries. c) Assist the client in developing a safety plan for times of increased violence. d) Tell the client that she needs to leave the abusive situation as soon as possible. e) Contact the local authorities to report suspicions of abuse. f) Call the client's husband to arrange a meeting to discuss the situation. - Correct answer-a) Provide the client with telephone numbers of local shelters and safe houses. b) Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries. c) Assist the client in developing a safety plan for times of increased violence. Reason: The nurse should objectively document her assessment findings. A detailed description of physical findings of abuse in the medical record is essential if legal action is pursued. All women suspected of being abuse victims should be counseled on a safety plan, which consists of recognizing escalating violence within the family, formulating a plan to exit quickly, and knowing the telephone numbers of local shelters and safe houses. The nurse should not report this suspicion of abuse because the client is a competent adult who has the right to self-determination. Contacting the client's husband without her consent violates confidentiality. The nurse should respond to the client in a nonthreatening manner that promotes trust, rather than ordering her to break off her relationship The nurse is admitting a patient who is a suspected victim of domestic abuse. Which action(s) should the nurse take? Select all that apply. a) Refer the patient to a substance abuse program. b) Consult with social services for temporary assistance. c) Question the patient regarding barriers to leaving the situation. d) Assess the patient's readiness to leave. e) Assess the patient's knowledge of available resources. - Correct answer-d) Assess the patient's readiness to leave. e) Assess the patient's knowledge of available resources. Reason: Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready. Regarding the other answer options: The reasons that victims stay in the relationship are complex and can be explored at a later time, and the use of drugs or alcohol is irrelevant A nurse is caring for a client who's unconscious. In which position should the nurse place the client? a) Prone with his knees sharply flexed b) Side-lying with the head of the bed elevated c) Flat on his back with his head turned to the side d) Trendelenburg position with his body in straight alignment - Correct answer-b) Side-lying with the head of the bed elevated Reason: Positioning the unconscious client on his side, with the head of the bed elevated, reduces the risk of airway occlusion by the tongue and aids the drainage of secretions. The other positions place the unconscious client at risk for aspiration. To decrease abdominal distention following a client's surgery, what actions should the nurse take? (Select all that apply.) 1. Encourage ambulation 2 . Give sips of ginger ale 3. Auscultate bowel sounds 4 . Provide a straw for drinking 5 . Offer an opioid analgesic - Correct answer-Answer: 1. Encourage ambulation 3. Auscultate bowel sounds Reason: Ambulation will stimulate peristalsis, increasing passage of flatus and decreasing distention. Monitoring bowel sounds is important because it provides information about peristalsis. Carbonated beverages, such as ginger ale, increase flatulence and should be avoided. Using a straw should be avoided because it causes swallowing of air, which increases flatulence. Opioids will slow peristalsis, contributing to increased distention. A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? 1. Famotidine (Pepcid) 2. Methyldopa (Aldomet) the client ultimately will assume the responsibility. The dietitian is a resource person who can give specific, practical information about diet and food preparation once there is a basic understanding of the reasons for the diet. - Correct answer- What response should a nurse be particularly alert for when assessing a client for side effects of long - term cortisone therapy? 1. Hypoglycemia 2. Severe anorexia 3. Anaphylactic shock 4. Behavioral changes - Correct answer-Answer: 4. Behavioral changes Reason: Development of mood swings and psychosis is possible during long-term therapy with glucocorticoids because of fluid and electrolyte alterations. Hypoglycemia, severe anorexia, and anaphylactic shock are not responses to long-term glucocorticoid therapy. A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next? 1. Encourage rest. 2. Obtain the vital signs. 3. Administer the prescribed analgesic. 4. Document the client's pain response. - Correct answer-Answer: 2. Obtain the vital signs Reason: Immediately before administration of an analgesic, an assessment of vital signs is necessary to determine whether any contraindications to the medication exist (e.g., hypotension, respirations ≤12 breaths/min). Pain prevents both psychological and physiological rest. Before administration of an analgesic, the nurse must check the health care provider's prescription, the time of the last administration, and the client's vital signs. A complete assessment including vital signs should be done before documenting. A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care? 1. Exploring the client's emotional conflict 2. Identifying personal feelings toward this client 3. Planning to discuss this with the client's family 4. Developing a rapport with the client's health care provider - Correct answer-Answer: 2. Identifying personal feelings toward this client Reason: Nurses must identify their own feelings and prejudices because these may affect the ability to provide objective, nonjudgmental nursing care. Exploring a client's emotional well-being can be accomplished only after the nurse works through one's own feelings. The focus should be on the client, not the family. Health team members should work together for the benefit of all clients, not just this client. A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the charge nurse or surgeon? 1. Incisional pain 2. Absent bowel sounds 3. Urine output of 20 mL/hour 4. Serosanguineous drainage on the dressing - Correct answer-Answer: 3. Urine output of 20 mL/hour Reason: A urinary output of 50 mL/hr or greater is necessary to prevent stasis and consequent infections after this type of surgery. The nurse should notify the surgeon of the assessment findings, as this may indicate a urinary tract obstruction. Incisional pain, absent bowel sounds, and serosanguineous drainage are acceptable assessment findings for this client after this procedure and require continued monitoring but do not necessarily require reporting to the surgeon. The family of an older adult who is aphasic reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding 1. Procedures for a client's benefit do not require a signed consent. 2. Clients who are aphasic are incapable of signing an informed consent. 3. A separate signed informed consent for routine treatments is unnecessary. 4. A specific intervention without a client's signed consent is an invasion of rights. - Correct answer- Answer: 3. A seperate signed informed consent for routine treatments is unnecessary Reason: This is considered a routine procedure to meet basic physiological needs and is covered by a consent signed at the time of admission. The need for consent is not negated because the procedure is beneficial. This treatment does not require special consent. The health care provider orders 1000 mL normal saline to be infused over 8 hours for a client with a diagnosis of dehydration. The intravenous (IV) tubing delivers 15 drops per milliliter (drop factor). The nurse should administer the IV infusion at a rate of ____ gtts/minute. Record your answer using a whole number. - Correct answer-Answer: 31 gtt/min A health care provider prescribes a vitamin tablet that contains vitamin B complex. What should the nurse teach the client? 1. It may turn the urine bright yellow. 2. The daily fluid intake should be increased. 3. The drug should be taken on an empty stomach. Reason: Peripheral vascular resistance is the impedance of blood flow, or back pressure, by the arterioles, which is the most influential component of diastolic blood pressure. Renal function through the renin - angiotensin-aldosterone system regulates fluid balance and does influence blood pressure. Cardiac output is the determinant of systolic blood pressure. Oxygen saturation does not have a direct effect on diastolic blood pressure. A nurse provides crutch-walking instructions to a client that has a left-leg cast. The nurse should explain that weight must be placed: 1. In the axillae. 2. On the hands. 3. On the right side. 4. On the side that the client prefers - Correct answer-Answer: 2. On the hands Reason: Body weight should be placed on the hands and not under the arms in the axillae when a client is walking with crutches to prevent damage to the brachial plexus nerves and prevent "crutch paralysis." Placing weight in the axillae during crutch walking is incorrect. Weight during walking with two crutches should be distributed equally to both sides of the body without regard to the unaffected side or either side. Which drug requires the nurse to monitor the client for signs of hyperkalemia? 1. Furosemide (Lasix) 2. Metolazone (Zaroxolyn) 3. Spironolactone (Aldactone) 4. Hydrochlorothiazide (HydroDIURIL) - Correct answer-Answer: 3. Spironolactone (Aldactone) Reason: Spironolactone is a potassium-sparing diuretic hyperkalemia is an adverse effect. Furosemide, metolazone, and hydrochlorothiazide generally cause hypokalemia. - Correct answer- To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what type of dietary plan does the nurse expect? 1. Low in fat 2. High in iron 3. High in fluids 4. Low in residue - Correct answer-Answer: 3. High in fluids Reason: A common side effect of vincristine is a paralytic ileus, which results in constipation. Preventative measures include high fiber foods and fluids that exceed minimum requirements. These will keep the stool bulky and soft, thereby promoting evacuation. Low fat, high in iron, and low in residue dietary plans will not provide the roughage and fluids needed to minimize the constipation associated with vincristine. A nurse is teaching members of a health care team how to help disabled clients stand and transfe r from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and next: 1. Bending and then straightening their knees 2. Bending at the waist and then straightening the back 3. Placing one foot in front of the other and then leaning back 4. Placing pressure against the client's axillae and then raising their arms - Correct answer-Answer: 1. Bending and then straightening their knees Reason: The leg bones and muscles are used for weight bearing and are the strongest in the body. Using the knees for leverage while lifting the client shifts the stress of the transfer to the caregiver's legs. By using the strong muscles of the legs the back is protected from injury. Bending at the waist and then using the back for leverage is how many caregivers and people who must lift heavy objects sustain back injuries. The anatomical structure of the back is equipped only to bear the weight of the upper body. By leaning back, the client's weight is on the caregiver's arms, which are not equipped for heavy weight bearing. The caregiver's arms are not strong enough to lift the client. In the struggle to lift the client, the client and caregiver may be injured. A client who is HIV positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through: (Select all that apply.) 1 . feces. 2 . blood. 3 . semen. 4 . urine. 5 . sweat. 6 . tears - Correct answer-Answer: 2. blood 3. semen Reason: HIV, which is the virus that causes AIDS, is transmitted through infected blood, semen, and bloody body fluids. HIV is not spread casually. Although HIV may be found in other body se cretions, including feces, urine, sweat, tears, saliva, sputum, and emesis, the amount of virus is likely not sufficient enough to be transmitted. The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1. A physiological response to stress. 2. A conscious defense against anxiety. 3 Intelligence and economic status 4 Previous experience and cultural values - Correct answer-Answer: 4. Previous experience and cultural values Reason: Interpretation of pain sensations is highly individual and is based on past experiences, which include cultural values. Age and sex affect pain perception only indirectly because they generally account for past experience to some degree. Overall physical condition may affect the ability to cope with stress however, unless the nervous system is involved, it will not greatly affect perception. Intelligence is a factor in understanding pain so it can be tolerated better, but it does not affect the perception of intensity - Correct answer- economic status has no effect on pain perception. - Correct answer- A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action? 1. Orient the client to the unit environment. 2. Have a copy of hospital regulations available. 3. Explain that that there is no reason to be concerned. 4. Reassure the client that the staff is available if the client has questions - Correct answer-Answer: 1. Orient the client to the unit environment Reason: Orienting the client to the hospital unit provides knowledge that may reduce the strangeness of the environment. Having a copy of hospital regulations available is part of orienting the client to the unit. This alone is not enough when orienting a client to the hospital. Explaining that that there is no reason to be concerned may be false reassurance, because no one can guarantee that there is no reason to be concerned. Reassuring the client that the staff is available to answer questions implies that staff members are available only if the client has specific questions. A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? 1. Skeletal and nervous 2. Circulatory and urinary 3. Respiratory and urinary 4. Muscular and endocrine - Correct answer-Answer: 3. Respiratory and Urinary Reason: Increased respirations blow off carbon dioxide (CO2 ), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to adjust the body's pH . The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH. When suctioning a client with a tracheostomy, an important safety measure for the nurse is to: 1. Hyperventilate the client with room air prior to suctioning. 2. Apply suction only as the catheter is being withdrawn. 3. Insert the catheter until the cough reflex is stimulated. 4. Remove the inner cannula before inserting the suction catheter. - Correct answer-Answer: 2. Apply suction only as the catheter is being withdrawn Reason: Use of suction upon withdrawal of a suction catheter reduces unnecessary removal of oxygen. In addition, suction should be applied intermittently during the withdrawal procedure to prevent hypoxia. A sterile catheter is used to prevent infection, and the catheter should only be inserted approximately 1 to 2 cm past the end of the trach tube to prevent tissue trauma. Hyperventilating a client before suctioning should always be with oxygen, not room air. Inserting the catheter until the cough reflex is stimulated frequently occurs and does help to mobilize secretions but is not a safety measure. Removal of the inner cannula before inserting the suction catheter is not necessary. What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? 1. Rapid, thready pulse 2. Distended jugular veins 3. Elevated hematocrit level 4. Increased serum sodium level - Correct answer-Answer: 2. Distended jugular veins Reason: Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged if fluid is retained independently of sodium, its concentration is decreased. - Correct answer- A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? 1. Skin turgor 2. Intake and output results Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia. After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? 1. Monitor for signs of electrolyte imbalance. 2. Change the tube at least once every 48 hours. 3. Connect the nasogastric tube to high continuous suction. 4. Assess placement by injecting 10 mL of water into the tube - Correct answer-Answer: 1. Monitor for signs of electrolyte imbalance Reason: Gastric secretions, which are electrolyte rich, are lost through the nasogastric tube the imbalances that result can be life threatening. Changing the nasogastric tube every 48 hours is unnecessary and can damage the suture line. High continuous suction can cause trauma to the suture line. Injecting 10 mL of water into the nasogastric tube to test for placement is unsafe - Correct answer- if respiratory intubation has occurred aspiration will result. - Correct answer- A nurse is caring for a client with pulmonary tuberculosis who is to receive several antitubercular medications. Which of the first-line antitubercular medications is associated with damage to the eighth cranial nerve? 1. Isoniazid (INH) 2. Rifampin (Rifadin) 3. Streptomycin 4. Ethambutol (Myambutol) - Correct answer-Answer: 3. Streptomycin Reason: Streptomycin is ototoxic and can cause damage to the eighth cranial nerve, resulting in deafness. Assessment for ringing or roaring in the ears, vertigo, and hearing acuity should be made before, during, and after treatment. Isoniazid does not affect the ear however, blurred vision and optic neuritis, as well as peripheral neuropathy, may occur. Rifampin does not affect hearing - Correct answer- however, visual disturbances may occur. Ethambutol does not affect hearing - Correct answer- however, visual disturbances may occur. - Correct answer- An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis - Correct answer-Answer: 1. Metabolic acidosis Reason: A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis it is elevated with respiratory acidosis. - Correct answer- The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of: 1. Hypercalcemia 2. Hypocalcemia 3. Hyperkalemia 4. Hypokalemia - Correct answer-Answer: 4. Hypokalemia Reason: Repeated tap water enemas deplete cells and extracellular fluid of potassium and sodium resulting in hypokalemia, hyponatremia, and the potential for water intoxication. Repeated tap water enemas do not have a direct effect on hyper- or hypocalcemia. Potassium is depleted from cells and extracellular fluid and does not result in hyperkalemia. What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? (Select all that apply.) 1 . Diuresis 2 . Pain relief 3. Antipyresis 4 . Bronchodilation 5 . Anticoagulation 6 . Reduced inflammation - Correct answer-Answer: 2. Pain relief, 3. Antipyresis & 6. Reduced inflammation Reason: Prostaglandins accumulate at the site of an injury, causing pain 1. Increase oral fluid intake to 2- 3 L per day Reason: Increasing oral fluid intake to 2 to 3 L per day, if not contraindicated, will dilute urine and promote urine flow, thus preventing stasis and complications such as renal calculi. Bed rest and limited fluid intake may lead to urinary stasis and increase risk for the formation of renal calculi. Voiding at least every hour has no effect on urinary stasis and renal calculi. The intake and output of a client over an eight-hour period is: 0800: Intravenous (IV) infusing - Correct answer- 900 mL left in bag - Correct answer- 0830: 150 mL voided - Correct answer- From 0900-1500 time period: 200 mL gastric tube formula + 50 mL water - Correct answer- Repeated x 2. - Correct answer- 1300: 220 mL voided - Correct answer- 1515: 235 mL voided - Correct answer- 1600: IV has 550 mL left in bag. What is the difference between the client's intake and output? Record the answer using a whole number. _________ mL - Correct answer-Answer: 495 ml Reason: Intake includes 350 mL of IV fluid, 600 mL of nasogastric intubation (NGT) feeding, and 150 mL of water via NGT, for a total intake of 1100 mL output includes voidings of 150, 220, and 235 mL, for a total output of 605 mL. Subtract 605 mL from 1100 mL for a difference of 495 mL. - Correct answer- A client reports vomiting and diarrhea for three days. What clinical finding most accurately will indicate that the client has a fluid deficit? 1. Presence of dry skin 2. Loss of body weight 3. Decrease in blood pressure 4. Altered general appearance - Correct answer-Answer: 2. Loss of body weight Reason: Dehydration is measured most readily and accurately by serial assessments of body weight 1 L of fluid weighs 2.2 lb. Although dry skin may be associated with dehydration, it also is associated with aging and some disorders (e.g., hypothyroidism). Although hypovolemia eventually will result in a decrease in blood pressure, it is not an accurate, reliable measure because there are many other causes of hypotension. Altered appearance is too general and not an objective determination of fluid volume deficit. - Correct answer- A nurse is preparing to administer an oil-retention enema and understands that it works primarily by: 1. Stimulating the urge to defecate. 2. Lubricating the sigmoid colon and rectum. 3. Dissolving the feces. 4. Softening the feces - Correct answer-Answer: 2. Lubricating the sigmoid colon and rectum Reason: The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil - retention enema does not dissolve feces . What clinical finding indicates to the nurse that a client may have hypokalemia? 1. Edema 2. Muscle spasms 3. Kussmaul breathing 4. Abdominal distention - Correct answer-Answer: 4. Abdominal distention Reason: Hypokalemia diminishes the magnitude of the neuronal and muscle ce ll resting potentials. Abdominal distention results from flaccidity of intestinal and abdominal musculature. Edema is a sign of sodium excess. Muscle spasms are a sign of hypocalcemia. Kussmaul breathing is a sign of metabolic acidosis. A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions? 1. "Inhale completely and exhale in short, rapid breaths." 2. "Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale." 3. "Exhale completely - Correct answer- take a slow, deep breath - Correct answer- hold it as long as possible, and slowly exhale." 5. The client's family statement about increases in pain with ambulation - Correct answer-Answer: 1. Pain history including location, intensity and quality of pain 3. Pain pattern including precipitating and alleviating factors Reason: Accurate pain assessment includes pain history with the client's identification of pain location, intensity and quality and helps the nurse to identify what pain means to the client. The pattern of pain includes time of onset, duration and recurrence of pain and it assessment helps to the nurse to anticipate and meet the needs of the client. Assessment of the precipitating factors helps the nurse to prevent the pain and determine it cause. Purposeless movements such as tossing and turning or involuntary mov ements such as a reflexive jerking may indicate pain. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is subjective experience and therefore the nurse has to ask the client directly instead of accepting statement of the family members A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next? 1. Encourage rest. 2. Obtain the vital signs. 3. Administer the prescribed analgesic. 4. Document the client's pain response. - Correct answer-Answer: 2. Obtain vital signs Reason: Immediately before administration of an analgesic, an assessment of vital signs is necessary to determine whether any contraindications to the medication exist (e.g., hypotension, respirations ≤12 breaths/min). Pain prevents both psychological and physiological rest. Before administration of an analgesic, the nurse must check the health care provider's prescription, the time of the last administration, and the client's vital signs. A complete assessment including vital signs should be done before documenting. At the conclusion of visiting hours, the parent of a 14-year-old adolescent scheduled for orthopedic surgery the next day hands the nurse a bottle of capsules and says, "These are for my child's allergy. Will you be sure my child takes one about 9 PM tonight?" What is the nurse's best response? 1. "I will give one capsule tonight before bedtime." 2. "I will get a prescription so that the medicine can be taken." 3. "Does your health care provider know about your child's allergy?" 4. "Did you ask your health care provider if your child should have this tonight?" - Correct answer- Answer: "I will get a prescription so that the medicine can be taken" Reason: Legally, a nurse cannot administer medications without a prescription from a legally licensed individual. The nurse cannot give the medication without a current health care provider's prescription this is a dependent function of the nurse. The nurse should not ask if the health care provider is aware of the problem - Correct answer- it is the nurse's responsibility to document the client's health history. It is the nurse's responsibility to review the health care provider's prescriptions and question them when appropriate - Correct answer- When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is: 1. Sodium 2. Potassium 3. Calcium 4. Calcitonin - Correct answer-Answer: 2. Potassium Reason: A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Sodium is the most abundant extracellular cation that regulates serum osmolarity, as well as nerve impulse transmission and acid-base balance. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction. Calcitonin is a hormone secreted by the thyroid gland and works opposite of parathormone to reduce serum calcium and keep calcium in the bones. Calcitonin does not have a direct effect on intracellular osmolarity. A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? 1. Sodium 2. Calcium 3. Potassium 4. Phosphorus - Correct answer-Answer: 2. Calcium Reason: The muscle contraction-relaxation cycle requires an adequate serum calcium-phosphorus ratio the reduction of the ionized serum calcium level associated with malabsorption syndrome cause s tetany (spastic muscle spasms). Sodium is the major extracellular cation. Sodium's major route of excretion is the kidneys, under the control of aldosterone. Although it plays a part in neuromuscular transmission, potassium is not related to the development of tetany. Potassium is the major intracellular cation. Potassium is part of the sodium-potassium pump and helps to balance the response of nerves to stimulation. Potassium is not related to the development of tetany. Although phosphorus is closely related to calcium because they exist in a specific ratio, phosphorus is not related to the development of tetany. - Correct answer- A pressure ulcer that is full thickness with necrosis and ulceration into the subcutaneous tissue and down to, but not through, the underlying fascia is characteristic of a stage III pressure ulcer. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial thickness wound with skin loss involving the epidermis, dermis, or both the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage IV pressure ulcer involves full thickness skin loss with extensive damage and tissue necrosis to muscles, support tissues, and bone - Correct answer- undermining and sinus tracts may also be present. - Correct answer- A client is scheduled to receive conscious sedation during a colonoscopy. The client asks the nurse, "How will they 'knock me out' for this procedure?" Which answer by the nurse correctly describes the route of administration for conscious sedation? 1. "You will receive the anesthesia through a face mask." 2. "You will receive medication through an intravenous catheter." 3. "We will give you an oral medication about one hour before the procedure." 4. "The nurse anesthetist will inject the medication into the epidural space of your spine." - Correct answer-Answer: 2. "You will receive medication through an intravenous catheter." Reason: Conscious sedation is administered by direct intravenous (IV) injection (IV push) to dull or reduce the intensity of pain or awareness of pain during a procedure without loss of defensive reflexes. General anesthesia usually is administered via inhalation of the vapor of a volatile liquid or an anesthetic gas via a mask or endotracheal tube as a result, the client is unconscious, unaware, and anesthetized. An epidural block, a type of regional anesthesia, involves the injection of a local anesthetic into the epidural (extradural) space - Correct answer- it works by binding to nerve roots as they enter and exit the spinal cord. Epidural blocks are not used for moderate sedation. The oral route of drug administration is commonly used for pediatric clients, not adults. - Correct answer- A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? 1. Discharge in am 2. Blood glucose monitoring ac and bedtime 3. Erythropoietin (Procrit) 6000 units subcutaneously TIW 4. Dalteparin (Fragmin) 5000 international units Sub-Q BID - Correct answer-Answer: 3. Erythropoietin (Procrit) 6000 units subcutaneously TIW Reason: "TIW", indicating three times a week is an unacceptable abbreviation . It may be mistaken for "three times a day" or "twice weekly." The abbreviation "AM" for in the morning is an acceptable abbreviation. The word "discharge" must be completely spelled out instead of just "D/C" because this may be confused with "discontinue." The use of "ac" (before meals) is an acceptable abbreviation. Bedt ime must be completely spelled out instead of just "hs" because "hs" may be confused with "half strength" or "every hour." The abbreviation "Sub-Q", indicating the subcutaneous route is an acceptable abbreviation. "BID," indicating twice a day, is an acceptable abbreviation. "International units" must be completely spelled out instead of just "IU" because it may be mistaken as a four. Which nursing interventions require a nurse to wear gloves? (Select all that apply.) 1 . Giving a back rub. 2. Cleaning a newborn immediately after delivery. 3. Emptying a portable wound drainage system. 4. Interviewing a client in the emergency department. 5. Obtaining the blood pressure of a client who is human immunodeficiency virus (HIV) positive - Correct answer-Answer: 2. Cleaning a newborn immediately after delivery 3. Emptying a portable wound drainage system Reason: Personal protective equipment (PPE) should be used because the newborn is covered with amniotic fluid and maternal blood. PPE should be used because the nurse may be exposed to blood and fluid that are contained in the portable wound drainage system. PPE is not required for a back rub there is no indication that the nurse is in contact with body secretions. PPE is not necessary when conducting an interview because it is unlikely that the nurse will come in contact with the client's body fluids. PPE is not necessary when obtaining the blood pressure of a client, even if the client is HIV positive. - Correct answer- A nurse anticipates that a hospitalized client will be transferred to a nursing home. When should the nurse begin preparing the client for the transfer? 1. At the time of admission 2. After a relative gives permission 3. When the client talks about future plans 4. As soon as the client's transfer has been approved - Correct answer-Answer: 1. At the time of admission Reason: Preparation of clients for discharge to their own home or to a nursing home should begin on the day of admission. The client gives permission for transfer to a nursing home. Intervention includes talking to the family members, including them in plans, and helping them understand the importance of early The nurse is caring for a client who is on a low carbohydrate diet. With this die t, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine? 1. Protein 2. Glucose 3. Ketones 4. Uric acid - Correct answer-Answer: 3. Ketones Reason: As a result of fat metabolism, ketone bodies are formed and the kidneys attempt to decrease the excess by filtration and excretion. Excessive ketones in the blood can cause metabolic acidosis. A low carbohydrate diet does not cause increased protein, glucose, or uric acid in the urine. A client is scheduled for a transurethral resection of the prostate (TURP). Which statement made by the client most indicates the need for further preoperative teaching? 1. "My urine will be red after surgery." 2. "I will have a catheter after surgery." 3. "My incision will probably be painful." 4. "I will need to drink a lot after surgery." - Correct answer-Answer: 3. "My incision will probably be painful" Reason: The TURP procedure is performed by insertion of a scope device into the urethra to reach the prostate from within the urinary tract. No incision is made to reach the prostate, therefore the client statement about an incision being painful after surgery warrants further evaluating and teaching by the nurse. The client is demonstrating correct knowledge about the TURP procedure by stating that after surgery his urine will be red, he will have a catheter, and he will need to increase fluid intake. A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? 1. Arrangements will be made by the client and the client's family. 2. The plan is formulated and implemented early in the client's care. 3. The rehabilitation is minimal and short term because the client will return to former activities. 4. Arrangements will be made for long-term care because the client is no longer capable of self-care - Correct answer-Answer: 2. The plan is formulated and implemented early in the client's care. Reason: To promote optimism and facilitate smooth functioning, rehabilitation planning should begin on admission to the hospital. The client and family often are unaware of the options avai lable in the health care system the nurse should be available to provide the necessary information and support. Rehabilitation helps a client adjust to a new lifestyle that must compensate for the paralysis. The goal of rehabilitation is to foster independence wherever the client may live after discharge. - Correct answer- A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? 1. Evaluation 2. Data Collection 3. Nursing interventions 4. Proposed nursing care - Correct answer-Answer: 1. Evaluation Reason: An actual or potential client health problem is based on the analysis and interpretation of the data previously collected during the assessment phase of the nursing process. Gathering data is included in the client's assessment. Nursing interventions are based on the earlier steps of the nursing process. The plan of care includes nursing actions to meet client needs. The needs first must be identified before nursing actions are planned. A nurse is assisting a client to transfer from the bed to a chair. What should the nurse do to widen the client's base of support during the transfer? 1. Spread the client's feet away from each other. 2. Move the client on the count of three. 3. Instruct the client to flex the muscles of the internal girdle. 4. Stand close to the client when assisting with the move. - Correct answer-Answer: 1. Spread the client's feet away from each other Reason: Spreading the feet apart widens the base of support. A wide base of support lowers the center of gravity, thereby increasing stability. Counting to three does not widen the base of support. Counting to three ensures a coordinated effort on behalf of the client and nurse to affect the move, which may alleviate some of the burden borne by the nurse. Flexing the muscles of the internal girdle (contracting the gluteal muscles in the buttocks downward and the abdominal muscles upward) stabilizes the pelvis and protects the abdominal viscera when lifting, pulling, reaching, or stooping, but it does not widen the base of support. Working close to the client is not based on the principle of widening the base of support. This action brings the center of gravity close to the client being moved, permitting the muscles of the nurse's legs and arms to carry the burden of the transfer rather than the muscles of the back. What should the nurse assess to determine whether a 75-year-old individual is meeting the developmental task associated with aging? 1. Achievement of a personal philosophy Reason: A neurovascular assessment involves evaluating of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular assessment should include evaluating of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurological assessment. A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: 1. A loss of skin elasticity and a decrease in libido 2. Impaired fat digestion and increased salivary secretions 3. Increased blood pressure and decreased hormone production 4. An increase in body warmth and some swallowing difficulties - Correct answer-Answer: 3. Increased blood pressure and decreased hormone production Reason: With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures hormone production decreases after menopause. There may or may not be changes in libido - Correct answer- there is a loss of skin elasticity. Salivary secretions decrease, not increase, causing more difficulty with swallowing - Correct answer- there is some impairment of fat digestion. There may be a decrease in subcutaneous fat and decreasing body warmth - Correct answer- some swallowing difficulties occur because of decreased oral secretions. - Correct answer- A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? (Select all that apply.) 1 . Diplopia 2 . Dysphagia 3. Tachypnea 4. Bradycardia 5. Hypotension - Correct answer-Answer: 3. Tachypnea 5. Hypotension Reason: Tachypnea occurs with Addisonian crisis because of inadequate circulating glucocorticoids and mineralocorticoids. Inadequate circulating glucocorticoids and mineralocorticoids cause hypotension, pallor, weakness, tachycardia, and tachypnea. Double vision does not occur with Addisonian crisis. Difficulty swallowing does not occur with Addisonian crisis. Tachycardia, not bradycardia, occurs with Addisonian crisis. Elizabeth Kubler-Ross, a psychiatrist, proposed a model that describes 5 stages commonly seen in those experiencing grief. These stages, which can occur in any order, include: denial, anger, bargaining, depression, and acceptance. The acronym "DABDA: can be used to help recall the 5 stages of grief. The purpose of inserting a chest tube is to: - Correct answer-Restore negatie pressure int he intrapleural space. Insertion of a chest tube is an invasive procedure designed to restore negative pressure in the intrapleural space. When the normally negative pressure of the intrapleural space is disrupted, it causes the lung to collapse and a patient to develop respiratory symptoms. Therefore, the tube is placed to restore negative pressure until the underlying condition can heal. Conditions that commonly necessitate a chest tube include a pneumothorax, blunt chest trauma, empyema, or hemothorax A 70-year-old obese males admitted to the cardiac unit with new onset of atrial fibrillation. While in the hospital, the night shift nurse notes that the patient is snoring loudly, then waking abruptly. In the early morning , he reports being excessively tired during the day. The nurse is suspicious for which of the following? - Correct answer-Obstructive sleep apnea Obstructive sleep apnea is a disorder found most often in older obese males. It is the lack of air flow due to an obstruction of the pharynx during sleep. Patients with obstructive sleep apnea often snore loudly and awaken frequently throughout the night following episodes of apnea. They often report daytime tiredness, sore throat, and headaches. For severe cases of sleep apnea, a device called a continuous positive airway pressure (CPAP) machine may be utilized. An elevated bilirubin may be a sign of: - Correct answer-Liver disease Bilirubin is a yellowish substance found in bile. It is produced by the body when red blood cells are broken down by the liver. Low levels of bilirubin are not typically a concern. High levels of bilirubin, however, may be a sign of disease and require further evaluation. The diagnostic marker used in patients with CHF is called: - Correct answer-B-type natriuretic peptide B-type natriuretic peptide (BNP) is secreted from the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens. The level of BNP in