- A client with a history of chronic cirrhosis of the liver was admitted two days ago to treat an infection. Today, during the initial shift assessment, the nurse notes that the client appears lethargic and their breath has a sweet, musty odor. Which assessment should the nurse perform NEXT?
- Measure client's abdominal girth
- Observe for flapping hand tremors
- Obtain a full set of vital signs
- Review recent serum bilirubin result
Correct answer: Observe for flapping hand tremors
In patients with chronic liver disease, acute episodes of encephalopathy are usually precipitated by reversible causes. The most common are the following: Metabolic stress (e.g., infection; electrolyte imbalance, especially hypokalemia; dehydration; use of diuretic drugs) and Nonspecific cerebral depressants (e.g., alcohol, sedatives, analgesics). Symptoms usually do not become apparent until brain function is moderately impaired. A musty, sweet breath odor (fetor hepaticus) can occur regardless of the stage of encephalopathy. Asterixis is a characteristic flapping tremor that is elicited when patients hold their arms outstretched with wrists dorsiflexed. Elevated bilirubin would cause jaundice. Vital signs are already part of an initial assessment.
- A healthcare provider is planning care for four patients. Which patient is most in need of interventions aimed at preventing anemia?
- The patient who is a vegetarian
- The patient with renal failure on hemodialysis
- The patient with a Jackson-Pratt drain
- The patient who has been NPO for 3 days
Correct answer: The patient with renal failure on hemodialysis
Because of decreased production of erythropoietin, renal failure causes fewer red blood cells to be produced by the bone marrow. Also, hemodialysis can cause hemolysis, so this patient is at the highest risk of anemia. While a true vegan diet may increase the risk of anemia, most vegetarian diets include proper nutrients to prevent anemia. Unless a post-op patient with a Jackson-Pratt drain shows signs of acute hemorrhage, anemia is unlikely.
- The team leader assigns a new nurse to change a client's tracheostomy tube. The new nurse has never performed this procedure before. What should the nurse do?
- Ask another nurse to trade assignments
- Request the team leader's assistance
- Check the procedure manual before starting
- Watch the procedure on YouTube first
Correct answer: Request the team leader's assistance
The new nurse should inform the team leader that the nurse has not been trained in changing a tracheostomy tube, and ask for the team leader's assistance. The team leader can then decide whether to train the new nurse or assign the task to someone else.
- The nursing instructor is preparing a lecture on medical billing. What is the purpose of the Diagnosis Related Group (DRG) Manual?
- To correlate the client's health history with nursing care plans
- To assist in identifying symptoms of the medical condition
- To establish nurse case manager coordination protocols
- To determine reimbursement for a specific diagnosis
Correct answer: To determine reimbursement for a specific diagnosis
A diagnosis-related group (DRG) is a patient classification system that standardizes prospective payments to hospitals and encourages cost containment initiatives. In general, a DRG payment covers all charges associated with an inpatient stay from the time of admission to discharge. Medicare and insurance companies use the DRG system to determine reimbursements for medical diagnoses.
- As a preceptor, the RN helps a graduate nurse learn to organize and prioritize tasks. Which action by the graduate nurse requires intervention by the preceptor?
- The graduate nurse prioritizes client needs for the shift
- The graduate nurse waits to document until the end of the shift
- The graduate nurse makes lists of supplies for tasks
- The graduate nurse allows time for unexpected situations
Correct answer: The graduate nurse waits to document until the end of the shift
The graduate nurse should learn to document throughout the shift. Time management is essential for nurses. Taking advantage of every opportunity to record client updates is efficient and also wise from a legal and risk management perspective. The other actions are appropriate for a graduate nurse.
- An unlicensed assistive personnel (UAP) who works in a rehab unit is floated to the pediatric unit for the shift. Which question should the charge nurse ask the UAP before making an assignment?
- What is your favorite kind of client to care for in the rehab unit?
- How long have you been working as a UAP at this hospital?
- Can you wait a minute so we can review your competency checklist?
- Will you feel comfortable caring for sick babies and children?
Correct answer: Can you wait a minute so we can review your competency checklist?
The UAP must be competent to accept assigned tasks in any unit. The most objective and comprehensive way to determine the UAP's skill set is to use a checklist developed by the hospital or healthcare corporation. The length of time at the facility, comfort level in pediatrics, or favorite types of clients are not appropriate ways to make assignments.
- A staff nurse approaches the nurse manager to complain that an unlicensed assistive personnel (UAP) is not completing assignments. What is the nurse manager's BEST action?
- Ask the staff nurse if they have already spoken with the UAP
- Add communication tips to the next staff meeting agenda
- Arrange for a 3-way meeting with the nurse and the UAP
- Assure the staff nurse that their complaints are noted
Correct answer: Ask the staff nurse if they have already spoken with the UAP
The nurse manager should assist the staff to manage conflict or difficult discussions directly. It's an important skill that is useful in both professional and personal areas. In this case, if the staff nurse is unable to resolve the situation, then a meeting with the staff nurse and the UAP is appropriate.
- A client has been transported to the preop area when the surgical nurse discovers that the client has not signed the informed consent. What is the most appropriate action for the nurse?
- Bring the client a new consent form to sign
- Notify the nurse manager of the situation
- Ask for the surgery to be rescheduled
- Contact the surgeon to receive guidance
Correct answer: Notify the nurse manager of the situation
If there is no signed informed consent form, the nurse should notify the nurse manager, who can speak with the surgeon. The surgeon is responsible for the informed consent process. If the client has already been given a pre-op sedative, it would be unethical to obtain a signature from the person. The nurse should not contact the surgeon directly or ask for the procedure to be rescheduled.
- When the nurse is assigning care of a newly admitted client to an unlicensed assistive personnel (UAP), which instruction is BEST?
- Starting at 9 a.m., empty the Foley every hour and write the output on the board by his bed
- Before you go to lunch, give him a bath and put the sequential compression device on
- Put his compression stockings on and try to get him up to ambulate a couple of times
- Take his vital signs often and let me know if anything else seems to be abnormal
Correct answer: Starting at 9 a.m., empty the Foley every hour and write the output on the board by his bed
When assigning tasks, directions must be clear, concise, correct, and complete. An example of directions that meet these requirements is to empty the Foley and record the amount hourly, starting at 9 a.m. The answer options related to ambulation, measuring the client's vital signs, and morning tasks are vague and incomplete. The UAP cannot assess a client.
- The nurse working in a long-term care facility is assigning tasks for a 77-year-old resident who is experiencing hyperglycemia. Which of the following tasks is appropriate for the unlicensed assistive personnel (UAP)?
- Revise the resident's care plan to reflect the current status
- Record the resident's food and fluid intake during the shift
- Monitor the resident for changes in level of consciousness
- Assess the resident's ankle edema after giving the person a bed bath
Correct answer: Record the resident's food and fluid intake during the shift
The nurse can assign the UAP to record the resident's dietary intake. The UAP can give a bed bath and inform the nurse if they observe edema, but only the nurse can assess the resident. The UAP can also notify the nurse if the resident shows a change in alertness, but it is the nurse's responsibility to monitor and document any alterations and notify the provider of them. The UAP may not make any changes in the plan of care.
- Parents bring their 7-year-old son to the Emergency Department, because they think he has a fractured ankle. During the physical assessment, the nurse notes multiple bruises and cigarette burns on the boy's arms and trunk. Which is the nurse's most appropriate action?
- Notify the supervisor to report suspected child abuse
- Inform the parents they may not take their son home
- Demand that the parents explain the cigarette burns
- Privately ask the boy what happened to cause his injuries
Correct answer: Notify the supervisor to report suspected child abuse
All healthcare professionals are required to report suspected child abuse. Demanding an explanation from the parents assumes that the parents are responsible, which may not be the case. It may not be possible to obtain accurate information from the boy either; many children are coached what to say. The nurse does not have the authority to keep the parents from taking their son home.
- On reporting to his Med-Surg unit, a nurse is told that he has been pulled to the ICU. The nurse has never worked in the ICU and is hesitant to "float" for his shift. What should he do?
- Refuse to float in the ICU
- Check with the hospital's attorney
- Go to the ICU and perform safe tasks
- Call the nursing supervisor
Correct answer: Go to the ICU and perform safe tasks
Being floated or pulled to another unit is acceptable and legal. To provide safe care to patients, the new unit should provide orientation to the nurse before the nurse is assigned to stable patients that are similar to those normally cared for. Refusal to float can result in termination.
- A client with a previous diagnosis of early-onset Alzheimer's disease is scheduled for a common surgical procedure. If the nurse is concerned about the client's ability to give informed consent, which of the following actions would be most appropriate?
- Contact administration for hospital policy
- Ask two other nurses to witness the signature
- Allow the client to sign the informed consent
- Notify the surgeon to countersign the consent
Correct answer: Contact administration for hospital policy
Informed consent can be obtained only from an adult patient who is mentally competent to sign it, except under certain circumstances and situations. When consent cannot be obtained, other people can provide legal consent for the patient. If the nurse has any concerns about the client's ability to sign or which other persons can sign, the nurse should contact the appropriate administrator for guidance consistent with policy. The other options are unethical and illegal.
- The caregiver of a 2-year-old calls the Poison Center to report that the child has swallowed a lithium "coin" battery. The caregiver is instructed to immediately go to the Emergency Department. What other instruction is indicated?
- Use a finger to induce vomiting
- Make the child drink a glass of milk
- Give the child 2 teaspoons of honey
- Administer syrup of ipecac
Correct answer: Give the child 2 teaspoons of honey
Coin (button) batteries (CR2032) are 20mm, about the size of a nickel coin. When the battery reacts with saliva and tissue of the esophagus, it creates a hydroxide-rich, alkaline solution that essentially dissolves tissue. The battery must be removed within 2 hours to avoid serious complications or death. Batteries in the esophagus may initially be asymptomatic; DO NOT WAIT FOR SYMPTOMS. If honey is available, it should be given before leaving for the ED, and every 10 minutes. Honey coats the battery and slows the risk of injury. Inducing vomiting or giving cathartics is not effective. If honey is not available, keep the child NPO.
- After assisting a physician with insertion of a central line, what is the nurse's first priority?
- Label the dressing with the date and time of insertion
- Prepare the client for a chest x-ray
- Administer saline to check for patency
- Assess the insertion site for infection
Correct answer: Prepare the client for a chest x-ray
The first priority after central line placement is to verify proper placement; a risk is pneumothorax from accidental lung puncture. No infusion can take place until the X-ray indicates proper placement of the catheter tip in the superior vena cava. Infection will not be evident immediately after the central line is inserted. Covering and labeling the dressing is necessary, but this is not the first priority.
- During a staff meeting, the supervisor reports on a recent infection control audit. Which finding indicates a need for staff training?
- A patient with active tuberculosis wears a mask when going to another department for testing
- A certified nursing assistant does not wear gloves when feeding an elderly patient
- A lab technician puts on a mask, gown, and gloves before entering the room of a patient on strict isolation
- A nurse with open lesions on her hands puts on gloves before giving direct patient care
Correct answer: A nurse with open lesions on her hands puts on gloves before giving direct patient care
There is no need to wear gloves when feeding a client. However, universal (standard) precautions (treating all blood and body fluids as if they were infectious) should be followed in all situations. A client with active tuberculosis should be on respiratory precautions, including wearing a mask outside his private room. Staff members with exudative lesions or weeping dermatitis should not give direct care or handle patient care equipment until the condition resolves, not even while wearing gloves. Strict isolation requires the use of mask, gown, and gloves for anyone entering the room.
- A small plane carrying the football team from the local university crashed. Survivors are being transported to the hospital. Four team members died in the crash. Before the survivors reach the hospital, what should the nurse anticipate being asked to do?
- Call the hospital's volunteer office
- Call the nearest crisis response team
- Alert the local news stations
- Notify the university of the crash
Correct answer: Call the nearest crisis response team
After a traumatic event, there will be a great need for support from disaster and crisis specialists. The survivors, families of the deceased team members, and fellow students as well as the rest of the community will need empathy and counseling. The news media usually monitor emergency radio, so they should already be aware of what has happened. Volunteers may be helpful, but they are not experts in assisting with disasters. The university will receive information from other sources.
- The nurse is providing discharge instructions to a client who was admitted with a diagnosis of acute pancreatitis. Which of the following statements by the client would indicate that the client understands how to prevent another episode?
- I will attend Alcoholics Anonymous meetings from now on
- I'll call the clinic if I get constipated
- I'll avoid eating uncooked vegetables
- I will only drink two beers every day
Correct answer: I will attend Alcoholics Anonymous meetings from now on
Pancreatitis can present as either acute pancreatitis or chronic pancreatitis. Acute pancreatitis is a sudden inflammation of the pancreas. Two common causes are alcohol abuse and gallstones. The pancreatic acinar cells metabolize alcohol into toxic byproducts that damage pancreatic ducts, and enzymes that are normally released into the digestive tract build up and begin to digest the pancreas itself. The damaged pancreatic tissue promotes inflammation, which leads to further damage of the pancreas. Clients with a history of alcohol abuse should stop all alcohol intake. Therefore, the appropriate client response here is the commitment to attend Alcoholics Anonymous meetings. The other responses are unrelated to acute pancreatitis.
- A neighbor brings her 10-year-old son to your house because he has a nosebleed. After you sit him down, what is the most appropriate way to care for him?
- Tilt his head back and place an ice pack on his nose
- Wipe off the blood and administer saline nose drops
- Pack his nostrils with clean cotton balls or gauze
- Lean him forward and gently pinch above his nostrils
Correct answer: Lean him forward and gently pinch above his nostrils
To stop a nosebleed, sit down and pinch the soft part of the nose, just above the nostrils. The bleeding should stop in 10-15 minutes. Leaning forward while doing this will allow the blood to exit by the nose, instead of down the throat. Tilting the head back can cause nausea. The other two answer options are incorrect.
- _________ are the most common cause of accidents in the home.
- Falls
- Burns
- Lacerations
- Abrasions
Correct answer: Falls
According to the National Safety Council, falls are the number one cause of home accidents. For persons age 65 and older, falls are the leading cause of injury-related deaths, including broken hips. Many falls can be prevented with simple measures, such as wiping up spills and removing small rugs and clutter.
- A home health nurse does an assessment of a client with mid-stage Alzheimer's disease who lives with his son and the son's family. Which of the nurse's observations should be addressed first?
- Stove burners are turned on remotely
- Extension cords are placed behind furniture
- Area rugs are in place, but secured to the floor
- The front door has a lock with a bolt
Correct answer: The front door has a lock with a bolt
The family seems to have taken measures to keep the client safe. However, doors need to have locks in atypical locations, such as the top of the door, to prevent the client from wandering when confused. Conventional locks can easily be opened.
- The health care provider (HCP) prescribed ambulation q.i.d. for a client who had undergone major abdominal surgery two days ago. The nurse assisted the client on the first postoperative day. Today, the nurse assigns the task to the unlicensed assistive personnel (UAP). Which of the following instructions to the UAP is CORRECT?
- Have the client stand for 2 minutes before ambulating
- Allow the client to dangle before he stands up
- Use a gait belt to support the client if he gets dizzy
- Stand the client up quickly to reduce incision pain
Correct answer: Allow the client to dangle before he stands up
To prevent orthostatic hypotension, clients should dangle (sit at the edge of the bed) before attempting to stand. Standing quickly can cause a sudden drop in blood pressure, resulting in dizziness or fainting. A gait belt should not be used on a client who has recently had abdominal surgery. The UAP should not ambulate a client who reports feeling dizzy. Standing for two minutes before starting to walk is unnecessary and tiring for the client.
- An oncology nurse is with an adult client when a Code Pink (infant abduction) is called. What is the nurse's BEST action?
- Watch for someone with a large package
- Remain with the client; it's not a pediatric unit
- Check all empty rooms and closets at once
- Evacuate all visitors to the hospital lobby
Correct answer: Watch for someone with a large package
If an infant abduction is announced, every hospital employee should be alert to anyone who matches the description of the suspected abductor or is wearing bulky clothing or carrying a large package. Checking rooms can be helpful, but it is not the priority. Visitors should remain in the unit to avoid extra confusion in public areas. Elevators will not work during a Code Pink. If the oncology client can be safely left for a few minutes, the nurse can step into the hall to check for anyone who appears suspicious.
- The pediatric nurse is caring for a 5-year-old boy with a diagnosis of a subdural hematoma, secondary to falling out of his top bunk bed. The nurse observes that he has a runny nose. What is the nurse's best action?
- Place him on his right side
- Test the discharge for glucose
- Help him gently blow his nose
- Call the neurologist immediately
Correct answer: Test the discharge for glucose
It's important for the nurse to assess the nasal discharge. Cerebrospinal fluid (CSF) is positive for glucose; mucus is not. If the boy has a CSF leak, blowing his nose is not advised. If the discharge is positive, the neurologist should be contacted.
- When a nurse enters a client's room to administer medications, the nurse notices black smoke coming from the client's television. What should the nurse do FIRST?
- Smother the smoke with wet towels
- Remove the client from the room
- Activate the nearest fire alarm
- Use a fire extinguisher from the hall
Correct answer: Remove the client from the room
Use the acronym "R.A.C.E." when encountering a fire or smoke. R: The nurse should first remove the client from the room. A: The nurse should activate the nearest alarm. C: The nurse should contain the fire by closing the client's door. E: The nurse should extinguish the fire with the appropriate fire extinguisher, or escape if this isn't possible. Attempting to smother this fire, which appears to be electrical, is not appropriate.
- All of the following are signs of an infected wound EXCEPT
- Loss of movement
- Swelling at the site
- Temperature over 101 °F
- Blanching of the wound
Correct answer: Blanching of the wound
Redness is a sign of wound infection, NOT blanching. Other signs include loss of movement or function, a fever over 101 degrees Fahrenheit (a low-grade temperature of under 100 degrees is common), overall malaise, purulent drainage, increasing or constant pain, swelling at or around the wound, and warm skin at or around the wound.
- A nurse working at a community health fair is administering intramuscular injections of influenza vaccine. Which injection technique will avoid leakage into subcutaneous tissue?
- Injection by the Z-track method
- Massaging the injection site
- Aspiration prior to injection
- Injection at a 45-degree angle
Correct answer: Injection by the Z-track method
The Z-track injection method avoids leakage into subcutaneous tissue. Pull the client's skin downward or upward, and inject the vaccination (or medication) at a 90-degree angle before releasing the skin. Aspiration is done to assure that the injection is not going into a vein or artery. Massaging the injection site can introduce the material into subcutaneous tissue. A 45-degree angle is incorrect.
- A client comes to the clinic, complaining of severe gastrointestinal distress. Which abdominal physical assessment step does the nurse do first?
- Inspection
- Auscultation
- Palpation
- Percussion
Correct answer: Inspection
The correct sequence for physical assessment of the abdomen is as follows: 1. Inspect. 2. Auscultate. 3. Percuss. 4. Palpate. Remember this sequence with the phrase "I Am a People Person." The order is different from the physical assessment of the body systems, for which you inspect, then palpate, percuss, and auscultate.
- A patient receiving chemotherapy is experiencing stomatitis. Which of the following should the healthcare provider offer the patient?
- Hot soup for lunch and dinner
- Warm saline rinses four times each day
- Plenty of ice chips between meals
- Vigorous oral care with a commercial mouthwash
Correct answer: Warm saline rinses four times each day
Stomatitis is irritation of the lips, mouth, tongue, and oropharynx, which occurs when chemotherapy kills healthy cells that are rapidly dividing. It can impair nutrition, speech, sleep, and the quality of life. Warm saline rinses are non-irritating and help eliminate bacteria that can cause infection. Other nursing interventions include gentle oral hygiene and administration of a topical analgesic as ordered by the physician.
- The nurse teaching a 14-year-old client about her cervico-thoracolumbosacral orthosis (CTLSO) brace. Which statement by the client would indicate a lack of understanding about the brace?
- I can take it off in hot weather.
- I can remove it when take a shower.
- I should wear loose clothing underneath it.
- I must wear it all day and night.
Correct answer: I can take it off in hot weather.
The Milwaukee brace, also known as a cervico-thoracolumbosacral orthosis or CTLSO, is a back brace used in the treatment of spinal curvatures such as scoliosis or kyphosis in children. It is a full-torso brace that extends from the pelvis to the base of the skull. Its aim is to keep the body upright and prevent progression of the curve while the patient is growing and awaiting possible need for operative intervention. The brace must be worn long term, during periods of growth, usually for 1 to 2 years. The client's statement about not wearing the brace in hot weather is incorrect and indicates a need for additional teaching. The other statements indicate correct understanding.
- The healthcare provider is preparing a patient for a total colectomy and the placement of an ileostomy. The patient asks where the stoma will be located. The healthcare provider identifies which of the following areas as the correct stoma site?
Correct answer: C
A total colectomy involves the removal of the large intestine. The gastrointestinal output will occur at the terminal end of the ileum. The stoma will be located in the right lower quadrant of the abdomen. A total colectomy is performed for intestinal inflammatory conditions such as Crohn's disease or ulcerative colitis. It may also be done for severe chronic constipation.
- After your patient dies, the patient's family gathers at the bedside and asks you to step out while their clergy performs a religious rite for the deceased. As the patient's nurse, what is your most appropriate course of action?
- Allow the ceremony but remain as a witness.
- Inform the family that religious rites are not allowed.
- Educate the family about custody of care and stay in the room.
- Allow the ceremony and step out of the room.
Correct answer: Allow the ceremony and step out of the room.
The nurse should honor the family's wishes and culture and leave the room. Most hospitals do not have a policy that prohibits religious rites or ceremonies at the time of death. Remaining in the room shows disrespect and lack of trust at a time of grieving.
- The nurse in the prenatal clinic is teaching a client who is a vegetarian how to avoid iron-deficiency anemia during her pregnancy. Which food choice by the client indicates a need for further instruction?
- Black bean burger and tomato juice
- Lentil stew and strawberries
- Instant oatmeal and orange juice
- Scrambled eggs and wheat toast
Correct answer: Scrambled eggs and wheat toast
Vegetarians, and especially vegans, must eat twice as much iron as non-vegetarians. Non-heme iron, the type of iron found in grains, lentils, vegetables, and fruits, is not as well absorbed as heme iron. Moreover, the iron stores of vegetarians are often lower than those of people who eat meat. Anemia during pregnancy can lead to premature delivery and can decrease the baby's birth weight. It can also reduce iron stores that are accumulated by the baby during gestation, putting the baby at greater risk for iron deficiency later on. It is important for pregnant vegetarians to eat plenty of iron-rich foods in combination with vitamin C-rich foods several times a day. When iron is consumed at the same time as vitamin C, its absorption rate is doubled.
- The nurse is educating a client with primary adrenal insufficiency (Addison's disease) on diet and nutrition changes needed to manage the client's disease. Which statement by the client would indicate that the nurse's instructions have been effective?
- I should increase sodium and fluids, but limit potassium
- I will increase sodium and potassium, but limit fluids.
- I should increase fluids, but limit sodium and potassium.
- I will increase potassium and fluids, but limit sodium.
Correct answer: I should increase sodium and fluids, but limit potassium
Addison's disease develops when the adrenal glands are damaged. They don't make enough of the hormones cortisol and aldosterone. Besides corticosteroid medications, dietary changes include increased sodium, decreased potassium, and adequate fluid intake.
- A client who sustained a fractured femur in a construction accident is admitted to the orthopedic unit directly from surgery. The client is in skeletal traction. Which nursing action is the PRIORITY?
- Maintain strict and proper body alignment
- Perform frequent neurovascular checks.
- Attach an overhead trapeze to the bed.
- Provide meticulous care at pin insertion sites.
Correct answer: Perform frequent neurovascular checks.
The nurse should perform neurovascular checks as ordered and as indicated. The neurovascular assessment of the extremities is performed to evaluate sensory and motor function ("neuro") and peripheral circulation ("vascular"). The components of the neurovascular assessment include pulses, capillary refill, skin color, temperature, sensation, and motor function. Pain and edema are also assessed during this examination. The other actions are appropriate but are not the priority.
- A 32-year-old female with no significant history comes to the clinic for a routine check-up. Where is the most appropriate spot to measure this client's pulse?
- Apical
- Radial
- Carotid
- Femoral
Correct answer: Radial
For a client with an uncomplicated medical history, taking a radial pulse is appropriate. An apical pulse is appropriate for clients taking cardiovascular medications, such as Digoxin. A carotid pulse is appropriate for emergency situations, such as cardiac arrest. Taking a femoral pulse is not necessary and can be considered an invasion of privacy.
- The nurse is instructing a client with a new sigmoid colostomy about caring for the colostomy. The nurse explains that to best regulate the bowel, the client should perform colostomy irrigation at the same time every day. What is the optimal time for doing this?
- Two hours before bedtime
- An hour before a meal
- An hour after a meal
- Every two hours all day
Correct answer: An hour after a meal
Colostomy irrigation is a way to regulate bowel movements by emptying the colon at a scheduled time. It distends the bowel to stimulate peristalsis and promote evacuation. Patients who had a permanent colostomy made in the descending or sigmoid portion of the colon and had regular bowel function before having the colostomy are good candidates for irrigation. It's most effective when performed about an hour after a meal, when the colon is most likely to be full.
- After a client was diagnosed with gastroesophageal reflux disease (GERD), the nurse educates the client about diet. Which of the following foods should the client avoid?
- White bread
- Bananas
- Pineapple
- Grilled salmon
Correct answer: Pineapple
A client with GERD should be instructed to avoid acidic foods, such as tomatoes or pineapple. Other foods to avoid are fatty or spicy dishes. The client should choose low-fat and high-fiber food items. White bread and bananas have fiber and are low in fat. Salmon is a low-fat alternative to fried foods.
- The results of an adult patient's blood pressure screening on three occasions were: 120/80 mmHg, 130/76 mmHg, and 118/86 mmHg. How will the healthcare provider interpret this information?
- Hypertension Stage 1
- Normal blood pressure
- Hypertension Stage 2
- Elevated blood pressure
Correct answer: Hypertension Stage 1
A patient is considered to have hypertension if even one of the parameters (either diastolic or systolic) is elevated. This patient has prehypertension, defined as 120–139 mmHg systolic or 8089 mmHg diastolic.
- A healthcare provider is caring for a patient with a history of fatigue, dyspnea, and dark stools. The patient states, "My stools are very smelly." The patient's complete blood count (CBC) reveals a hemoglobin of 7 g/dL (70 g/L). Based on this patient's history, the healthcare provider anticipates an order to prepare the patient for
- A computed tomography (CT) scan
- An upper gastrointestinal endoscopy
- A comprehensive dietary inventory
- A bone marrow aspiration
Correct answer: An upper gastrointestinal endoscopy
Melena (dark, smelly stools) refers to the black, "tarry" feces that are associated with upper gastrointestinal bleeding. The black color results from the iron in hemoglobin being mixed with the chemicals and intestinal bacteria of the digestive tract. Bleeding can be confirmed by endoscopy. Causes of upper GI bleeding include peptic ulcers, gastritis, esophageal varices, cancer, and a Mallory-Weiss tear.
- Following the birth of a healthy baby, the nurse allows bonding time between the infant and its mother. Before mother and infant leave the delivery room, what must be done?
- The nurse must instill medication into the infant's eyes
- Mother and infant must have identical ID tags in place
- All instruments and supplies must be counted
- The time of birth and Apgar scores must be documented
Correct answer: Mother and infant must have identical ID tags in place
The top priority is to ensure proper identification of the newborn and birth mother. This must be done before they leave the delivery room. Identical numbers are on each of the ID bands and will be checked every time the mother and baby are together. Some hospitals also provide a matching ID band for the father.
- A 72-year-old female is scheduled for a coronary angiogram in the morning. When the nurse does post-procedure teaching, which instruction should be included?
- The client will be on bedrest with bathroom privileges
- The client will remain NPO for 8 hours post-procedure
- The client's leg must be kept straight for 8-12 hours post-procedure
- The client can expect oozing of blood at the puncture site
Correct answer: The client's leg must be kept straight for 8-12 hours post-procedure
An angiogram (also known as an arteriogram) is an X-ray of the arteries and veins, used to detect blockage or narrowing of the vessels. The procedure involves inserting a catheter into an artery in the leg and injecting a contrast dye, making the vessels visible on the X-ray. Complete bedrest is prescribed for 8-12 hours after the procedure, keeping the leg with the puncture site straight. NPO is maintained before the angiogram; the client may eat as soon as safely possible.
- After a client has had major surgery, the nurse provides information about the client's condition to a visitor whom the nurse believes is a family member. Later, the nurse finds out that the visitor is not a relative. Which legal violation has occurred?
- Negligence to provide appropriate care
- Disregard of the client's right to privacy
- Failure to follow the chain of command
- Responsibilities beyond the scope of duty
Correct answer: Disregard of the client's right to privacy
Providing information about a client's medical status without the client's permission violates the client's right to privacy and confidentiality. It also puts the nurse and the institution in legal jeopardy. The other options are incorrect.
- When assisting a conscious client who is choking, which of the following actions would be INCORRECT?
- Ask the client if they are choking and say that help is here.
- Swipe the client's mouth with one finger
- Thrust quick, hard, and upward on the client's stomach
- Assist the client to a standing position
Correct answer: Swipe the client's mouth with one finger
DO NOT swipe the client's mouth with one finger. This could push the blockage farther into the airway. The other actions are appropriate and correct.
- A 52-year-old client with a 30-year history of alcohol abuse has been diagnosed with cirrhosis of the liver and esophageal varices. To avoid rupturing the varices, which should the client avoid?
- Taking acetaminophen
- Becoming constipated
- Walking outdoors
- Losing weight
Correct answer: Becoming constipated
Valsalva maneuvers (straining at stool, vomiting, and coughing) can increase intrathoracic and variceal pressure. Weight loss can improve a fatty liver and reduce risk. Acetaminophen (Tylenol) is preferred over NSAIDs such as ibuprofen; the client should follow the provider's orders. Moderate-to-vigorous exercise should be avoided, but walking is beneficial for wellbeing.
- Which is the MOST appropriate position for a client admitted with increased intracranial pressure (ICP)?
- Lateral recumbent position with no pillow
- Head of bed (HOB) at 30 degrees, head in neutral position
- Supine position with legs elevated on pillows
- Low Fowler's with head turned to the side
Correct answer: Head of bed (HOB) at 30 degrees, head in neutral position
The nurse must be careful to prevent an elevation of the ICP. The head of the bed (HOB) should be not be above 30 degrees, and the head should be maintained in a neutral position. The other positions can increase ICP by impeding cerebrospinal fluid drainage.
- An experienced RN is observing a new graduate nurse perform dressing changes with transparent film. Which dressing change will cause the experienced RN to intervene?
- Using the film to secure an elbow dressing
- Covering a Stage I pressure ulcer
- Applying the film to a third-degree burn
- Protecting a client's heels from friction
Correct answer: Applying the film to a third-degree burn
Transparent film dressing has a porous adhesive layer that lets oxygen pass through to the wound and moisture vapor escape from the wound. Transparent film dressings are indicated for partial-thickness wounds, Stage 1 and Stage Il pressure ulcers, superficial burns, and donor sites. A transparent film dressing can also be used as a secondary dressing to cover or secure a primary dressing. Transparent film dressings are NOT used on third-degree burns. Advantages of transparent film dressings: It's easy to visualize the wound; the dressing doesn't have to be removed when you examine the wound. The dressing's flexible shape allows use at elbows, knees, etc. Transparent film is impermeable to external fluid and bacteria, promotes autolytic debridement, and prevents or reduces friction. Disadvantages of transparent film dressings: They may stick to some wounds and cause pain when removed. Also, most transparent dressings don't absorb moisture and aren't indicated for draining wounds.
- A nasal cannula can be used to deliver oxygen from 1-6 L/min. What is the fraction of oxygen delivered (FiO2) at 2 L/min?
Correct answer: 28%
Room air is 21% oxygen. Every increase of 1 L/min (LPM) raises the Fraction of Inspired Oxygen (FiO2) by 4%, starting from 24% at 1 L/min. At 2 L/min: 24%+4%=28%. FiO2 via nasal cannula → 1 L/min: 24%; 2 L/min: 28%; 3 L/min: 32%; 4 L/min: 36%; 5 L/min: 40%; 6 L/min: 44%.
- A noninvasive method of measuring ventilation and perfusion that is considered more accurate than pulse oximetry is
- Arterial blood gas
- Blue spectroscopy
- Anoximeter
- Capnography
Correct answer: Capnography
Capnography is a monitoring method that measures the concentration of carbon dioxide in exhaled air and displays a numerical readout and waveform tracing. Commonly used during anesthesia procedures, it is increasingly used by EMS and in acute settings to evaluate the success of resuscitative efforts, to confirm clinical death, and to analyze causes of respiratory distress. Capnography is increasingly preferred over pulse oximetry for its superior accuracy while measuring alveolar ventilation and gas exchange. Arterial blood gas is an invasive method. There is no such thing as an anoximeter. Red and near-infrared spectroscopy is used to measure hemoglobin 02 saturations, pulse oximetry uses this method.
- For a client with asthma, which of the following is MOST important to self-monitor every day?
- Respiratory rate
- Breathing effort
- Pulse oximetry
- Peak air flow
Correct answer: Peak air flow
Peak flow measurement with a peak flow meter is useful for people with asthma. During an asthma flare-up, the large airways in the lungs slowly narrow. This slows the speed of air moving through the lungs. A peak flow meter can detect the narrowing of the airways about 24 hours before an asthma attack happens. The other three assessments are useful but don't predict an exacerbation of asthma.
- A patient diagnosed with type 2 diabetes mellitus is admitted to the medical unit with pneumonia. The patient's oral antidiabetic medication has been discontinued, and the patient is now receiving insulin for glucose control. Which of the following statements best explains this change in medication?
- Insulin administration will help prevent hypoglycemia during the illness.
- The infection has compromised beta cell function, so the patient will need insulin from now on.
- Stress-related states such as infections increase the risk of hyperglycemia.
- Acute illnesses like Pneumonia will cause increased insulin resistance.
Correct answer: Stress-related states such as infections increase the risk of hyperglycemia.
Infections cause a stress response in the body by increasing the amounts of such hormones as glucocorticoids and epinephrine, which suppress the natural immune response. These stress hormones work against insulin and cause an increase in blood glucose levels. With high glucose levels, white cells are slowed and take longer to fight the infection. Type 2 diabetics may temporarily require insulin during acute illnesses and hospitalizations, but they often return to their normal medication regimen after they recover. Insulin injections also permit more accurate control of glucose levels than oral medications.
- A patient receiving vancomycin has an order for a trough level to be drawn. When should the lab collect the blood sample?
- 1 hour before the infusion
- 30 minutes after the infusion
- 30 minutes before the infusion
- 1 hour after the infusion
Correct answer: 30 minutes before the infusion
A trough level should be drawn 30 minutes before the third or fourth dose. The other answers are incorrect times to draw blood levels. Vancomycin is indicated for serious gram-positive bacterial infections, so it is important to monitor dosage levels. The typical trough level range for vancomycin is 10-20 ug/mL. The reference range for peak levels is 25-50 ug/mL.
- All of the following are equivalent to 25% EXCEPT
Correct answer: 25
A percentage is a number that is expressed as a fraction of 100, or parts per 100. Percentages are used in medicine in several ways, including IV solutions (such as Sodium Chloride 0.9%), injectable medications (such as lidocaine hydrochloride 2%), and calculations of an infant's weight loss or gain.
- A 10-year-old girl is diagnosed with Type 1 diabetes. Her endocrinologist orders both a short-acting insulin and an intermediate-acting insulin. Which of the following is an intermediate-acting insulin?
- Lispro (Humalog)
- Regular (Humulin R)
- Glargine (Lantus)
- NPH (Novolin N)
Correct answer: NPH (Novolin N)
Lispro (Humalog) is a rapid-acting insulin that starts to work in about 15 minutes, peaks in 1 hour, and lasts 2-4 hours. Regular (Humulin R, Novolin R) insulin is a short-acting insulin that starts to work in about 30 minutes, peaks in 2-3 hours, and lasts 3-6 hours. NPH (Humulin N, Novolin N) is an intermediate-acting insulin that starts to work in about 2-4 hours, peaks in 4-12 hours, and lasts 12-18 hours. Long-lasting insulins (Levemir, Lantus) start to work within a few hours and help lower blood glucose levels for up to 24 hours.
- A client is transported to the Emergency Department after sustaining 30% full-thickness burns on the torso and arms. Which IV fluid can the nurse expect to administer?
- Normal Saline
- Lactated Ringer's
- 5% Dextrose in Water
- 0.45% Saline
Correct answer: Lactated Ringer's
Lactated Ringer's (LR) solution is often administered during the first 24 hours for burns, because it is similar to the extracellular fluid that shifts following the injury. LR contains physiologic concentrations of major electrolytes, and lactate may reduce the incidence of hyperchloremic acidosis that can occur with administration of large volumes of isotonic saline (i.e., 0.9 percent sodium chloride). D5W and 0.45% NS are not used in fluid resuscitation post-burn trauma.
- What is the bioavailability of a medication that is administered by the intravenous (IV) route?
Correct answer: 100%
Bioavailability is the proportion of the administered drug that reaches the circulatory system and is available for its intended site and purpose. Because intravenous drugs enter the bloodstream directly, their bioavailability is 100%. In non-intravenous administration, other factors influence how much of a drug must be given to attain an optimal outcome. Examples are drug formulation, how the drug is absorbed, whether the stomach is empty, interactions with other drugs or food, and the client's status (age, gender, organ function, etc.).
- The nurse is educating a client with cardiac heart disease about the client's new prescription for nitroglycerin ER 2.5 mg PO tid. Which statement by the client would indicate a lack of understanding about the medication?
- I'll take these on a regular daily schedule.
- A headache means the medication is working.
- I must swallow this medication whole.
- When I feel chest pain, I'll take a capsule.
Correct answer: When I feel chest pain, I'll take a capsule.
Nitroglycerin ER (extended-release) capsules are taken daily to prevent angina in people with coronary artery disease. The nurse should explain that PO nitroglycerin does not relieve chest pain once it occurs. It is also not intended to be taken just before physical activities (such as exercise or sexual activity) to prevent chest pain. The capsules are taken 3 or 4 times a day, at the same times each day. They are taken whole; crushing could release too much nitroglycerin. Headache is often a sign that this medication is working. Typical dosage for an adult is 2.5 to 6.5 mg, 3 or 4 times a day.
- While teaching a client with hypertension about taking a thiazide diuretic, which statement by the nurse is correct?
- Stop taking this medication if you start to urinate frequently.
- With this medication, you'll need to eat foods that have potassium.
- I'll teach you how to count your pulse before taking this medication.
- Take this medication at dinner with a large glass of water.
Correct answer: With this medication, you'll need to eat foods that have potassium.
Thiazide diuretics increase sodium (Na) delivery to the distal tubules of the kidney, which also increases the loss of potassium (K). Clients should be instructed to eat plenty of potassium-rich foods, such as bananas, oranges, cantaloupe, cooked spinach, and many types of beans. Diuretics are taken in the morning, so the client can urinate while awake. The other two options are incorrect.
- When a health care provider (HCP) prescribes alprazolam for a client, what effect should the nurse tell the client to expect?
- Improves ability to focus and retain information
- Decreases symptoms of neuropathy
- Reduces feelings of depression
- Increases a sense of calm and relaxation
Correct answer: Increases a sense of calm and relaxation
Alprazolam (Xanax) is a benzodiazepine used to treat anxiety and panic disorders. It works by enhancing the effects of gamma-aminobutyric acid (GABA), a natural chemical in the body. Alprazolam is the single most prescribed psychiatric medication in the United States. The medication will not increase coordination or the ability to concentrate and remember. Nor will it alleviate symptoms associated with peripheral nerve damage, such as tingling and numbness. Alprazolam can be prescribed off-label for depression, but this is not recommended because alprazolam is highly addictive and there are more effective medications for treating depression.
- A client who has been receiving a transfusion of packed red blood cells (PRBC) for 3 hours tells the nurse that they are experiencing shortness of breath and an itchy, raised rash. The nurse also notes that the client is anxious and restless. Which type of transfusion reaction does the nurse suspect?
- Febrile transfusion reaction
- Allergic transfusion reaction
- Hemolytic transfusion reaction
- Delayed transfusion reaction
Correct answer: Allergic transfusion reaction
This client is experiencing an allergic transfusion reaction, characterized by dyspnea, wheezing, and urticaria (hives). A hemolytic transfusion reaction is indicated by fever, chills, chest pain, hypotension, and tachypnea. Signs and symptoms of a febrile transfusion reaction include fever, chills, and headaches; this is a non-hemolytic reaction. A delayed hemolytic reaction occurs at least 24 hours (typically 2-10 days) after a transfusion, due to alloimmunization from a previous transfusion.
- A client is prescribed glipizide (Glucotrol) 5 mg every morning. The nurse educates the client that the purpose of this medication is
- To promote urination
- To reduce hypertension
- To reduce blood glucose
- To promote weight loss
Correct answer: To reduce blood glucose
Glipizide (Glucotrol) is an oral diabetes medication that helps control blood sugar levels by stimulating the pancreas to produce insulin. Glucotrol is used together with diet and exercise to improve blood sugar control in adults with type 2 diabetes mellitus. In general, the starting dose is 5 mg taken daily, 30 minutes before breakfast. Glucotrol is not for treating type 1 diabetes.
- A client weighing 165 lb is admitted with a diagnosis of deep vein thrombosis (DVT). The health care provider (HCP) prescribes an initial heparin bolus of 80 units/kg. How many units will the nurse administer?
- 2700 units
- 176 units
- 610 units
- 6000 units
Correct answer: 6000 units
The nurse will administer 6,000 units of heparin. To calculate: 1. Convert 165 lb to kg (2.2 lb/kg165 lb=75 kg). 2. Multiply by the ordered dose: 75 kg×80 units/kg=6,000 units.
- A post-operative client has a prescription for hydromorphone 0.015 mg/kg IM q 34 hr PRN for pain. The client weighs 156 pounds. Pharmacy sends a vial of hydromorphone with 4 mg/mL. How much will the nurse draw up and administer for this client? Round final answer to two decimal places.
- 1.71 mL
- 0.28 mL
- 0.82 ml
- 3.63 mL
Correct answer: 0.28 mL
The nurse should draw up and administer 0.28 mL of hydromorphone. Use the formula dose on handdesired dose×vehicle. 1. Convert weight: 2.2 lb/kg156 lb=70.9 kg, round to 71 kg. 2. Find the dose: 71 kg×0.015 mg/kg=1.065 mg, round to 1.1 mg. 3. Apply the formula: 4 mg/mL1.1 mg=0.275 mL, round to 0.28 mL.
- A client with a diagnosis of aspiration pneumonia started intravenous (IV) antibiotic therapy eight hours ago. When the nurse enters the client's room to perform a respiratory assessment, the nurse notes an unpleasant odor in the room. Which comment by the client BEST indicates that a complication has developed?
- I've been sweating all day long
- My chest hurts when I take deep breaths
- I'm coughing up thick, brown sputum
- The diarrhea is really bothering me
Correct answer: I'm coughing up thick, brown sputum
The foul smell and client's statement about a productive cough with thick, brown or pus-like secretions can indicate a lung abscess. Most lung abscesses develop after aspiration of oral secretions by patients with gingivitis or poor oral hygiene. Typically, patients have altered consciousness as a result of alcohol intoxication, illicit drugs, anesthesia, sedatives, or opioids. The other options are typical pneumonia symptoms. Antibiotic treatment was initiated only 8 hours earlier. Clients with pneumonia may not begin to feel better until 3-5 days after starting antibiotic therapy.
- A healthcare provider is assisting during the insertion of a pulmonary artery catheter. Which of these, if assessed in the patient, would indicate the patient is experiencing a complication from the catheter insertion?
- Diaphragmatic excursion of 3 cm
- Inspiration phase greater than expiration
- Tracheal deviation from midline
- Vesicular breath sounds noted on auscultation
Correct answer: Tracheal deviation from midline
Tracheal deviation from midline is associated with a tension pneumothorax, a potential complication associated with central line insertion. It is caused by a collection of air between the chest cavity and the lung. The inspiration phase is normally greater than expiration, but it may also be noted in pneumothorax. Vesicular breath sounds are a normal finding. Diaphragmatic excursion of 3 cm is a normal finding.
- For a patient in the late stages of chronic bronchitis, which of the following would indicate the patient has developed cor pulmonale?
- Hypocapnia
- Hepatomegaly
- Night sweats
- Venous stasis ulcers
Correct answer: Hepatomegaly
Cor pulmonale, or right-sided heart failure, is the result of a lung condition such as chronic bronchitis or COPD. The diseased lungs deliver less oxygen to the right ventricle, putting a strain on the heart from pulmonary hypertension. Over time, the right ventricle fails, causing increased venous pressure and liver enlargement (hepatomegaly). Common early symptoms include fatigue, tachypnea, shortness of breath on exertion, and cough.
- The nurse is educating a client about their scheduled procedure to insert an inferior vena cava (IVC) filter. Which of the following teaching points is INCORRECT?
- The IVC filter will be replaced every six months
- The procedure is done in a same-day surgical center
- Anticoagulant medication will be discontinued
- The IVC insertion procedure is safe and effective
Correct answer: The IVC filter will be replaced every six months
An inferior vena cava (IVC) filter is a type of vascular filter, a medical device that is implanted into the inferior vena cava to prevent life-threatening pulmonary emboli (PEs). Although an IVC can be left in permanently, some providers will remove it when the associated medical issue is resolved. Anticoagulants can usually be discontinued. Although every procedure has risks, IVC insertion is considered safe and effective. The procedure is done without general anesthesia, usually as an outpatient procedure or in a same-day surgical center
- The nurse enters a client's room and finds the client on the floor, with their arm at an awkward angle. The nurse suspects the arm may be broken. What is the nurse's FIRST action?
- Immobilize the client's arm
- Take a full set of vital signs
- Assist the client back to bed
- Notify the radiology department
Correct answer: Immobilize the client's arm
Whether a client is in the healthcare setting or the community, always immobilize the suspected break or fracture first. Call or phone for assistance before moving the client. Vital signs should be taken but not as the first action. If in the hospital, notify the client's provider. If the client is a visitor or in a community setting, notify emergency services.
- The ICU nurse assists with the insertion w of a pulmonary artery catheter for a client with a myocardial infarction (MI). The health care provider (HCP) orders monitoring of the pulmonary artery pressure and pulmonary wedge pressure. What is the purpose of these measurements?
- To evaluate the client's post-Ml prognosis
- To monitor any changes in acid-base balance
- To measure stability of the coronary arteries
- To assess left ventricular end-diastolic pressure
Correct answer: To assess left ventricular end-diastolic pressure
A pulmonary artery catheter is used to obtain hemodynamic measurements which, together with clinical observations, indicate how efficiently the heart is functioning. It's indicated for assessment of shock, cardiovascular function, pulmonary function, hemodynamic function, fluid requirements and balance, and multiorgan failure. The pulmonary artery pressure assesses the heart's ability to receive and pump blood. Normal pulmonary artery pressure is 8–20 mmHg at rest. If the pressure in the pulmonary artery is greater than 25 mmHg at rest or 30 mmHg during physical activity, it is abnormally high and is called pulmonary hypertension. The pulmonary capillary wedge pressure assesses left ventricular end-diastolic pressure.
- A client in the ICU has a Swan-Ganz W catheter in place. When the nurse assesses the client's hemodynamics, which of the following values is abnormal?
- Pulmonary capillary wedge pressure 8 mmHg
- Cardiac output 3 L/min
- Pulse pressure 50 mmHg
- Central venous pressure 4 mmHg
Correct answer: Cardiac output 3 L/min
A Swan-Ganz catheter (pulmonary artery catheter) is placed into the right side of the heart and the arteries leading to the lungs. It is done to monitor the heart's function and blood flow and pressures in the pulmonary artery. Cardiac output is the amount of blood that the heart is able to pump in one minute. This client has a low cardiac output; the problem is that the heart isn't pumping out enough blood (low stroke volume), resulting in heart failure. Normal values are as follows. Cardiac output: 4-8 L/min; central venous pressure (CVP): 2-6 mmHg; pulmonary capillary wedge pressure: 4–12 mmHg. The pulse pressure is the difference between systolic and diastolic blood pressures; the normal range is 40-60 mmHg. It is not a Swan-Ganz measurement.
- A 17-year-old comes to the OB/GYN clinic because she is worried she might be pregnant. After an initial discussion and assessment, the nurse measures the client's fundus and finds it at the level of the umbilicus. The nurse tells the client,
- You're about 20 weeks pregnant
- You aren't pregnant
- You're about 10 weeks pregnant
- You're about 30 weeks pregnant
Correct answer: You're about 20 weeks pregnant
At 20 weeks' gestation, the fundus is at the level of the umbilicus. At 10 weeks, it is at or slightly above the symphysis pubis, about where pubic hair begins. At 30 weeks, the fundus is about 10 cm above the umbilicus. After 20 weeks, the fundus height correlates with the number of weeks of gestation. This client is about 5 months pregnant.
- After a provider diagnoses a client with choledocholithiasis, the client asks the nurse, "I know I have stones, but where are they?" The nurse explains to the client that the stones are located in the
- Salivary glands
- Common bile duct
- Gallbladder
- Kidneys
Correct answer: Common bile duct
Choledocholithiasisis is the term for the presence of stones in the common bile duct. The medical term for salivary stones is sialoliths. Cholelithiasisis is the term for the presence of stones in the gallbladder. Nephrolithiasis refers to kidney stones (renal calculi).
- EMS transports a client who fell from the roof. On arrival at the Emergency Department, the nurse performs an assessment. Which finding is most indicative of a serious head injury?
- Because of pain, the client does not want to move
- The client complains of a severe, throbbing headache
- The client can't recall any events regarding the fall
- The client has serous fluid draining from the ears
Correct answer: The client has serous fluid draining from the ears
The most crucial finding is the clear (serous) fluid draining from the client's ears, indicating a tear in the meninges and a risk of infection. The fluid is cerebrospinal fluid. The other findings should be attended to, but they are not the priority.
- The nurse is caring for a patient who was admitted with a diagnosis of deep vein thrombosis. The provider orders heparin infusion therapy. After 24 hours, the nurse reviews the patient's partial thromboplastin time (PTT) and notes a result of 70 seconds with a control of 30 seconds. Which is the nurse's most appropriate action?
- Document the PTT in the patient's medical record
- Administer protamine sulfate as ordered
- Discontinue the heparin infusion immediately
- Notify the provider of the patient's PTT result
Correct answer: Document the PTT in the patient's medical record
The range for therapeutic anticoagulation is 1.5-2.5 times the control. For this patient, the range is 45-75 seconds, so no action by the nurse is necessary.
- A mother takes her 11-year-old daughter to the clinic. She is concerned because the girl is always tired and thirsty. The girl has a good appetite but is losing weight, and she has started urinating frequently. Which laboratory assessments can the nurse anticipate?
- ECG and stress test
- Serum glucose and A1c
- Urine culture and sensitivity
- Complete blood count
Correct answer: Serum glucose and A1c
The daughter is displaying signs and symptoms of Type 1 diabetes (T1D) and will require measurements of serum glucose and A1c levels. The most common symptoms of T1D are polyuria, polydipsia, and polyphagia, along with fatigue, nausea, and blurred vision. All are related to hyperglycemia. Polyuria is caused by osmotic diuresis secondary to hyperglycemia. The other assessments are not indicated.
- A pregnant client experiences a spontaneous rupture of membranes at 36 weeks' gestation. She is admitted to labor and delivery. What is the nurse's first action?
- Obtain maternal vital signs
- Prepare for precipitate delivery.
- Notify the client's obstetrician
- Measure the fetal heart rate
Correct answer: Measure the fetal heart rate
Following the rupture of membranes, the fetus is at greater risk of complications than the mother is, so the nurse should start by assessing the fetal heart rate. After assessing the mother and stage of labor, the nurse can notify the provider. There is no evidence of a precipitate delivery.
- Before touching a crying client to offer comfort, the nurse should consider
- Whether the client's family should be notified
- The client's recent vital signs
- The client's cultural background
- Whether the client has been sad recently
Correct answer: The client's cultural background
Western culture uses therapeutic touch as a way to offer support or comfort, but other religions or cultures may consider it a violation of privacy. For example, Asians or Muslims do not welcome touch by strangers or by someone of the opposite gender. When in doubt, ask for permission or be conservative in your approach.
- The children of a patient diagnosed with Alzheimer's disease (AD) tell the healthcare provider, "Our mother seems better during the day, but she gets very confused and agitated in the late afternoon and evenings." How should the healthcare provider document the patient's behavior?
- Sundowning
- Delirium
- Depression
- Psychosis
Correct answer: Sundowning
This patient is experiencing sundowning or sundowners syndrome (also called "late-day confusion"), a phenomenon prevalent in patients diagnosed with dementia. Sundowning may be associated with impaired circadian rhythms, impaired cognition, and environmental or social factors. The patient may also start pacing or wandering, or become aggressive.
- A pediatric nurse is caring for a 9-year old girl with a known history of having been abused. Which therapeutic action should the nurse include in the child's care plan?
- Ensure that the care setting allows the child to redevelop trust
- Encourage the child to identify potential abusive settings
- Ask the child to call the nurse if the abuser visits the unit
- Instruct the child on typical characteristics of abusers
Correct answer: Ensure that the care setting allows the child to redevelop trust
An abused child will require long-term support and therapy, starting with an environment of safety, security, and empathy. The nurse can model appropriate behavior while giving care.
- Which of the following alterations in sensory function is normal for an elderly client?
- Decreased sensitivity to bright light
- Increased ability to taste spices
- Decreased chronic pain perception
- Increased sound discrimination
Correct answer: Decreased chronic pain perception
As people age, the perception and reporting of chronic pain decreases after the seventh decade. Studies show that many elderly people believe that chronic pain is a natural part of aging, and they consider pain less serious than other life events, such as loss of a spouse or independence. Acute pain remains consistent across all age groups. In general, the aging process causes the sense of taste to diminish because of reduction in the number of taste buds and shrinkage of those that remain. The sense of smell also decreases, which compromises both smell and taste. Eyes become more sensitive to glare and harder to adapt to darkness. Hearing and balance are also affected because of changes in the auditory nerves.
- After a client learns that they sustained a C7 spinal cord injury due to trauma, the client tells the nurse, "I wish I were dead. I'm useless to everyone." What is the nurse's MOST therapeutic response?
- You are feeling a sense of hopelessness now
- Don't say that. It makes me very sad.
- I'll ask your doctor to send a therapist
- I'm sure you still have a lot to offer others
Correct answer: You are feeling a sense of hopelessness now
The nurse should reflect the client's feelings, so the client can continue to talk about their situation. Restating the client's words is a validation technique. The other statements are nontherapeutic; they shut off the client's feelings, offer a quick solution, or turn the conversation back to the nurse. A C7 spinal cord injury will result in quadriplegia, paralysis of the arms, trunk, and legs. However, because the C7 segment is farther down the cervical region of the spinal cord, the majority of arm functions will remain intact.
- A patient is admitted to an inpatient psychiatric unit because of their plan to commit suicide by taking an overdose of medication. When a healthcare provider administers medications to this patient, which of these interventions is the priority?
- Make sure that the patient is not "cheeking" the medications
- Monitor the patient's vital signs before administering the medications
- Monitor the patient for signs of anorexia, nausea, and xerostomia
- Teach the patient how to recognize adverse effects of the medications
Correct answer: Make sure that the patient is not "cheeking" the medications
A patient who has suicidal ideation, especially by overdosing on medications, should be monitored for "cheeking." Cheeking means hiding the medication in the mouth with the intention of hoarding it, so it can be used in another suicide attempt.
- A client tells the mental health nurse that they have suddenly stopped taking their prescribed fluoxetine because of the side effects, especially the insomnia. What should the nurse do FIRST?
- Ask the provider to lower the dose
- Provide behavioral therapy referrals
- Initiate admission to an inpatient facility
- Assess the client for risk of suicide
Correct answer: Assess the client for risk of suicide
The nurse should assess the client for risk of suicide. Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI). SSRIs are generally thought to treat depression by blocking the reuptake of serotonin in the brain. Stopping the medication abruptly can cause severe anxiety or depression, putting the client at risk for self-harm. Withdrawal symptoms include: irritability, nausea, vomiting, dizziness, headaches, nightmares, and paresthesias, although fluoxetine is the least likely of the SSRIs to cause withdrawal symptoms, because of it's long halflife, the nurse should carefully assess the client for all symptoms, including suicidal ideation. Close observation and assessment are especially important during the first few months of SSRI therapy and whenever antidepressant dosage is changed (either increased or decreased).
- After visiting his father in the Alzheimer's unit, the adult son finds the nurse and says, "I'm so excited! Dad's been telling me stories about growing up. I think his memory is returning!" What is the nurse's best response?
- He still has long-term memory, so that's what he talks about
- I'm so glad you were able to be here for those wonderful stories
- I'm so glad you told me. I'll let the doctor know right away
- Yes. We listen to him all day long, repeating the same thing
Correct answer: He still has long-term memory, so that's what he talks about
The progression of Alzheimer's disease can confuse family members. The client's ability to relate a long-term memory may make it seem as if the client is improving. The nurse should remind family members of the true situation and not provide false hope.
- Which of the following statements best explains the role of the nurse when the nurse is planning care for a culturally diverse population?
- Focus only on the needs of each client demographic, ignoring the nurse's beliefs and practices
- Blend the values of the nurse that are for the good of the client and minimize the client's individual values and beliefs during care
- Include care that is culturally congruent with the staff from predetermined national data
- Provide care while remaining aware of one's own biases, focusing on the client's individual needs rather than the staff's usual practices
Correct answer: Provide care while remaining aware of one's own biases, focusing on the client's individual needs rather than the staff's usual practices
The nurse must remain aware of their own beliefs and values. Otherwise, the nurse's biases or preconceived notions might create an unexpected conflict or an area of neglect in the plan of care for a client (who might be expecting something totally different from the care). During assessment, the nurse should identify the client's values, beliefs, and practices and use them as a guide when making choices to meet the client's needs and outcomes. Identification of values, beliefs, and practices allows for planning meaningful and beneficial care specific to the client.
- The best therapeutic action for a client with organic brain syndrome is to
- Maintain a safe, consistent environment
- Encourage long visits by the family
- Provide sudoku and word search games
- Give detailed explanations of activities
Correct answer: Maintain a safe, consistent environment
Organic brain syndrome is a term used to define dementia or other brain diseases that have a physiological cause, as contrasted with conditions that are psychiatric. Care and actions are the same as for any client with dementia or Alzheimer's disease. Client safety and a sense of security are the priorities.
- A client is brought by his friends to the Emergency Department. They tell the nurse that he has been shouting, "I am God!" The nurse knows the client is experiencing
- A hallucination
- An effusion
- An illusion
- A delusion
Correct answer: A delusion
Delusion is a false belief. Hallucination is a false sensory perception involving any of the senses. Illusion is the misrepresentation of a real, external sensory experience. Effusion is a non-psychiatric term, meaning giving off a light, smell, or liquid.
- In Maslow's Hierarchy of Needs, which stage is the most fundamental?
- Belonging
- Safety
- Esteem
- Physiological
Correct answer: Physiological
In Maslow's Hierarchy of Needs, the biological essentials for human survival must be met first: air, food, drink, shelter, clothing, warmth, and sleep. Once these are met, the next level is safety, then love and belonging, followed by esteem. The final level is self-actualization.
- According to Erikson's stages of psychosocial development, which intervention is most appropriate for a hospitalized 16-year-old?
- Restrict visitors to the teen's best friend
- Request the hospital chaplain to stop by
- Ask parents to assist with missed homework
- Encourage friends to visit the teen at the hospital
Correct answer: Encourage friends to visit the teen at the hospital
In Erikson's Identity vs. Role Confusion stage, at about 12-18 years of age, adolescents learn a sense of self and independence. Their most significant social relationships are with their peers. Parents and adults have influence, but friends, social groups, and societal trends help shape the adolescent's identity.
- When you prepare a checklist for an older adult who is learning to do self catheterization, which action is most helpful?
- Write at a high school reading level
- Include charts and graphs
- Print material in a fun and colorful font
- Use short words and sentences
Correct answer: Use short words and sentences
When planning education or writing instructions for an elderly client, keep information as simple as possible. Use short words, sentences, and paragraphs. Write at a fifth-grade level, and avoid medical jargon. Formatting should include a large font that is easy to read. Charts or graphs are unnecessary and can lead to confusion.
- During a routine checkup, the nurse assesses a 76-year-old female whose husband died seven months ago. Which statement would indicate ineffective coping on her part?
- I've gone back to my craft club at the Senior Center
- I've been going to visit his grave every month
- I've been sorting through our old family photos
- I've had no interest in how I look or what I wear. Why bother?
Correct answer: I've had no interest in how I look or what I wear. Why bother?
Coping mechanisms are behaviors used to decrease stress and anxiety. Following a death, grief is normal. However, ineffective coping can lead to depression and inability to care for oneself or make good decisions. The nurse should ask about the client's support system and resources. The other responses are all appropriate.
- What is the best way to educate a 10year-old girl about her upcoming heart surgery?
- Use a model of the heart to show her how the surgery will go
- Give her a booklet to read about the surgery
- Introduce her to another child who just had the same surgery
- Provide a verbal explanation just prior to the surgery
Correct answer: Use a model of the heart to show her how the surgery will go
According to Piaget, the school-age child is in the concrete operational stage of development (6-12 years of age), which is the beginning of logical thinking. Using something concrete, such as a life-size model, will help the child better understand the explanation of the heart surgery.
- A multiparous client at 16 weeks' gestation is diagnosed as having a fetus with probable anencephaly. The client is fervently pro-life. She decides to continue the pregnancy and donate the neonate's organs after its death. Which of the following actions by the nurse is most appropriate?
- Contact the client's minister to discuss the client's options related to the pregnancy
- Advise the client that a prolonged neonatal death will be very painful for her
- Explore their own feelings about the issues of anencephaly and organ donation
- Ask the client and her husband if they have discussed this decision with the family
Correct answer: Explore their own feelings about the issues of anencephaly and organ donation
Anencephaly is a neural tube defect that is not compatible with life, although some neonates live for several days before death occurs. If the client decides to carry the fetus to term, the nurse should remain nonjudgmental. The nurse should explore their own feelings. The nurse should not contact a minister. (The client has probably discussed the decision with the clergy already.) Describing the demise of the infant is neither helpful nor accurate; death may occur immediately. Contacting the family is not within the nurse's domain. The parents may wish to be confidential and private.
- A new mother is resting after an uncomplicated delivery of a healthy newborn. When a nurse assesses the mother's heart rate, which of the following is typical?
- Tachycardia
- Thready pulse
- Bradycardia
- Bounding pulse
Correct answer: Bradycardia
Puerperal bradycardia with rates of 50-70 bpm commonly occurs during the first 6-10 days of the postpartum period. It may be related to decreased cardiac strain, decreased blood volume, contraction of the uterus, and increased stroke volume. Tachycardia is not typical in postpartum. A thready pulse is a scarcely perceptible and often rapid pulse; it is often present with excessive blood loss and hypotension. A bounding pulse feels strong and throbbing; it can be related to several things, including anxiety, overexertion, or heart failure.
- A nurse is instructing a 46-year-old primigravid client prior to a percutaneous umbilical blood sampling (PUBS) procedure. When the client asks why, the nurse explains that it will
- Assess fetal lung maturity
- Measure the alpha-fetoprotein level
- Diagnose a multiple pregnancy
- Diagnose genetic disorders
Correct answer: Diagnose genetic disorders
Percutaneous umbilical blood sampling (also called cordocentesis) is performed to determine Rh disease, to test fetal CBC, and for karyotyping chromosomes to detect genetic disorders. It can be done after week 18. It is different from amniocentesis because it does not screen for neural tube defects. However, results are available in a few days, compared with a few weeks for amniocentesis.
- When a mother enters the playroom of the pediatrics unit to visit her three-year-old son, he does not immediately go to her. What is the reason for his behavior?
- The child is angry and withdrawn
- The child has become self-centered
- The child has adapted to the hospital setting
- The child is displaying normal behavior
Correct answer: The child is displaying normal behavior
When young children are separated from their parents, the phases they go through include protest, despair, and denial or detachment. In the stage of protest, when the parents return, the child readily goes to them. In the despair stage, the child may not readily approach them, or may cling to a parent. In denial or detachment, when the parents return, the child is cheerful and interested in the environment and new people. The child may even be unaware of the parents, while being friendly toward the staff.
- The nursing instructor is observing a student assigned to a postpartum client with a diagnosis of human immunodeficiency virus (HIV). As the student assists the client in caring for her infant, which action by the student requires the instructor to intervene?
- The student helps the baby latch on to the mother's breast
- The student places the baby on its back after the mother holds the baby
- The student wears clean gloves to change the baby's soiled diaper
- The student folds the diaper below the baby's umbilical stump
Correct answer: The student helps the baby latch on to the mother's breast
Mother-to-child transmission can occur during pregnancy, birth, or breastfeeding. In the United States, where mothers have access to clean water and affordable replacement feeding (infant formula), CDC and the American Academy of Pediatrics recommend that HIV-infected mothers completely avoid breastfeeding their infants regardless of antiretroviral therapy (ART) and maternal viral load. Wearing gloves is a standard precaution when dealing with body fluids and excretions. The umbilical stump should be kept outside the baby's diaper. To help prevent sudden infant death syndrome (SIDS), the baby should be placed on its back to sleep.
- A nurse is educating the parents of a 9year-old girl who will be undergoing chemotherapy. The nurse explains that alopecia is a side effect. Which statement by the nurse is most appropriate?
- You'll all adapt quickly to her appearance without hair
- She should choose a wig that's similar to her own hair now
- Her hair will fall out gradually, so it won't be noticeable
- Your daughter is too young to worry about losing her hair
Correct answer: She should choose a wig that's similar to her own hair now
It's important for the child to continue looking as much as possible as she always has. A wig will provide her with both a positive appearance and a way to adjust to her hair loss. During chemotherapy, hair often falls out in clumps, creating a patchy baldness that is noticeable. Parents and others close to the child do get used to the baldness, but it can still be disturbing and a reminder of the situation.
- A mother calls the pediatric clinic to report that her three-year-old child has diarrhea. She asks how to manage it at home. What should the nurse suggest?
- Continue the child's usual diet as tolerated
- Clear liquids only for the next 24 hours
- Serve low-fat, low-sodium foods for 2 days
- Switch to bananas, rice, applesauce, and toast
Correct answer: Continue the child's usual diet as tolerated
The American Academy of Pediatrics recommends continuing the child's usual diet to maintain the electrolytes and complex carbohydrates found in a balanced diet. The other options, including the popular BRAT diet (bananas, rice, applesauce, and toast) are lower in electrolytes. The nurse should also ask the mother to describe the diarrhea in terms of frequency and appearance, to determine what the mother means by "diarrhea."
- At a community health fair, a nurse gives a presentation on colorectal cancer. The nurse is asked about prevention and screening. Which statement by the nurse is most accurate?
- At age 50, if you're at average risk, you should get a complete screening every ten years
- You can lower your risk by eating vegetables and foods that are low fiber and high fat
- Adults at low risk should have a colonoscopy and fecal occult blood test every five years
- All adults should begin screening at age 40, regardless of family history
Correct answer: At age 50, if you're at average risk, you should get a complete screening every ten years
Unless there is a personal or family history of colorectal cancer, a regular complete screening (colonoscopy and fecal occult blood testing) can start at age 50. Dietary recommendations include high-fiber and low-fat foods.
- Nurses agree to be advocates for their patients. The practice of advocacy calls for the nurse to
- Document all clinical changes in the medical record every two hours
- Seek out the nursing supervisor to resolve conflicts
- Apply the law to the patient's clinical condition
- Assess the patient's perspective and explain it when necessary
Correct answer: Assess the patient's perspective and explain it when necessary
Nurses always strive to assess and understand their patients. When a nurse can identify a patient's personal values and then accurately describe these values and defend the patient's point of view, the nurse can be a successful advocate.
- A health care provider (HCP) writes a prescription for a client with a new diagnosis of conjunctivitis: "Gatifloxacin solution 1 gtt OD q4H." The client shows the script to the nurse. What is the nurse's BEST action?
- Contact the HCP to clarify and rewrite the prescription
- Educate the client to squeeze one drop into the left eye every 4 hours
- Educate the client to squeeze one drop into the right eye every 4 hours
- Contact the pharmacy to ensure that gatifloxacin is in stock
Correct answer: Contact the HCP to clarify and rewrite the prescription
Abbreviations, symbols, and dose designations can be misinterpreted and lead to medication errors. For example, "OD" can mean either "right eye" (oculus dexter) or "once daily"; it should never be used when communicating medical information. The abbreviation "Q" or "q" should be written out as "every." Although "gtt" is not on the Joint Commission's official "Do Not Use" List, writing out "drop" is recommended. In this case, the nurse should contact the health care provider (HCP) who prescribed the medication and clarify the order. Gatifloxacin ophthalmic solution 0.5% is an anti-infective medication prescribed for conjunctivitis. Contacting the pharmacy is not necessary.
- If a nurse applies a restraint vest without the patient's permission or a physician's order, the nurse may be charged with
- Assault
- Neglect
- Battery
- Invasion of privacy
Correct answer: Battery
Restraining a patient or resident without the person's consent or a doctor's order constitutes battery. Assault is the threat of harm, and battery is the actual action of harm. Battery is a criminal offense. In addition, mechanical restraints may never be applied for staff convenience.
- A client wearing expensive jewelry reports for same-day surgery. What should the nurse tell the client?
- We keep all expensive items in the narcotic box so no one will take them
- We will tape the jewelry to you so it will remain secure during surgery
- We'll put the jewelry in an envelope. We'll both sign it and put it in our safe
- We'll ask the supervisor to hold your jewelry until you're in the recovery room
Correct answer: We'll put the jewelry in an envelope. We'll both sign it and put it in our safe
To ensure the safety of a client's valuables while the client is having a procedure, the nurse should list the items on an envelope, insert the valuables, and seal it. Then both the client and the nurse should sign it before placing the envelope in the safe.
- After completing the interviews for a staff nurse position in a busy medical unit, the nurse manager recognizes that the most qualified candidate has disclosed a need for accommodation related to a sensory impairment. What is the nurse manager's MOST appropriate action?
- Contact the corporate attorney to legally prevent hiring the nurse
- Advise the nurse to apply for a position in a less challenging unit
- Determine what types of accommodation the candidate requires
- Inform the candidate that accommodation for nurses isn't possible
Correct answer: Determine what types of accommodation the candidate requires
The Americans with Disabilities Act (ADA) mandates that individuals with motor, cognitive, psychiatric, or sensory impairment receive equal access to employment opportunities. Employers must evaluate each applicant's ability to perform the job on a case-by-case basis and cannot legally discriminate on the basis of a disability. According to the ADA, "During the application stage, employers are not allowed to ask medical questions and applicants are not required to disclose their disabilities unless they need an accommodation." If the nurse has not disclosed a disability, then "Once an employer makes a job offer, but before the new hire actually starts working, employers can ask any medical questions they want as long as they ask all new employees in the same job category the same questions. At this stage, the new hire must disclose a disability if asked." The other answer options could be illegal and discriminatory. [Technical Assistance Manual for Title I of the Americans with Disabilities Act (ADA), January 1992]
- When a nurse is assigning a task to an unlicensed assistive personnel (UAP), which is the most important factor in the nurse's decision?
- The UAP's strengths and weaknesses
- Where the UAP got their certification
- The UAP's experience in the unit
- Which tasks the UAP prefers
Correct answer: The UAP's strengths and weaknesses
The nurse should consider the UAP'S strengths and weaknesses so that the client can receive the best possible care. A UAP's experience in the unit may not be relevant to the task at hand. Which tasks the UAP prefers and where the UAP got their certification do not factor in to the nurse's decision.
- Which of the following pediatric clients is at the GREATEST risk to develop pediatric acute respiratory distress syndrome (PARDS)?
- A child with a near-drowning experience
- The child with a known congenital heart defect
- The child with a fractured femur
- A child with a sudden fever of 103.4°F (39.7°C)
Correct answer: A child with a near-drowning experience
Pediatric acute respiratory distress syndrome (PARDS) occurs when fluid fills the lungs due to an infection or injury. Acute respiratory distress syndrome (ARDS) is a major complication caused by aspiration of water upon near-drowning, in which permeabilities of the lung alveolar and capillary walls increase, resulting in exudates in the alveoli that cause hypoxia unresponsive to oxygen therapy due to lung injury. While pneumonia can lead to ARDS, a temperature of 103.4 F does not provide enough information to determine if pneumonia is present. Congenital heart defects must be monitored, but this is not the condition most likely to cause ARDS. A leg fracture is a risk for pulmonary embolism, rarely associated with ARDS.
- The nurse is reviewing the health care provider's (HCP) admit orders for a client with a diagnosis of gastroesophageal reflux disease (GERD). The HCP has prescribed omeprazole daily, Maalox a.C., acid-reflux diet, and the bed to be maintained in Fowler's position. Which order should the nurse clarify with the HCP?
- Reason for omeprazole
- Bed position
- Schedule for Maalox
- Prescribed diet
Correct answer: Schedule for Maalox
The nurse should question the order for Maalox before meals; it is usually taken after meals and at bedtime. Omeprazole (Prilosec) is used to treat certain stomach and esophagus problems (such as acid reflux and ulcers). It works by decreasing the production of stomach acid. It relieves symptoms such as heartburn, difficulty swallowing, and persistent cough. This medication helps heal acid damage to the stomach and esophagus, helps prevent ulcers, and may help prevent cancer of the esophagus. Omeprazole belongs to a class of drugs known as proton pump inhibitors (PPIs). It is usually prescribed daily for adults. The other orders do not need to be clarified.
- While transcribing a physician's orders, the unit secretary asks the nurse to decipher an illegible medication order. What should the nurse do?
- Duplicate the previous medication order
- Check the admission record medication list
- Clarify the medication order by asking the pharmacist
- Clarify the medication order by calling the physician
Correct answer: Clarify the medication order by calling the physician
It is always the responsibility of the nurse to accept, verify, and administer orders. For example, the Massachusetts Nurse Practice Act includes the following statement on the topic: "In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse may not implement the order until it is verified for accuracy with a duly authorized prescriber."
- Which of the following is NOT considered protected health information (PHI)?
- Email addresses
- Social Security number
- Driver's license number
- Pedometer log
Correct answer: Pedometer log
There are specific identifiers in medical records that can potentially identify an individual or be traced back to an individual. This could result in revealing information about a person's healthcare services, including diagnosis and treatment. A pedometer log is not linked to health records, so it's not considered to be protected health information (PHI). Examples of PHI are any address information lower than state level, dates, telephone or fax numbers, medical record numbers, vehicle identification numbers, vehicle license plate numbers, names of family members, and device serial numbers.
- A female patient with a diagnosis of terminal cancer has a Do Not Resuscitate (DNR) order. She stops breathing. Her husband begs the nurse, "Save her!" What should the nurse do?
- Inform the husband that she has a terminal diagnosis
- Notify the physician of the patient's demise
- Honor his wishes and proceed with a full code
- Remind the husband that a DNR order is in place
Correct answer: Remind the husband that a DNR order is in place
Generally, a family member cannot override a DNR order, which is between a patient and their physician. The nurse should be aware of the patient's Living Will and Power of Healthcare Attorney status.
- After the hospital Quality Improvement Team discovers a sudden increase in IV site infiltrations in a surgical unit, they implement a Plan-Do-Study-Act (PDSA) initiative. Which step will come first?
- Implement a new IV insertion policy
- Perform chart audits
- Analyze the data
- Monitor which IV needle gauges are used
Correct answer: Monitor which IV needle gauges are used
A quality improvement initiative begins with agreeing on what aspect of a problem to study. Plan: In this case, the team suspects that the needle gauge is a factor. Do: A chart audit is performed, then the data are analyzed or studied. The "Act" step is the decision to implement a new policy.
- Many lawsuits involving a nursing professional happen when the nurse
- Abandons patients when going to lunch
- Follows an order that is incomplete or incorrect
- Documents the physician's errors
- Watches a new employee to verify the employee's skills level
Correct answer: Follows an order that is incomplete or incorrect
Nurses are responsible for implementing doctors' orders. They are also responsible for questioning the doctor about an order that seems incomplete or incorrect. If an inaccurate order is followed and the patient suffers harm, the nurse can be held liable if the doctor was not contacted. Always document communication with physicians when questioning an order. If unsure, ask a supervisor.
- A pediatric nurse gets a call from the Emergency Department that a 2-year-old is being admitted with a diagnosis of febrile seizures. As the nurse prepares for his admission, which of the following is the most important nursing action?
- Place a cooling mattress on the child's bed
- Order a STAT admission CBC
- Pad the side rails of the child's bed
- Place a urine collection bag and specimen cup at the bedside
Correct answer: Pad the side rails of the child's bed
With a diagnosis of febrile seizures, precautions to prevent injury and promote safety should take precedence. Padding the side rails is appropriate. Laboratory tests and a cooling blanket must be ordered by the physician, and both may have been done in the ED.
- What is the proper way to dispose of a used needle and syringe?
- Separate the needle and syringe and place both in the sharps disposal container in the patient's room
- Cut the needle at the hilt in a needle cutter before disposing of it in the sharps disposal container in the patient's room
- Recap the needle and place the needle and syringe in the sharps disposal container in the patient's room
- Immediately place the needle and syringe in the sharps disposal container in the patient's room
Correct answer: Immediately place the needle and syringe in the sharps disposal container in the patient's room
Never recap a used syringe. Immediately place uncapped, used needles and syringes in the sharps container in the patient's room.
- After a patient's primary care physician has made the rounds, the nurse notices that the physician wrote an order for a medication at triple the normal dose. What should the nurse do?
- Administer the medication as ordered
- Contact the physician immediately
- Ask the nurse supervisor for advice
- Call the pharmacy to see if the dosage is safe
Correct answer: Contact the physician immediately
The nurse should call the physician who wrote the order as soon as possible to clarify the order. Administering the medication is incorrect because the nurse should know that the dose is outside the normal range. Giving the medication could cause harm to the patient, and the nurse could be liable. A pharmacist may be helpful, but the pharmacist cannot change the physician's order.
- After outpatient surgery, a client comes to the clinic for a follow-up appointment. The nurse documents the client's surgical incision as having red granulation tissue. This indicates that the wound is
- Necrotic
- Dehisced
- Healing
- Infected
Correct answer: Healing
This client's wound is healing. Healthy granulation tissue is pink or red in color and is an indicator of healing. Dark granulation tissue can be a sign of infection, ischemia, or poor perfusion.
- The nurse is educating a client who is to receive brachytherapy for a diagnosis of prostate cancer. Which of the following instructions should the nurse include?
- Children under age 18 and pregnant women may not visit the client
- Visiting hours are limited to 4 hours a day per person
- Visitors must stand at least 18 inches away from the client
- The client may ambulate in the hall for 5 minutes at a time
Correct answer: Children under age 18 and pregnant women may not visit the client
Brachytherapy, also called internal radiation, is a treatment for cancer, especially prostate cancer. Other cancers that are treated with brachytherapy include cervical, uterine, breast, head and neck, gallbladder, lung, rectal, and eye. Sealed radiation is placed inside or next to the area that requires treatment. This allows a higher dose of radiation in a small area for less time than other radiation therapies. Federal regulations prohibit children under 18 and pregnant women from visiting the client. Visitors must stand 6 feet away and may not spend more than 2 hours a day with the client. The client is confined to a private room, with limited care by staff.
- If a nurse is assigned to care for a patient with a Sengstaken-Blakemore tube, which item MUST be kept at the patient's bedside?
- Sutures
- Scissors
- A Yankauer
- A hemostat
Correct answer: Scissors
A Sengstaken-Blakemore tube is a medical balloon device inserted through the nose or mouth and used in the management of upper gastrointestinal hemorrhage caused by esophageal varices. If the tube ruptures, scissors are used to cut the balloon and prevent blocking the patient's airway. A hemostat is used to clamp blood vessels or tubing, because it can lock. A Yankauer is used for oral suctioning. Sutures are for wound closure.
- What precautions are necessary when caring for a patient with hepatitis A?
- Wearing gloves for direct care
- Placing the patient in a private room
- Gowning before entering the room
- Wearing a mask at all times
Correct answer: Wearing gloves for direct care
Hepatitis A is transmitted by the fecal-oral route. Unlike hepatitis B and C, it is self-limiting and does not cause chronic liver disease. Contact precautions are recommended for patients with hepatitis A. No private room is necessary unless the patient is incontinent of stool.
- A 2-year-old girl is admitted for 24-hour observation after she fell from her crib onto her head. The pediatric nurse should call the provider to report which of the following?
- Drop in respirations from 36 to 28 per minute
- Rise in temperature from 99.2 °F to 101.6 °F
- Rise in B/P from 82/40 to 98/56 mmHg
- Drop in heart rate from 120 to 100 bpm
Correct answer: Rise in temperature from 99.2 °F to 101.6 °F
Normal pulse for a child 1–2 years of age is 80-130 bpm. Normal respiratory rate for a child 1-3 years of age is 24-40 per minute. Normal systolic B/P for a child 2-6 years of age is 70106 mmHg, and normal diastolic B/P is 25-65 mmHg. A child is considered to have a fever when the child's temperature is 100.4 °F (38 °C) or higher, measured rectally. The nurse should notify the provider about the child's temperature, whether or not it is related to the fall.
- According to the CDC guidelines on hand hygiene, nurses who have direct contact with high-risk patients should not wear artificial nails, because the nails
- Do not meet professional dress codes
- Get torn off when changing bed linens
- Can transmit gram-negative pathogens
- Tend to puncture sterile gloves
Correct answer: Can transmit gram-negative pathogens
Nurses who work in critical care units or have direct contact with high-risk patients can transmit infections to patients. Subungual areas of the hand harbor high concentrations of bacteria, most frequently coagulase-negative staphylococci, gram-negative rods (including Pseudomonas spp.), corynebacteria, and yeasts. Studies have shown that even with aggressive handwashing, artificial nails are difficult to clean.
- Shortly after the nurse enters a client's room, the client experiences a tonic-clonic seizure. What is the nurse's FIRST action?
- Turn the client onto their side
- Notify the rapid response team
- Place a tongue blade in the client's mouth
- Put the client's bed in Fowler's position
Correct answer: Turn the client onto their side
To open the client's airway and prevent aspiration of saliva, the nurse should first position the client on their side to maintain with face and mouth angled downward. Do not insert anything into the client's mouth. Do not hold the client's arms down or try to restrain the client. Summon emergency help if the client's seizure lasts longer than 5 minutes. The Epilepsy Foundation recommends remembering the cues: "Stay. Safe. Side": STAY with the person. Make sure the person is SAFE. Turn the person on their SIDE.
- A 12-year-old child has a near-drowning experience with submersion for about 10 minutes. EMS resuscitates and transports the child to the hospital. The nurse knows that the organ most likely to sustain irreversible damage is the
Correct answer: Brain
A brain requires constant oxygen and nutrients. After about 6 minutes without 02, brain cells begin to die. All organs are susceptible to hypoxia, but all except the brain have a survival time of up to 30 minutes. Factors such as water temperature and salt vs. fresh water can affect the outcome, but the brain is always most vulnerable.
- A nurse is instructing a newly diagnosed diabetic client and his wife about lispro (Humalog) insulin. The client is to receive 6 units by subcutaneous (SC) injection each morning at 7:30 a.m. At what time should the client and his wife be alert to a possible hypoglycemic reaction?
- 8:30 a.m.
- 11:30 a.m.
- 7:45 a.m.
- 10:45 a.m.
Correct answer: 8:30 a.m.
Lispro (Humalog) is a fast-acting insulin. Onset starts 15 minutes after injection and peaks at 30-90 minutes, with a duration of 3 hours. A hypoglycemic reaction is most likely to occur at peak time. For this client, the time would be 8:30 a.m.
- While preparing a client for dialysis, the nurse should assess the client's arteriovenous (AV) fistula by
- Checking for discoloration
- Palpating for vibration
- Inspecting for leakage
- Observing for swelling
Correct answer: Palpating for vibration
Palpate the vascular access to feel for a thrill or vibration that indicates arterial and venous blood flow and patency. Auscultate the vascular access with a stethoscope to detect a bruit or swishing sound that indicates patency. The access should be checked every 8 hours. Since the access is internal, observations of the site are not effective.
- The nurse is educating the parents of a young child with a recent diagnosis of cystic fibrosis. The nurse tells the parents that the child will be at risk for which vitamin deficiencies?
- Folic acid and biotin
- B12, C, and E
- B1 and pantothenic acid
- A, D, and K
Correct answer: A, D, and K
People with cystic fibrosis have trouble absorbing fats, which means they also have trouble absorbing vitamins that need fat to be absorbed - A, D, E, and K. These fat-soluble vitamins are critical to normal growth and good nutrition. B-complex, C, folic acid, biotin, and pantothenic acid are water soluble and easily absorbed.
- When instructing a patient with Addison's disease about nutrition, the healthcare provider should NOT recommend which of the following dietary modifications?
- A diet high in grains
- A restricted-sodium diet
- A high-protein diet
- A diet with adequate caloric intake
Correct answer: A restricted-sodium diet
A patient with Addison's disease (adrenal insufficiency) requires normal dietary sodium to maintain electrolyte balance and prevent excess fluid loss. The patient should be instructed to maintain adequate caloric intake with a diet high in protein and complex carbohydrates, including grains.
- Before administering a scheduled 300 ml enteral feeding bolus to a comatose adult client, the nurse aspirates 100 mL of gastric residual volume. Which nursing action is MOST appropriate?
- Flush the tubing with warm water.
- Hold the feeding bolus for two hours.
- Administer the bolus as prescribed.
- Request a different enteral formula.
Correct answer: Administer the bolus as prescribed.
Standard practice includes measuring gastric residual volume prior to administering an enteral feeding. According to current American Society for Parenteral and Enteral Nutrition, enteral feedings can be administered with a residual up to 500 ml; however, individual HCP orders should be followed. signs of feeding intolerance include abdominal distention and/or pain, constipation, nausea, vomiting, and sense of fullness.
- Despite frequent turning and skin assessment, occasional urinary incontinence has caused a bedridden resident to develop a reddened and tender area on the coccyx. The resident weighs 192 pounds. Which pressure-relieving device should be used for the client?
- Natural sheepskin
- Low air loss bed
- Egg crate foam
- Alternating overlay
Correct answer: Alternating overlay
For clients who weigh less than 250 pounds, an alternating pressure overlay is the best choice because it is liquid resistant. It has compartments that alternately inflate and deflate to relieve pressure. Foam and sheepskin surfaces are not appropriate for clients with urinary incontinence. A low air loss bed is ideal but expensive, and it can cause hypothermia if not carefully monitored.
- During assessment, the home health nurse learns that the client has a fecal impaction. Before proceeding to manually remove the stool, what is the nurse's PRIORITY?
- Advise the family to increase the client's fluid and fiber intake.
- Teach family members to perform the disimpaction process.
- Give an analgesic or sedative to make the client comfortable.
- Recall that cardiac dysrhythmias are a possibility.
Correct answer: Recall that cardiac dysrhythmias are a possibility.
A fecal impaction is a large lump of dry, hard stool that stays stuck in the rectum. It is most often seen in people who are constipated for a long time. Treatment of a fecal impaction includes administrating an enema to soften the stool to produce a bowel movement, or manually removing the impaction. With a lubricated glove, insert the index finger into the rectum to break up the hardened stool with a circular motion. Cardiac dysrhythmias and reflex bradycardia can occur from vagal nerve stimulation.
- A father brings his 6-month-old son and 3year-old daughter for their routine check-ups. What is the nurse's best strategy?
- Examine the 3-year-old first so she can show her brother.
- Examine the 6-month-old first while his sister watches.
- Let the 3-year-old play during the baby's examination.
- Ask the father to step out with one child while the other child is examined.
Correct answer: Let the 3-year-old play during the baby's examination.
Start with the least anxious and most cooperative sibling. Allow the older sibling to play; this reduces anxiety and allows them to become familiar with the examination. Children are more comfortable and cooperative when a parent is present.
- While providing pre-operative education to a client, the nurse explains that the client will return from surgery with a sequential compression device (SCD). Which of the following statements by the nurse would be most correct?
- You will wear the SCD when ambulating.
- The SCD means you can stay on bed rest.
- You won't have to do any other exercises.
- The SCD imitates the action of walking.
Correct answer: The SCD imitates the action of walking.
A Sequential Compression Device (SCD) is a method of DVT prevention that improves blood flow in the legs. SCDs are shaped like "sleeves" that wrap around the legs and inflate with air one at a time. This imitates walking and helps prevent blood clots. The SCD is worn while sitting or in bed; the device is removed for ambulating. Clients should still do foot exercises, included circles and flexing. Clients should be up and walking as soon as possible post-surgery, and continue to ambulate frequently.
- A primigravida client comes to the prenatal clinic after missing three periods. After her pregnancy has been confirmed, the client tells the nurse that her last period started on June 10. Using Naegele's Rule, what is the client's estimated date of delivery (EDD)?
- March 17
- March 10
- March 3
- March 24
Correct answer: March 17
According to Naegele's Rule, the estimated date of delivery (EDD) is calculated by subtracting 3 months from the first day of the normal menstrual period (June 10 - 3 months = March 10) and then add 7 days. (March 10 + 7 days = March 17). The other dates are incorrect. NOTE: EDD replaces the former term, estimated date of confinement (EDC).
- The nurse calculates the 1-minute Apgar score for a neonate with the following: 1. Respiratory effort: slow; 2. heart rate: 120 bpm; 3. muscle tone: some flexion of extremities; 4. reflex irritability: vigorous; 5. skin color: body pink, blue extremities. What score does the nurse assign?
Correct answer: 7
Apgar is a quick test performed on a baby at 1 and 5 minutes after birth. The 1-minute score determines how well the baby tolerated the birthing process. The 5-minute score tells the health care provider how well the baby is doing outside the mother's womb. Scoring is 0, 1, or 2 for each category. A perfect Apgar score is 10. Scoring categories are as follows: 1. Respiratory effort: 0 = not breathing, 1 = slow or irregular, 2 = strong cry. 2. Heart rate by stethoscope; 0 = no HR, 1=< 100 bpm, 2 => 100 bpm. 3. Muscle tone: 0 = loose/floppy, 1 = some tone, 2 = active motion. 4. Reflex irritability or grimace response: O = no reaction, 1 = grimacing, 2 = cough, sneeze, or cry. 5. Skin color: 0 = pale blue, 1 = body pink, extremities blue, 2 = entire body pink. Hence, the nurse assigns a 1-minute Apgar score of 7 to this infant.
- A pediatric patient has been admitted to the unit with a diagnosis of right lower lobe (RLL) pneumonia. When auscultating the RLL, which sound should the nurse expect to hear?
- Stridor
- Crackles
- Rhonchi
- Wheezes
Correct answer: Crackles
Crackles would most likely be heard because this would indicate fluid in the airspace. Fluid in the airspace is consistent with pneumonia. Wheezes indicate a narrowing of the airways. Stridor is an emergency lung sound that is heard in airway constriction that can lead to complete closure. Rhonchi is heard in mixed-issue airway constriction and secretions.
- During a routine check-up, a client asks the nurse to suggest a breakfast that can help prevent constipation. Which of the following would be the best food choices?
- Fried eggs and bacon
- Oatmeal and a banana
- Plain bagel and cream cheese
- Donut and orange juice
Correct answer: Oatmeal and a banana
The American Heart Association recommends a daily fiber intake of 25-30 grams from food (not supplements) on a 2,000calorie diet for adults. Oats, with 5 grams of fiber, include nearly equal parts soluble and insoluble dietary fiber. Apples, bananas, oranges, and strawberries all have 3-4 grams of fiber; raspberries have 8 grams. A plain bagel and cream cheese have a combined total of 4 grams of fiber. Eggs and bacon contain 0 grams of fiber. A donut has 0.8 grams of fiber, and a glass of orange juice has 0.2 grams.
- A client in the Emergency Department is experiencing the "fight-or-flight" response, a sympathetic nervous system reaction. Which of the following will the nurse expect to observe?
- Increased urine output
- Decreased pupil size
- Decreased perspiration
- Increased pulse rate
Correct answer: Increased pulse rate
The fight-or-flight response evolved as a survival mechanism, enabling humans and other mammals to react quickly to life-threatening situations. The carefully orchestrated yet near-instantaneous sequence of hormonal changes and physiological responses helps a creature fight off the threat or flee to safety. The catecholamine release results in increased pulse, blood pressure, bronchodilation, perspiration, pupil dilation, and mental acuity. Urine output is decreased.
- The earliest identifying sign for a developing pressure sore is a localized
- Loss of sensation
- Change in color
- Edema
- Coolness to touch
Correct answer: Change in color
When pressure over a bony prominence is not relieved, the result is ischemia and damage to the underlying tissue. In the earliest stage (Stage 1), the skin remains intact but appears red. The area does not blanch when touched. Skin temperature may be warmer.
- A patient with a fractured hip has been placed in Buck's traction. Which of the following statements about this treatment is true?
- The purpose is to immobilize the leg(s)
- Kirschner wires are inserted
- It utilizes a Steinmann pin
- It is primarily used to heal fractured hips
Correct answer: The purpose is to immobilize the leg(s)
Buck's traction is one of the most common orthopedic mechanisms for temporary immobilization of a hip or femur until surgery can be performed. It exerts traction on one or both legs by using a system of ropes, weights, and pulleys. A Steinmann pin goes through large bones and is used to stabilize large bones such as the femur. Kirschner wires are used to stabilize small bones such as fingers and toes. Buck's traction is not intended for healing.
- Which of these would be most important to include in discharge teaching for a patient with a platelet count of 40,000/mcL (40×109/L)?
- Use a soft toothbrush and floss gently
- You should take a multivitamin daily
- Be sure to take your aspirin with meals daily
- You may continue shaving with a straight-edge razor
Correct answer: Use a soft toothbrush and floss gently
Platelets (thrombocytes) are important for blood clotting. The normal platelet count range is 150,000-400,000/mcL (150-400×109/L). This patient has thrombocytopenia and should be on bleeding precautions. Using a soft toothbrush and flossing gently can prevent the gum tissue from bleeding. To avoid cuts, this patient should shave with an electric razor. Aspirin can interfere with clotting and should be discontinued. Multivitamins have no effect on platelet production.
- A daughter takes her 85-year-old father to the clinic because he is confused and weak. She tells the nurse that his appetite is poor. The nurse also observes that his blood pressure is lower than normal. The provider orders blood work for the client. Which lab result should the nurse immediately report?
- Potassium (K) 4.2 mEq/L
- Sodium (Na) 115 mEq/L
- Calcium (Ca) 9.6 mg/dL
- Chloride (CI) 100 mEq/dL
Correct answer: Sodium (Na) 115 mEq/L
Sodium serum levels should be 136-145 mEq/L. Hyponatremia causes the brain to swell and must be treated at once. The other lab values are normal: calcium (9-10.5 mg/dL), chloride (98-106 mEq/L), and potassium (3.5-5.0 mEq/L).
- On reviewing the culture results of a newly admitted patient, the nurse notes that the patient has methicillin-resistant Staphylococcus aureus (MRSA). Which transmission-based precautions should be instituted for this patient?
- Contact precautions
- Enteric precautions
- Droplet precautions
- Airborne precautions
Correct answer: Contact precautions
Beside standard precautions, contact precautions include use of barrier personal protective equipment (PPE) such as gloves and goggles. Diarrhea, draining wounds, and secretions containing MRSA can be transmitted by contact. Enteric precautions are for pathogens transmitted by the Gl system. Droplet and airborne precautions are for pathogens from the respiratory tract.
- The nurse is caring for a fresh postoperative cholecystectomy client with a T-tube in place. As the nurse records the output from the T-tube, what is the typical drainage for the first 24 hours?
- More than 500 ml
- Less than 100 mL
- 300-500 mL
- 100-300 ml
Correct answer: 300-500 mL
During the first 24 hours post-operatively, drainage from a Ttube is about 300 to 500 mL of thick, blood-tinged, brightyellow to dark-green bile drainage. Report drainage greater than 500 mL/day. After about 4 days, the amount will be less than 200 mL/day.
- The nurse is preparing a client for a liver biopsy. Which instruction regarding the procedure is correct?
- The client will be placed on the right side after the procedure
- The client will receive an enema to prevent bowel perforation
- The client will be NPO for 12 hours before the procedure
- The client will have to hold their breath for 15 minutes
Correct answer: The client will be placed on the right side after the procedure
Following a routine liver biopsy, the client is placed on the right side to minimize bleeding. All other options are incorrect.
- In the proper sequence for removing personal protective equipment (PPE), which item is removed last?
Correct answer: Mask
According to the CDC, the proper sequence for doffing PPE is 1. gloves; 2. goggles; 3. gown; 4. mask. An easy way to remember this sequence is to just go alphabetically!
- On Thursday, January 1, following a motor vehicle crash, EMS transports a male named Robert to the Emergency Department. The nurse asks the client to state his name, where he is, and the date. Robert answers, "Robert, hospital, December." What verbal response score on the Glasgow Coma Scale does the nurse assign?
- Words=3
- Oriented = 5
- Confused = 4
- Sounds = 2
Correct answer: Confused = 4
If the client is unable to answer at least one question (such as the current month) correctly for whatever reason, they should be rated as Confused. Even though it is the first day of a new month, the highest response observed by the nurse is "Confused," so the score is 4.
- The nurse is performing an assessment of a client who had major abdominal surgery 5 days ago. The client reports feeling a "pop where my surgery was" when the client coughed. On inspection, the nurse notes that the wound edges have separated at the incision line. What should the nurse do FIRST?
- Notify the health care provider (HCP)
- Stress the importance of splinting when coughing
- Administer a cough suppressant medication STAT
- Apply an antibiotic ointment and sterile dressing
Correct answer: Notify the health care provider (HCP)
Postoperative wound dehiscence occurs in up to 3% of abdominal surgeries. Dehiscence is a surgical complication in which the wound edges open or separate along the incision. This can occur 5 to 10 days postoperatively. Coughing, sneezing, or vomiting, especially without splinting, can cause dehiscence. Infection is another cause. Obese clients and clients with diabetes or immune deficiencies are at greater risk of dehiscence. Nursing actions include the following steps: 1. Notify the HCP. 2. Place the client in a low-Fowler's position with knees bent to reduce abdominal tension. 3. Cover the wound with a sterile towel or dressing. 4. Keep client NPO and on complete bed rest. 5. Prevent wound infection with strict asepsis. 6. Provide emotional support.
- When a client is on warfarin therapy, which laboratory value should the nurse monitor?
- International Normalized Ratio
- Bleeding time
- Factor V assay
- Platelet count
Correct answer: International Normalized Ratio
The goal of warfarin therapy is to maintain a balance between preventing clots and causing excessive bleeding. Prothrombin time (PT) measures how well the blood clots and how long it takes. For patients on warfarin, most laboratories report PT results that have been adjusted to the INR. These people should have an INR of 2.0 to 3.0 for basic "blood-thinning" needs. For those who are at high risk of a blood clot, the INR needs to be higher - about 2.5 to 3.5. The other answer options are not used to monitor warfarin. An abnormal factor V assay may indicate liver disease or disseminated intravascular coagulation (DIC). Bleeding time is performed to monitor basic platelet function. Platelet count is part of a CBC; abnormal results may indicate bleeding or blood disorders.
- A client's arterial blood gas (ABG) values are pH 7.48, PO2 98 mmHg, PCO2 28 mmHg, HCO3 24 mEq/L. These results are consistent with which of the following clients' conditions?
- Chronic obstructive pulmonary disease (COPD)
- Type 1 diabetes with diabetic ketoacidosis (DKA)
- Anxiety-related hyperventilation
- Vomiting and diarrhea for the past two days
Correct answer: Anxiety-related hyperventilation
The pH is high, the PCO2 is low, and the HCO3 is normal, so this is respiratory alkalosis. The cause is hyperventilation; rebreathing into a paper bag will restore the CO2. Normal ABG ranges are pH 7.35-7.45, PO 2 80-100, PCO2 35-45, HCO3 2228. COPD will result in respiratory acidosis, related to CO2 retention. DKA will have a pH less than 7.35, with metabolic acidosis. Diarrhea and vomiting will cause metabolic alkalosis.
- The physician orders an IV theophylline drip at 40 mg/hr. The pharmacy sends a 250 ml bag of D5W mixed with 500 mg theophylline. What should the infusion rate on the pump be?
- 80 mL/hr
- 20 ml/hr
- 60 mL/hr
- 40 ml/hr
Correct answer: 20 ml/hr
To calculate the infusion rate: 1. Find the concentration: 250 mL500 mg=2 mg/mL. 2. Divide the ordered dose by the concentration: 2 mg/mL40 mg/hr=20 mL/hr. ANSWER: 20 mL/hr.
- When a drug's effect is increased after a second drug is administered, this interaction is called
- Synergism
- Antagonism
- Absolution
- Potentiation
Correct answer: Potentiation
Potentiation is a type of drug interaction. Potentiation occurs when two drugs are taken together and the action of one drug increases the action of the other, causing the pharmacologic response to be greater for one of the drugs.
- If a drug is 50% protein-bound, it means that
- 50% of the drug is available
- 50% will pass through the intestines
- 50% less protein should be eaten
- 50% of the drug destroys protein
Correct answer: 50% of the drug is available
The percentage of the drug that is NOT protein bound is the amount of the drug that is free to work as expected. In this case, 50% of the drug is unable to be effective because it is protein-bound. Protein binding has nothing to do with drug excretion, protein in the diet, or the destruction of protein.
- Celecoxib (Celebrex) can be prescribed for all of the following EXCEPT
- Juvenile rheumatoid arthritis
- Hereditary colon polyps
- Third-trimester pregnancy
- Severe menstrual pain
Correct answer: Third-trimester pregnancy
Celecoxib (Celebrex) is a nonsteroidal anti-inflammatory drug (NSAID). It works by reducing hormones that cause inflammation and pain in the body. It can be harmful to the fetus during the last 3 months of pregnancy and should not be used during breastfeeding. Celebrex may be prescribed for the other conditions.
- IV lidocaine (Xylocaine) is contraindicated for which cardiac condition?
- Coronary artery bypass
- Ventricular arrhythmias
- Third-degree heart block
- Myocardial ischemia
Correct answer: Third-degree heart block
IV lidocaine is contraindicated in third-degree heart block or severe sinus node dysfunction. Lidocaine is particularly useful in treating myocardial infarction or ischemia. It increases the electrical stimulation threshold.
- The health care provider (HCP) prescribes a beta blocker for a client with hypertension: "Atenolol 75 mg PO BID." The nurse notes that the medication comes as a scored 50 mg tablet. How many tablets will the nurse instruct the client to take each time?
- 2/3 tablet each dose
- 1.5 tablets each dose
- Ask for a liquid form
- 1 tablet in a.m., 2 tablets in p.m.
Correct answer: 1.5 tablets each dose
The client will take 1.5 (one and one-half) tablets each dose. Using the "what you want / what you've got" formula: 50 mg/tablet75 mg=1.5 tablets. Tablets should only be cut or split in half if they are scored. Capsules and coated tablets or pills should not be split.
- The safe blood level range for lithium is
- 0.25–1.0 mEq/L
- 1.3-2.0 mEq/L
- 2.1-2.5 mEq/L
- 0.6-1.2 mEq/L
Correct answer: 0.6-1.2 mEq/L
The therapeutic range for lithium is 0.6-1.2 mEq/L. Each client has a different sensitivity in that range. Lithium toxicity can occur at high ranges. Levels of 2.0 mEq/L and above can be life-threatening. A level of 3.0 mEq/L is a medical emergency.
- The provider orders furosemide (Lasix) oral solution 0.5 mL stat. The pharmacy sends a bottle marked 10 mg/mL. What dosage will the nurse administer?
Correct answer: 5 mg
10 mg/mL=0.1 mL1 mg, so 0.5 mL×10 mg/mL=5 mg.
- A postoperative client has developed thrombophlebitis in a leg. The physician has ordered heparin sodium 7500 units SC q 12 hours. Which lab value should the nurse report to the physician before administering the heparin?
- Prothrombin time (PT)
- Partial thromboplastin time (PTT)
- Glycated hemoglobin (HbA1c)
- Complete blood count (EBC)
Correct answer: Partial thromboplastin time (PTT)
PTT is used to monitor and prescribe varying heparin doses. The therapeutic range is 1.5 to 2.5 times the control time. HINT: The two Ts in PTT resemble an H, and H stands for heparin. PT is used to monitor oral anticoagulant therapy, such as warfarin. CBC reports the total number of blood cells. HbA1c is used for diabetic management and control.
- When a provider prescribes sodium polystyrene sulfonate (Kayexalate) for a client, the nurse can expect the client's subsequent lab values to show
- A decrease in serum bicarbonate
- A decrease in serum potassium
- An increase in serum calcium
- An increase in serum magnesium
Correct answer: An increase in serum magnesium
After administering sodium polystyrene sulfonate (Kayexalate), the nurse can anticipate a decrease in serum potassium, the expected response of sodium polystyrene sulfonate, is secondary to the binding of this drug and potassium in the colon, and potassium is removed through the feces. The other laboratory outcomes are not related to administration of Kayexalate
- A patient is receiving propranolol (Inderal) for a diagnosis of supraventricular tachycardia (SVT). When the nurse does an assessment, which finding would indicate an adverse reaction to the drug?
- Paresthesia
- Aphasia
- Oliguria
- Bradycardia
Correct answer: Bradycardia
Propranolol is a beta blocker, used to treat arrythmias and hypertension. It can cause bradycardia and reduced cardiac output. The nurse should immediately notify the primary care provider.
- The health care provider (HCP). prescribes 1/2 strength tube-feeding formula for a client who is restarting enteral nutrition. A standard can of formula contains 240 mL. How much water should the nurse add to obtain 1/2 strength?
Correct answer: 240 mL
The nurse will add 240 mL of water. The V1C1=V2C2 formula is used to calculate dilutions, where V1/C1 are the starting volume/concentration and V2/C2 are the final volume/concentration. For this question: 1. 240 mL×1.0=V2×0.50. 2. V2=0.50240 mL×1.0=480 mL (final total volume). NOTE: total volume minus starting volume equals diluent volume: 480 mL−240 mL=240 mL.
- A client receiving hemodialysis therapy weighs 78 kg today. The nurse notes that the client's previous weight was 76 kg. What is the percent change? Round to two decimal places.
Correct answer: 2.63%
To calculate a percent change, use V1V2−V1×100% (final minus initial, divided by initial). For this question: 1. 78 kg−76 kg=2 kg. 2. 76 kg2 kg=0.026315. 3. 0.026315×100%=2.6315%. 4. Round to 2.63%.
- Which characteristic of a breast lump is most likely to indicate the possibility of cancer?
Correct answer: Immobile
According to Breast Cancer.org, lumps are most likely to be cancerous if they do not cause pain and are hard, unevenly shaped, and immobile. Most malignant tumors first appear as single, hard lumps or thickenings. Commonly developing from the mammary glands or ducts, about 50% of malignant lumps generally appear in the upper, outer quadrant of the breast, extending into the armpit, where tissue is thicker than elsewhere. Over 80% of biopsied breast lumps are benign.
- A nurse's neighbor tells the nurse that the neighbor's provider recommended that they take docusate sodium (Colace). Which of the following statements by the nurse is correct?
- You'll have regular bowel movements
- You may experience mild headaches at first
- You'll probably feel less anxious very soon
- Your heartburn is going to go away
Correct answer: You'll have regular bowel movements
Docusate is an emollient laxative that is prescribed to treat occasional constipation. It works by increasing absorption of water by the feces, leading to a soft stool. It is an over-the-counter (OTC) medication. The nurse can also suggest that the neighbor increase fluid intake when using docusate. The other choices are incorrect.
- The nurse is preparing a patient for a total colectomy and the placement of an ileostomy. The patient asks where the stoma will be located. The nurse identifies which of the following areas as the correct stoma site?
Correct answer: C
A total colectomy involves the removal of the large intestine. The gastrointestinal output will occur at the terminal end of the ileum. The stoma will be located in the lower right quadrant of the abdomen. A total colectomy is performed for intestinal inflammatory conditions such as Crohn's disease or ulcerative colitis. It may also be done for severe chronic constipation.
- Which of the following conditions most commonly causes acute glomerulonephritis?
- A congenital condition leading to renal shutdown
- Group A Streptococcus infection within the past 10-14 days
- Chronic viral destruction of the glomeruli
- End-stage renal disease
Correct answer: Group A Streptococcus infection within the past 10-14 days
Acute glomerulonephritis is most commonly caused by an over-response of the immune system to an infection such as strep throat from Group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Facial edema and hypertension are common signs at diagnosis. Other causes of acute glomerulonephritis include lupus, Goodpasture syndrome, and impetigo.
- An electrocardiogram strip shows that the PR interval is 6 small boxes in length. The nurse knows this indicates
- A delay in AV node conduction
- Stress is causing sympathetic stimulation
- An impending myocardial infarction
- The interval is within normal limits
Correct answer: A delay in AV node conduction
The PR interval is the time taken for the atria to depolarize and the action potential to travel through the AV node to the HisPurkinje system. Each small box on the ECG strip equals 0.04 seconds. The patient's interval is longer than normal, indicating an impulse delay through the AV node.
- A healthcare provider is teaching a group of students about the characteristics of type 1 diabetes mellitus. Which of the following is the underlying cause of this disease?
- Destruction of pancreatic beta cells
- Cellular resistance to insulin
- Increased hepatic glycogenesis
- Atrophy of pancreatic alpha cells
Correct answer: Destruction of pancreatic beta cells
Insulin is produced by the beta cells of the pancreas. In type 1 diabetes, the pancreatic beta cells are destroyed by an autoimmune process. The person loses the ability to produce insulin and must rely on injections to survive. There is currently no cure for type 1 diabetes. It requires intensive, lifelong medical management of the blood glucose level.
- A client is admitted to the unit with ascites secondary to a diagnosis of cirrhosis. The nurse knows that the cause of cirrhotic ascites is
- Decreased albumin production
- Decreased renal function
- Acute portal hypertension
- Acute electrolyte imbalance
Correct answer: Decreased albumin production
Albumin, produced only in the liver, is the major plasma protein that circulates in the bloodstream. Albumin is essential for maintaining the oncotic pressure in the vascular system. A decrease in oncotic pressure caused by a low albumin level allows fluid to leak out from the interstitial spaces into the peritoneal cavity, producing ascites. Renal function is not related to ascites. Portal hypertension causes varices, not ascites. Electrolyte imbalance can be a result of the ascites, not the cause.
- EMS transports a patient with a gunshot wound to the head. The patient is unresponsive and displaying decorticate posturing. Which area of the brain has been damaged?
- Brainstem
- Midbrain
- Amygdala
- Medulla
Correct answer: Midbrain
Decorticate posture is a sign of damage to the nerve pathway in the midbrain, which is between the brain and spinal cord. The midbrain controls motor movement. Damage to the rostrum brainstem causes decerebrate posturing, which is more severe than decorticate. Flaccid posturing results from injury to the medulla. The amygdala is the area of the brain that processes fear.
- A previously healthy 60-year-old female is transported by EMS for a complaint of chest pain. EMS places her on an 02 cannula at 2 L/min. On arrival at the Emergency Department, which nursing action is MOST important to address?
- Complaints of nausea and indigestion
- Inability to focus and complete assessment with the nurse
- Restlessness and feelings of apprehension
- Assessment of previous personal and family cardiac history
Correct answer: Restlessness and feelings of apprehension
Restlessness and expression of apprehension demonstrate lack of oxygenation and indicate impending cardiac arrest. Nausea and indigestion may be part of angina or myocardial infarction but are not emergent. Fatigue can contribute to the inability to focus. Assessment of history is not a nursing priority at this time.
- A client is admitted with a diagnosis of central diabetes insipidus, related to insufficient secretion of antidiuretic hormone (ADH). Which urine specific gravity result supports the diagnosis?
Correct answer: 1.002
A urinary specific gravity of 1.005 or less and a urinary osmolality of less than 200 mOsm/kg are indicators of diabetes insipidus. Diabetes insipidus is caused by a lack of antidiuretic hormone (ADH), also called vasopressin, which prevents dehydration, or the kidney's inability to respond to ADH. ADH enables the kidneys to retain water in the body. When diabetes insipidus is caused by a lack of ADH, it is called central diabetes insipidus. This form of the disease can be caused by damage to the hypothalamus or pituitary gland. The normal range for urine specific gravity is 1.005 to 1.030.
- A new client tells the nurse that her previous provider told her she has endometriosis, but the client doesn't understand what that means. How should the nurse explain it to the client?
- It's when tissue that normally lines the uterus grows in other places
- It's the cause of pelvic inflammatory disease
- It's a condition that increases the risk of ovarian cancer
- It's the sharp pain that occurs in the mid-menstrual cycle
Correct answer: It's when tissue that normally lines the uterus grows in other places
Endometriosis is the presence of endometrial tissue outside of the uterus, often around the fallopian tubes and ovaries and in the pelvis. Pelvic inflammatory disease (PID) is an infection, sometimes caused by sexually transmitted infections. Endometriosis does not increase the risk of ovarian or other cancer. The pain that occurs in the middle of the menstrual cycle is called mittelschmerz.
- In order for the nurse to accurately assess the progress of a client in a weight-loss program, which is most effective?
- Weigh the client consistently
- Follow serum protein lab results
- Track daily food caloric values
- Monitor intake and output
Correct answer: Weigh the client consistently
Measuring the client's weight is the most accurate and reliable method of determining weight loss. Weight should be taken in a consistent manner: same scale and same time of day, with the client wearing the same clothing. The other options are methods of determining nutritional and hydration status.
- Knowing that a client undergoing head and neck radiation will likely develop stomatitis, which daily routine measure should the nurse include in client teaching?
- A glass of wine with dinner will be relaxing
- Limit oral hygiene to the morning and evening
- Omit fruits and vegetables until therapy is complete
- A weak saltwater solution can soothe the mouth
Correct answer: A weak saltwater solution can soothe the mouth
Stomatitis (or oral mucositis) is the inflammation, irritation, or ulceration of the mouth and lips. It is a common side effect of head and neck radiation and chemotherapy. To soothe the tissues and provide gentle cleansing, the client should "swish and spit" with a weak saline and water solution before and after meals and as needed. Clients should avoid hot beverages and foods that are salty, spicy, or citrus based. Fruits and vegetables provide vitamins and nutrients for healing and preventing infections. Alcohol can increase dryness and should also be avoided. Using a straw can keep liquids away from sore areas of the mouth. Pain relievers such as acetaminophen or ibuprofen may be helpful.
- The nurse in a mental health unit is caring for a 15-year-old who was admitted after a suicide attempt. Which of the following factors is MOST likely to contribute to an adolescent's risk of suicide?
- Academic and homework difficulties
- Peer pressure and bullying
- The end of a romantic relationship
- Increased financial stress at home
Correct answer: Peer pressure and bullying
Adolescents may attempt suicide for many reasons. Erikson's theory of psychosocial development puts teens in the identity Vs. role confusion stage. Peer pressure and bullying can affect this stage. According to the CDC, youth who report any involvement with bullying behavior are more likely to report high levels of suicide-related behavior than youth who do not report any involvement with bullying behavior. The other answer options are also risk factors for teen suicide but not as reliable as peer pressure and bullying.
- When a 5-year-old child is hospitalized, the nurse encourages the parents to bring in some of the child's favorite toys. The purpose of this is to
- Limit the spread of pathogens
- Help the child stay calm during procedures
- Minimize separation anxiety during the stay
- Create a trusting relationship with the staff
Correct answer: Minimize separation anxiety during the stay
The purpose of providing familiar items is to reduce separation anxiety when the parents can't be present. The purpose of having toys or objects from the child's home is not to reduce the spread of pathogens. Familiar objects do not create a trusting relationship or help the child remain calm during a procedure.
- A patient who overdosed on oxycodone is given naloxone. When assessing the patient, the healthcare provider should anticipate which of these clinical manifestations of opioid withdrawal?
- Hyperthermia and euphoria
- Depressed respirations and somnolence
- Bradycardia and hypothermia
- Irritability and nausea
Correct answer: Irritability and nausea
Naloxone, an opioid antagonist, will displace opioids at the opioid receptor sites. The healthcare provider should expect to observe irritability and nausea. Heart rate and blood pressure will be baseline or elevated, and temperature will be unchanged. Depressed respirations and somnolence are signs of opioid intoxication.
- A provider notifies the inpatient mental health unit that he is admitting a client with a diagnosis of severe anxiety disorder. The client arrives to the unit, crying hysterically. The most appropriate action for the nurse is to
- Ask her what her main problem is
- Invite her to join a group activity
- Give the client a tour of the unit
- Stand or sit calmly next to her
Correct answer: Stand or sit calmly next to her
An extremely anxious client will not be able to tolerate activity, so the nurse should offer compassion and a sense of security. Later in treatment, the client may be able to verbalize her feelings or participate in activities.
- While reviewing the medical record of a patient diagnosed with Alzheimer's disease (AD), the healthcare provider notes that the patient is aphasic. Which behavior supports this finding?
- Difficulty with motor function
- Unable to speak
- Unable to recognize objects
- Difficulty swallowing
Correct answer: Unable to speak
Aphasia is the inability to understand or express speech; it can also affect reading and writing. It's caused by damage to the language center of the brain, which is usually on the left side. In Alzheimer's disease, aphasia is just one component of the brain's deterioration.
- While the nurse is giving a client a bed bath, the client begins to cry. Which of the following nursing interventions is MOST appropriate?
- After the bath, document signs of depression
- Stop the bath, and allow the client private time
- Continue the bath and remain silent
- Pause the bath, cover the client, and sit with the person
Correct answer: Pause the bath, cover the client, and sit with the person
If a client cries, the nurse should stay with the client and let them know that they can cry without fear of being judged. Acknowledge the tears and ask the client if they want to talk about their thoughts or feelings. Continuing the bath ignores the client. Stopping the bath and leaving the room makes the client feel alone. Documenting that the client is depressed is not appropriate.
- A client with chronic migraine headaches tells the nurse that they are considering acupuncture therapy. The nurse responds, "Acupuncture is weird. No normal person would let someone poke needles into them like that." What behavior or belief is the nurse displaying?
- Discrimination
- Prejudice
- Insensitivity
- Ethnocentrism
Correct answer: Ethnocentrism
Ethnocentrism is the belief that one's own culture is natural and correct. Prejudice is An adverse judgment or opinion formed beforehand or without knowledge of the facts. Discrimination is the unfair or prejudicial treatment of people and groups based on characteristics such as race, gender, age or sexual orientation. Insensitivity is the absence of feeling or tact. Acupuncture, a branch of Traditional Chinese Medicine (TCM) is 3,500 years older than Western medicine. According to the NIH, it works well on chronic pain: back, neck, osteoarthritis, and headaches. It can reduce the incidence and severity of tension headaches, as well as prevent migraines.
- A 17-year-old girl has been transported to the Emergency Department by EMS after she was in a motor vehicle accident. She starts to sob inconsolably, telling the nurse, "I just got my license, and I wrecked the car. My parents are going to kill me!" Which should be the nurse's first action?
- Sit at eye level and tell her, "It's scary. Just take some deep breaths
- Stand next to her and tell her, "Calm down. I'm sure it wasn't your fault.
- Touch her arm and say, "When they see you're okay, they won't be mad
- Hold her hand and say, "Relax. The police will explain everything
Correct answer: Sit at eye level and tell her, "It's scary. Just take some deep breaths
When a client is in a crisis situation, start by helping the client to decrease anxiety. Give simple directions that are helpful. Focus on the client. Use therapeutic touch if appropriate. The other answer options do not address the client's anxiety, and they may not be true statements.
- When a new client is admitted to the mental health unit, who should provide the client's history?
- The client
- The court
- The physician
- The family
Correct answer: The client
Unless a client is in a mental health crisis, such as psychosis, the nurse should collect information from the client. If more data is needed, secondary sources, such as family, friends, health care providers, attorneys, or police can be employed, too.
- A 4-year-old is admitted for a tonsillectomy and adenoidectomy. The pediatric nurse observes that the parents are reluctant to participate in their child's care. Which of the following might be a reason for their behavior?
- The parents are fearful that child abuse is suspected
- The parents feel anxious and intimidated
- The parents do not have adequate schooling
- The parents require support from their clergy
Correct answer: The parents feel anxious and intimidated
As the advocate for patients and their families, the nurse should seek to understand their behaviors. These parents are in an unfamiliar setting, and their child's health is at stake. They may not know what to do or how to get the accurate information they need. Involving them in their child's care decreases their sense of helplessness and increases their confidence. The other responses are judgmental and inappropriate for the nurse.
- A client who has experienced chronic neck and back pain is diagnosed with pain disorder and depression. During a clinic appointment, she tells the nurse, "Nothing anyone has done here has helped me." Which of the following statements by the client requires IMMEDIATE intervention?
- I'm hiring a malpractice attorney to sue all of you
- Sometimes I think the pain is making me mentally ill
- I'm going to finally find a way to end this terrible pain
- Sometimes I buy or steal other people's pain pills
Correct answer: I'm going to finally find a way to end this terrible pain
Immediate follow-up and intervention are necessary when a client makes a statement indicating possible suicide. Pain disorder is a psychological disorder that causes sufferers to experience pain. It is considered a mental disorder because psychological factors can aggravate the physical pain. These factors can influence the onset, severity, and maintenance of pain. Common symptoms of pain disorder are: negative or distorted cognition, such as feelings of despair or hopelessness; inactivity and passivity, in some cases disability; increased pain, sometimes requiring clinical treatment; sleep disturbance and fatigue; disruption of social relationships; depression and anxiety.
- Parents discover their 8-month-old infant in his crib, not breathing. EMS is called to resuscitate, but the baby is pronounced dead on arrival (DOA) at the hospital, with a tentative cause of sudden infant death syndrome (SIDS). What is the nurse's most appropriate action?
- Determine if the parents want to donate the baby's organs
- Obtain the parents' signatures for consent to perform an autopsy.
- Provide the parents with a list of funeral homes so they can plan the funeral
- Take the parents to a private room to be with their baby
Correct answer: Take the parents to a private room to be with their baby
Sudden Infant Death Syndrome (SIDS) is the sudden and unexplained death of an infant usually between 2 weeks and 1 year of age. Because of the unexpected event, parents can't comprehend that their healthy baby has died. Their most immediate need is to have the opportunity to begin to face and accept their loss. Personal contact and the chance to say goodbye can promote a healthy grieving process. An autopsy will likely be mandated, so no parental consent is needed. The other actions can take place at a later time.
- A new father tells the nurse that he wants to quit smoking to be healthy for his child. What should the nurse suggest as the first step for the client?
- Make an "I Quit" plan to start the process
- Throw away his cigarettes today
- Sign a cessation contract with the nurse
- Involve his family as a support system
Correct answer: Make an "I Quit" plan to start the process
A client who wants to stop smoking should make a "quit plan" with a cessation date within two weeks. The client can inform family, friends, and co-workers so they can provide support. The client can make a list of the benefits of not smoking. They can also make a list of the possible adverse effects of smoking, such as withdrawal symptoms and tobacco cravings, and how they plan to deal with them. Stopping immediately and signing a contract with the nurse are not effective actions.
- A home health nurse is visiting a new client with COPD, who has just been discharged from the hospital. What is the most important topic for the nurse to teach the client?
- The importance of maintaining social ties
- Removing potential lung irritants from the home
- Starting a gradual exercise and walking program
- Better oxygenation and less CO2 retention
Correct answer: Better oxygenation and less CO2 retention
Chronic obstructive pulmonary disease (COPD) is the inability to move air in or out of the lungs efficiently. The two main types of COPD are chronic bronchitis and emphysema. COPD can't be cured, but treatment can improve the condition. For a client with COPD, the most important thing is learning how to improve oxygenation and reduce carbon dioxide retention. The other options will support the client's efforts to stay as healthy as possible.
- The nurse is caring for a 3-month-oldinfant with infectious gastroenteritis. The infant is lethargic, and the mucous membranes are dry. Which other finding would indicate moderate dehydration?
- Loss of gag reflex
- No urine output
- Sunken fontanelle
- Increased thirst
Correct answer: Sunken fontanelle
A sunken fontanelle is a sign of increasing dehydration. It is first noticed when dehydration progresses from mild to moderate. Mild dehydration may be evidenced by increased thirst and decreased urine output. Anuria (no urine output) is a sign of severe dehydration.
- An 18-year-old male asks about using condoms to keep his girlfriend from becoming pregnant. What is the nurse's best response?
- Condoms will commonly increase sensitivity of the penis
- Be sure to get natural skin condoms. They prevent sexually transmitted infections.
- You should know that the failure rate for condoms is about 25%
- If you use a spermicide with the condom, you'll get more protection
Correct answer: If you use a spermicide with the condom, you'll get more protection
The failure rate for condoms is 12-14%. Adding a spermicide can further reduce the failure rate. Men should avoid natural skin condoms because they allow viruses to pass through; latex condoms should be used instead. A common complaint of condom users is decreased penile sensitivity.
- The school nurse has been invited to participate in a workshop for parents on childhood nutrition. The nurse knows that the PRIMARY nutritional disorder for school-aged children is
- Childhood obesity
- Bulimia nervosa
- Picky eating
- Anorexia nervosa
Correct answer: Childhood obesity
School-age children (ages 6-12) have a consistent but slow rate of growth and usually eat four to five times a day (including snacks). The Centers for Disease Control (CDC) reports an 18.4% obesity rate for this age group. Factors that contribute to childhood obesity are often lifestyle-related: too many calories and too little physical activity. Other factors include family history and habits; psychological reasons, such as stress, boredom, and emotions; socioeconomic issues, such as limited resources or access to fresh foods; and lack of knowledge about nutrition. Obesity in childhood can lead to adult health problems: diabetes, high blood pressure and high cholesterol. Many obese children become obese adults, especially if one or both parents are obese. Childhood obesity can also lead to poor self-esteem and depression. Eating disorders (Anorexia and bulimia) tend to occur in adolescence. Picky eating often begins in earlier than school age.
- Which of the following are the most appropriate toys for a five-month-old infant?
- Teething objects
- Plastic toy cars
- Wooden puzzles
- Stuffed animals
Correct answer: Teething objects
Washable teething toys are appropriate for infants, who put everything in their mouths. Babies at this age enjoy biting on objects that relieve the discomfort of teething. These toys are not harmful and should be encouraged. Plastic toys may be unsafe because of small parts. Games and puzzles are too advanced, and pieces can be swallowed. Stuffed animals have eyes that can be swallowed or aspirated.
- A nurse is assessing a new client who is being evaluated for hepatitis C. Which question should the nurse ask?
- Did you drink any contaminated water?
- Did you travel to India recently?
- How often do you eat shellfish?
- Have you ever gotten a tattoo?
Correct answer: Have you ever gotten a tattoo?
Hepatitis C is a blood-borne virus. It can be transmitted by contaminated needles used for tattoos. The most common means of transmission is sharing needles or syringes to inject drugs. The other options are questions about hepatitis A transmission.
- The nurse reviews recent lab results with a new client. Which elevated test level is most important for the nurse to address to reduce the client's risk of coronary artery disease (CAD)?
- Glucoamylase
- Low-density lipoprotein
- Triglyceride
- High-density lipoprotein
Correct answer: Low-density lipoprotein
Low-density lipoproteins (LDL) are directly associated with coronary artery disease (CAD). Along with cholesterol levels, LDL levels have a higher correlation with the risk of developing CAD than triglyceride levels. Glucoamylase is a digestive enzyme.
- A 17-year-old unmarried primigravida who is 9 weeks pregnant tells the nurse that her family doesn't have much money. Her dad just got laid off from his job. Which of the following actions would be most appropriate?
- Determine whether the client qualifies for local assistance programs
- Ask the client if she has a job and how much she earns
- Refer her to a social worker to enroll her in a food assistance program
- Teach the client ways to make low-cost, highly nutritious meals
Correct answer: Refer her to a social worker to enroll her in a food assistance program
The nurse should refer the client to a social worker to enroll her in a food assistance program. Teaching the client to make meals won't help if she and her family don't have any money. Determining qualifications for assistance is the social worker's job. Asking about a job is simply inappropriate.
- When reviewing the lab results of a neonate born 12 hours ago, which serum value should the nurse immediately report?
- WBC 22,000/mm3
- Glucose 28 mg/dL
- Platelets 180,000/mm2
- Hemoglobin 18.1 g/dL
Correct answer: Glucose 28 mg/dL
Neonatal hypoglycemia is defined as a plasma glucose level of less than 30 mg/dL (1.65 mmol/L) in the first 24 hours of life and less than 45 mg/dL (2.5 mmol/L) thereafter. The normal range for hemoglobin in the newborn is 17-19 g/dL; 17.2 g/dL. The normal range for platelets in the newborn is 150,000-400,000 mm?; 250,000/mm2. A white blood cell count of 18,00040,000/mm3 is normal in the newborn.
- On the third postpartum day, the color of the lochia discharge is typically
Correct answer: Rubra
Lochia is the vaginal discharge after giving birth, containing blood, mucus, and uterine tissue. There are three types of lochia: rubra (red or red/brown), which lasts up to 7 days; serosa (pink), which lasts up to 2 weeks; and alba (white), which lasts up to 6 weeks. The colors should not reverse. Mucous is not a type of lochia.
- A mother brings her 3-month-old infant to the pediatric clinic for a routine checkup. She tells the nurse that breastfeeding has gone well until the past week. She doesn't seem to be producing enough milk to satisfy the baby. What is the nurse's best response?
- Nurse more frequently during these growth spurts
- Wait at least 4 hours between feedings, so your breasts can fill
- It's now time to introduce solid foods to your baby
- Alternate formula with nursing to provide enough nourishment
Correct answer: Nurse more frequently during these growth spurts
Infants commonly have a growth spurt at about 3 months, so more frequent feedings will stimulate milk production. Solid foods are generally not introduced until 4-6 months of age. Supplemental formula and restricting feeding times will not increase the mother's milk supply.
- The nurse reviews a patient's recent orders and sees that informed consent must be obtained before tomorrow's surgery. The nurse was not present when the doctor explained the procedure to the patient. When the nurse brings the form to the patient, which statement to the patient is best?
- Do you have any questions about your surgery tomorrow?
- You have the right to change your mind at any time
- Your surgeon asked me to make sure that you sign the consent form
- What were you told about your surgical procedure?
Correct answer: What were you told about your surgical procedure?
Since the nurse was not in the room when the patient's doctor explained the procedure, the nurse should assess how much the patient understands. After listening, the nurse can answer further questions, provide patient education, or contact the doctor to get more information. As the patient's advocate, the nurse should make certain that the patient understands the surgery and is comfortable with the procedure before the patient signs the consent form.
- The nurse works in a unit that has a primary nursing care delivery model. What nursing activity is unique to this model?
- The nurse shares care of clients with unlicensed assistants
- The nurse has the responsibility from admission to discharge
- The nurse serves as liaison between providers and clients
- The nurse provides all care for assigned clients
Correct answer: The nurse provides all care for assigned clients
With primary nursing, one nurse manages care for assigned clients for the shift. Generally, the nurse provides care for a small group of clients, depending on their acuity. All nurses serve as a liaison between other team members and their clients. Working with other nursing staff is part of the team nursing model. Case management is the responsibility for guiding a client through the entire process.
- A nurse in the neonatal ICU (NICU) administers adult-strength digitalis (Digoxin, Lanoxin) to a 3-pound infant. As a result, the neonate experiences permanent heart and brain damage. The nurse can be charged with
- Negligence
- Tort
- Malpractice
- Assault
Correct answer: Malpractice
This nurse can be charged with malpractice, which is performing or failing to perform an act that results in harm to a client. Giving the infant an overdose, even if accidentally, constitutes malpractice. Negligence is failing to provide the proper standard of care for a patient. Tort is a wrongful act committed on the patient or the patient's belongings. Assault is a violent physical or verbal attack.
- Which legal document lists the medical procedures and treatments that a person will refuse if the person is unable to make decisions?
- Advance Directive
- Informed Consent
- Patient's Bill of Rights
- Power of Attorney
Correct answer: Advance Directive
An advance directive is a legal document that makes provision for future health care decisions if the person is unable to do so. It can include a Living Will and durable Power of Attorney for Health Care.
- The health care provider (HCP) prescribes bilateral soft wrist restraints for a client. Which of the following tasks can the nurse delegate to a certified nursing assistant (CNA)?
- Teach the client's family about the need for restraints
- Assist with bathing, feeding, and toileting
- Document the client's status every hour
- Assess when restraints are no longer indicated
Correct answer: Assist with bathing, feeding, and toileting
CNAs can be delegated tasks within their scope of practice Thus, they should be able to assist with activities of daily living (ADLs). The nurse is responsible for assessing the client and documenting the client's status every hour, including the person's mental status. The nurse is also responsible for monitoring the client's physical safety and providing any education regarding the need for, or the use of, restraints.
- The nurse is at home with their 10-year-old son when the child falls off his bike and his front tooth is avulsed (knocked out). The nurse is able to quickly retrieve the tooth. What is the nurse's BEST action before going to the Emergency Department?
- Quickly brush dirt off the root of the tooth
- Place the tooth in milk for transport to the ED
- Ask the child to hold the tooth in his cheek pouch
- Use a ziplock bag to protect the tooth
Correct answer: Place the tooth in milk for transport to the ED
An avulsed tooth is totally dislodged from its socket. It is medical/dental emergency that requires prompt treatment to minimize hypoxia and necrosis of the pulp of the tooth. Reinsertion should be done within a few hours. Do not touch or handle the root of the tooth. Rinse the tooth with saline and pack the socket with sterile gauze. The preferred storage solution is milk, with saline or saliva if milk is not available. Holding the tooth in the cheek helps keep it moist, but there is a risk of the child swallowing it, so this is not an ideal solution.
- Which ethical principle is used when a client asks about her prognosis?
- Veracity
- Beneficence
- Nonmaleficence
- Fidelity
Correct answer: Veracity
Veracity is the ethical principle that means to tell the truth. There can be no mistruth or deceit. Beneficence is the duty to do good and promote kindness. Fidelity is being faithful and keeping promises. Nonmaleficence is the duty to prevent harm and not to harm.
- The nurse manager notes that a staff nurse has been tardy three times in the last two weeks. Which of the following should the nurse manager do FIRST?
- Schedule a staff meeting to review policies
- Notify Human Resources of the nurse's behavior
- Place a reminder in the staff break room
- Ask the nurse to meet privately
Correct answer: Ask the nurse to meet privately
The nurse manager should first meet with the nurse in a private setting to find out why the nurse has been late and to review the attendance policy. Then the nurse manager can document the meeting for the staff nurse's employee file. If tardiness continues, the nurse manager should follow policy. Signs or reminders and staff meetings are neither useful nor effective.
- The PDCA cycle is a quality improvement method of implementing change. Which of the following steps is INCORRECT?
- P = Plan
- C = Check
- A = Access
- D=Do
Correct answer: A = Access
In healthcare, the PDCA Cycle is Plan-Do-Check-Act. Plan is the first step, to determine what to change. Do is the second step, to implement the change. The third step is Check, to compare the change to baseline. Act is the final step, to make the change permanent and continue to monitor.
- When a client is scheduled for a transesophageal echocardiogram (TEE), which task may be assigned to the unlicensed assistive personnel (UAP)?
- Give the client brief instructions on the procedure
- Ensure that the client has signed the informed consent
- Remove the water pitcher from the client's bedside
- Assess the client's anxiety level and tell the nurse
Correct answer: Remove the water pitcher from the client's bedside
The UAP may only perform basic tasks with a predictable outcome, such as removing the water pitcher from the client's bedside. The nurse must ensure that the client has signed the informed consent, give the client pre- and post-procedure instructions, and assess the client's anxiety level.
- Which of the following findings indicates the need to IMMEDIATELY stop a treadmill (exercise) stress test?
- Blood pressure 150/86 mmHg
- Heart rate of 142 bpm
- Pulse oximeter (SpO2) of 91%
- Chest pain of 4 on a 0-10 scale
Correct answer: Chest pain of 4 on a 0-10 scale
A report of chest pain can indicate myocardial ischemia; the test should be stopped immediately to avoid injury or infarction. An exercise stress test is usually performed on a treadmill. It requires about 8-12 minutes of making the heart work harder than baseline. The test is stopped for client complaints of chest pain or dizziness, severe or unexplained shortness of breath, extreme hypertension or hypotension, arrythmias, or abnormal changes in the ECG. Changes in vital signs related to exercise, such as increases in blood pressure and pulse and a decrease in oxygenation, are considered normal and should continue to be monitored.
- A client comes to the clinic with complaints of heart palpitations, shortness of breath, fatigue, and syncope. An ECG indicates atrial fibrillation. When the nurse performs an assessment, which finding is MOST concerning?
- Difficulty speaking
- History of type 2 diabetes
- Unplanned weight loss
- Heart rate of 150
Correct answer: Difficulty speaking
Difficulty speaking is indicative of a stroke. During atrial fibrillation (AF), (the atria beat chaotically and irregularly - out of coordination with the ventricles. Atrial fibrillation symptoms often include heart palpitations, shortness of breath, chest pain, fatigue, weakness, lightheadedness, fainting, and intolerance of exercise. The heart rate in AF can range from 100-175 bpm, sometimes higher, reducing cardiac output by 10-30%. AF causes a higher risk of stroke, due to the inability of the atria to contract. This leads to blood collecting in the atria and clot formation. Anticoagulant therapy is a priority in managing AF. Type 2 diabetes is a risk factor for developing AF, but is not the greatest concern at this time. Unplanned weight loss should be investigated, but is not the priority at this time.
- Nurse Practice Acts are an example of
- Statutory law
- Common law
- Civil law
- Criminal law
Correct answer: Statutory law
Statutory law comes from authoritative and legislative sources. Each US state has enacted a Nurse Practice Act, which establishes licensing agencies or boards that develop rules and regulations and oversee the practice of nursing.
- A preceptor is instructing a new nurse on the reasons for applying wrist or ankle restraints to a client. The preceptor realizes that further education is needed when the new nurse states,
- A restraint can limit movement of an arm or leg
- A restraint keeps the client in bed all night
- A restraint prevents a client from hurting himself or herself or others
- A restraint prevents a client from pulling out lines and catheters
Correct answer: A restraint keeps the client in bed all night
Restraints are ordered for specific situations to keep the client safe, immobilize a limb, or allow treatments or procedures to proceed. Restraints may never be applied for punishment or the convenience of the staff. Protocols for checking the client when restraints are in place must be followed.
- After instructing a client on how to provide a urine sample for a stat urinalysis, the nurse returns two hours later to find the specimen in the client's bathroom. What should the nurse do?
- Discard the urine and obtain a fresh specimen
- Immediately send the sample to the laboratory
- Refrigerate the sample before sending it to the lab
- Initiate an incident report for the delay
Correct answer: Discard the urine and obtain a fresh specimen
A urine sample that has been at room temperature for more than one hour is not acceptable and should be discarded. The urine will become alkaline, and bacteria can start to grow, leading to inaccurate results. If a sample cannot be immediately delivered to the laboratory, it should be refrigerated.
- When a nurse assesses the pin insertion site of a client in skeletal traction, which sign indicates normal healing?
- Exudate
- Crust
- Edema
- Colonization
Correct answer: Crust
Crusts or scabs (dry, scaly) are signs of normal healing and should be left in place. Exudate (moist, active drainage) is a clinical sign of wound infection. Colonization is the growth of pathogens, determined by lab cultures. Edema may be a sign of infection and should be evaluated.
- When you use a fire extinguisher, you should aim the nozzle at
- The area around the flames
- The top of the flames
- The middle of the flames
- The base of the fire
Correct answer: The base of the fire
The Occupational Safety and Health Administration (OSHA) states that the fire extinguisher nozzle should be aimed at the base of the fire. Remember to use the P.A.S.S. technique: Pull, Aim, Squeeze, Sweep. Your facility will provide annual training on fire emergencies.
- For a client with frequent fainting spells, the doctor orders a 24-hour ambulatory electrocardiography using a Holter monitor. To obtain the most accurate record, the nurse should instruct the client to avoid all of the following EXCEPT
- Eating with metal utensils
- Shaving with an electric razor
- Standing close to a microwave
- Using a cellular telephone
Correct answer: Eating with metal utensils
Using electrical devices, such as electric razors and toothbrushes, may alter the data recorded with a Holter monitor. Patients are also generally advised to avoid magnets, microwaves, electric blankets, cell phones, and MP3 players.
- Before the nurse sends a client for a CT with contrast dye, what is the nurse's most important action?
- Teach the client about the need for post-procedure hydration
- Place the side rails of the bed up before transport
- Verify that the informed consent is complete
- Check the client's health record for allergies
Correct answer: Check the client's health record for allergies
It is most important to ask the client about allergies and check the client's health record for allergies. Contrast dye contains iodine, which is related to shellfish allergies.
- The nurse is caring for a client with a right-brain stroke with accompanying unilateral neglect (hemineglect). Which of the following actions is most appropriate?
- Place the nightstand on the client's right side
- Encourage the client to use the right side
- Tell the client, "Look to your left."
- Approach the client from the left side
Correct answer: Approach the client from the left side
Unilateral neglect is a lack of awareness of the side that was affected by the stroke. For a right-sided stroke, the client will have left-sided deficits, and in this case, no awareness of the left side. Helpful actions include approaching the client from the neglected side, placing a chair and bedside table with belongings on the neglected side, holding the neglected hand, and including the neglected hand in daily tasks. Saying "Look to the left" or "Where is your glass of water?" is not helpful. However, place the call light on the strong or unaffected side so that the client can use it easily.
- As the nurse completes a routine preoperative checklist before transporting the patient to surgery, the patient tells the nurse about an allergy that is not on the health record. What should the nurse do first?
- Tape a note to the chart
- Contact the anesthesiologist
- Notify the OR charge nurse
- Proceed to give the pre-operative medication
Correct answer: Contact the anesthesiologist
The anesthesiologist (and the nurse anesthetist) must have all available knowledge about the patient's medical information, because they monitor the patient's physical condition during surgery. If any new information becomes available prior to transporting the patient, a direct call to the anesthesiologist is required to ensure patient safety.
- The nurse is caring for an 84-year-old client with a Stage Il pressure ulcer on the coccyx. Which of the following is an appropriate action?
- Elevate the head of the bed to 45 degrees
- Obtain daily cultures of the pressure ulcer
- Reposition the client every 2 hours
- Leave the wound uncovered to dry out
Correct answer: Reposition the client every 2 hours
A Stage Il pressure ulcer is partial thickness skin loss involving the epidermis or dermis. The skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The nurse should relieve the pressure on the wound as well as protect it. The client should be repositioned every 2 hours, and the head of the bed should not be elevated more than 30 degrees. The ulcer should be covered with a protective dressing. Daily cultures are not indicated unless ordered by the provider.
- A second-day post-op client tells the day nurse, "I was in agony last night! couldn't sleep because of the pain!" Which of the following is the nurse's best response?
- Did you tell the night nurse that you were in pain?
- Why didn't you just ask for pain medication?
- Oh, I'm so sorry. You must be exhausted
- Your pain doesn't seem to be well controlled
Correct answer: Your pain doesn't seem to be well controlled
The best response is the one that shows the nurse is listening to the client's concerns. Restating the message is therapeutic. Avoid saying "should" or blaming the client for not doing something. Feeling sorry for the client lets the client be a victim, which is not helpful.
- A client is admitted with a diagnosis of a respiratory infection and is placed on droplet precautions. What is the MINIMUM PPE required when caring for this client?
- Face shield, mask, gloves, gown
- Gloves, gown, N95 respirator mask
- Gloves, disposable surgical mask
- Face shield, mask, sterile gloves
Correct answer: Gloves, disposable surgical mask
Droplet precautions are necessary when a patient infected with a pathogen such as influenza may come within three to six feet of others. Infections are transmitted through air droplets by coughing, sneezing, talking, and close contact. Droplets are about 30 to 50 micrometers in size. According to the CDC, droplet precautions include following standard precautions (hand hygiene and gloves) and wearing a mask: "Personnel should wear protective surgical masks before interacting between an infected patient or his/her environment." A N95 mask is not indicated for droplet precautions. Face shield, mask, gloves, and gown are the maximum PPE for droplet precautions. Sterile gloves are not indicated for droplet precautions.
- Which is the correct sequence for using a fire extinguisher?
- 1. Squeeze the handle. 2. Pull the pin. 3. Step back. 4. Sweep side to side
- 1. Aim the nozzle. 2. Pull the pin. 3. Squeeze the handle. 4. Sweep side to side
- 1. Pull the pin. 2. Aim the nozzle. 3. Squeeze the handle. 4. Sweep side to side
- 1. Pull the pin. 2. Squeeze the handle. 3. Aim the nozzle. 4. Sweep side to side
Correct answer: 1. Pull the pin. 2. Aim the nozzle. 3. Squeeze the handle. 4. Sweep side to side
Remember the acronym "P.A.S.S." when using a fire extinguisher: Always pull the pin first, then aim the nozzle at the fire. Start to squeeze the handle and sweep side to side. The other answer options are not in the proper sequence.
- One of the major safety concerns after a client receives conscious sedation (also called moderate or procedural sedation) is a risk of
- Hypertensive crisis
- Inability to swallow
- Falls or accidents
- Loss of hearing
Correct answer: Falls or accidents
Conscious sedation (moderate or procedural sedation) is a combination of medicines to relax (a sedative) and to block pain (an anesthetic) during a medical or dental procedure. Conscious sedative is rapid in terms of its actions and it is relatively rapid in terms of the client's return to their preanesthesia state, however, the client remains at risk for falls and other accidents until they have fully recovered. The other options are not related to conscious sedation.
- Contraindications for administering an enema include all of the following EXCEPT
- Recent colon surgery
- Hypercalcemia treatment
- Acute myocardial infarction
- Suspected appendicitis
Correct answer: Hypercalcemia treatment
An enema may be used to administer sodium polystyrene sulfonate (Kayexalate) for the treatment of hyperkalemia. Kayexalate can be administered either orally or as an enema. Sodium polystyrene sulfonate is not absorbed from the gastrointestinal tract. As the resin passes through the gastrointestinal tract, the resin removes the potassium ions by exchanging them for sodium ions. Recent colon surgery, acute myocardial infarction, and suspected appendicitis are contraindications for administering an enema. With elderly clients, enemas should be used with caution because of their higher risk of hyperphosphatemia, perforation, and sepsis.
- The nurse is providing education for a client who has just been prescribed a transcutaneous electrical nerve stimulation (TENS) unit for relief of chronic back pain. Which of the following instructions to the client is correct?
- Each TENS unit session lasts about 3 hours.
- Muscle twitching means the TENS is working.
- Don't go to sleep with the TENS unit on.
- It will take several days to build up tolerance.
Correct answer: Don't go to sleep with the TENS unit on.
TENS relieves acute and chronic pain by using a mild electrical current that stimulates nerve fibers to block the transmission of pain impulses to the brain. The current is delivered through electrodes placed on the skin at points determined to be related to the pain. Clients should not go to sleep with the TENS unit on. Clients are typically instructed to use the TENS unit for 30–60 minutes at a time, depending on the type of pain. TENS may result in instant and possibly prolonged pain relief. Muscle twitching may indicate overstimulation.
- A patient diagnosed with Crohn's disease has a new colostomy. When assessing the patient's stoma, which of these would alert the healthcare provider that the stoma has retracted?
- Dry and reddish purple
- Concave and bowl shaped
- Narrowed and flattened
- Pinkish red and moist
Correct answer: Concave and bowl shaped
A colostomy is created when the bowel is pulled through an opening in the abdominal wall, creating a stoma through which intestinal contents will pass. A healthy stoma will protrude about 2.5 cm with an open lumen at the top. The stoma should appear pinkish red and moist. A dry, dusky, or reddish-purple stoma indicates ischemia. A narrowed, flattened, or constricted stoma indicates stenosis. A concave and bowl-shaped stoma has retracted. A retracted stoma can be difficult to care for. Complications include problems maintaining appliance placement, leading to leakage and sore skin.
- A patient with a total hip replacement requires certain equipment for recovery. Which of the following will assist the patient with activities of daily living (ADL)?
- Abduction pillow
- Recliner
- High-seat commode
- TENS unit
Correct answer: High-seat commode
A high-seat commode keeps the hip higher than the knee. A recliner is helpful because it prevents 90° flexion, but it is not necessary for activities of daily living (ADL). A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management, and an abduction pillow is used to prevent hip adduction and possibly dislocation of the prosthesis, but neither are part of ADL.
- Of the following positions, which one facilitates maximum air exchange?
- Orthopneic
- Trendelenburg
- Lithotomy
- High Fowler's
Correct answer: Orthopneic
Orthopneic (sitting in a leaning position) allows for the most lung expansion. High Fowler's can help, but it isn't as effective as the orthopneic position. Trendelenburg is used for hypotension or low cardiac output. Lithotomy is used for vaginal examinations and childbirth.
- After a high school athlete sustains a fractured femur during a competition, a full leg plaster cast is applied. When the nurse provides discharge instructions to the athlete and their parents six hours later, which statement by the athlete indicates a need for further education?
- I should walk around on my cast as soon as I get home.
- I should call my doctor if my toes turn blue or become numb.
- I'll put an ice pack over the cast to relieve itching.
- I will prop my cast on two pillows when I lie down.
Correct answer: I should walk around on my cast as soon as I get home.
Plaster casts are made up of a bandage and a hard covering, usually plaster of Paris. Client instructions include: 1 keep the limb raised on a soft surface, such as a pillow, for as long as possible in the first few days. This will help any swelling to go down. 2. Keep the cast dry. If the plaster gets wet, it weakens and is unable to support the bone. 3. Do not put anything into the cast to relieve itching. This can damage the skin and cause an infection. A hair dryer set on cool or an ice pack over the itchy area can help. 4. Immediately report any pain, tingling, or numbness, or if the toes turn blue or white.
- A client with a severe ankle sprain will be using crutches. Which of the following indicates that the crutches have been fitted correctly?
- The client's elbow is locked with the hand on the handgrip
- The client's axilla rests on the erutch pad when the client ambulates.
- The client's axilla is at the same level as the top of the crutch.
- The client's elbow is at a 30-degree angle with the hand on the handgrip.
Correct answer: The client's elbow is at a 30-degree angle with the hand on the handgrip.
Proper crutch measurements result in the client's weight being on the hands, not the axilla. This avoids damage to the brachial plexus. The elbow should be at a 30-degree flex, not straight. The top of the crutch should be 2 to 3 finger widths lower than the axilla.
- The nurse is providing discharge instructions to parents of a 3-year-old who was hospitalized for severe croup. In the event of a future croup attack, what non-pharmacological intervention can the parents do at home?
- Position the child on their back or side.
- Place the child in a warm, dry room.
- Encourage the child to cough and cry.
- Take the child into a steamy bathroom.
Correct answer: Take the child into a steamy bathroom.
If their child develops croup at home, the parents should make steam by running a hot bath or shower in a closed bathroom. They can then take the child into the steamy room and let the child breathe the moist, humid air. This will liquefy and mobilize secretions. The parent should hold the child in an upright position and reassure the child. A dry room does not help loosen secretions. Crying can irritate and contribute to hypoxia.
- When providing postmortem care for a patient who will be an eye donor, which action is most appropriate?
- Tape the eyes tightly and place the patient in a high Fowler's position.
- Close the eyes and place the patient in a supine position.
- Cover the eyes with saline-soaked pads and place the patient in a low Fowler's position.
- Apply silver nitrate to the eyes and place the patient in a Trendelenburg position.
Correct answer: Cover the eyes with saline-soaked pads and place the patient in a low Fowler's position.
When preparing a deceased patient for eye or corneal donation, close the eyes and cover them with soaked gauze pads to keep them moist. Apply a small ice pack to the eyes, if possible. Elevating the head of the bed will help the eyes remain closed.
- Before administering a soap suds enema, which position is appropriate for the client?
Correct answer: Sims
To receive an enema, the client should be in the Sims position. The client lies on their left side, with the right leg flexed forward. This position facilitates the flow of the enema solution into the rectum and colon. Supine position is lying horizontally with the face and torso facing up. Prone position is lying horizontally with the torso down and the head turned to the side. Lithotomy position is lying on the back with hips and legs flexed 90 degrees.
- The nurse is educating a client with cardiac disease who is taking furosemide and digoxin about eating foods rich in potassium. The client states, "I know need potassium, but I get tired of eating bananas." The nurse then suggests choosing any of the following foods EXCEPT
- Spinach
- Blueberries
- Potatoes
- Avocados
Correct answer: Blueberries
One baked potato (with the skin on) can deliver over 1,000 milligrams of potassium - more than twice the potassium in one small banana. Other foods that have more potassium than a small banana are raisins, lima beans, avocados, sweet potatoes, spinach, white or black beans, and squash. Blueberries are low in potassium and are often recommended for clients with chronic kidney disease.
- A client has a nephrostomy tube. When the nurse assists the client to ambulate, which is the best way to keep the tube safe?
- Ask the client to hold the drainage bag.
- Clamp the tube during ambulation.
- Attach the tube to a leg collection bag.
- Use a walker and tie the drainage bag.
Correct answer: Attach the tube to a leg collection bag.
The nurse should attach the nephrostomy tube to a leg collection bag during ambulation. This allows easier movement and maintains the collection bag below waist level. Using a walker or holding the bag increases the risk of the tube being pulled out. The tube should not be clamped without a provider's prescription.
- The healthcare provider is assessing a patient recovering from a total knee replacement. Which of these assessment findings indicates the patient is at risk of developing a complication from the surgery?
- Pale toenail beds
- Incision site edema
- Hemoglobin 12.5 g/dL
- Homans' sign negative
Correct answer: Pale toenail beds
Pale nailbeds of the toes indicate neurovascular damage. Other signs of neurovascular dysfunction in an extremity include diminished or absent pedal pulses; capillary refill in toes > 3 seconds; inability to flex or extend the knee, foot, or toes; and numbness or tingling in the foot. Edema should be monitored but is an expected finding during the initial recovery period. A negative Homans' sign is part of an expected assessment finding if the patient is not experiencing a deep vein thrombosis. The patient's hemoglobin is within the normal range of 13.5–17.5 gm/dL for males and 12.0-15.5 gm/dL for females.
- While doing admit for a male client, the nurse asks about possible allergies. The client denies any drug allergies but states he is allergic to bananas and avocados. The nurse knows these allergies put the client at risk for an allergy to
- Adhesive
- Betadine
- Latex
- Penicillin
Correct answer: Latex
The proteins in bananas, avocados, apples, carrots, melon, and tomatoes are similar to those in latex, so persons who are allergic to any of those foods should also avoid latex products. Clients with a history of using latex products, such as healthcare workers, may also have developed a sensitivity. Allergic reactions to latex include rash, itching, reddened skin, asthma-like symptoms, or even anaphylaxis.
- For a stroke patient, what is the best position for insertion of a nasogastric (NG) tube?
- Low Fowler's
- Supine
- High Fowler's
- Trendelenburg
Correct answer: High Fowler's
High Fowler's position is the best position to avoid aspiration. Have an emesis basin and suction equipment nearby because tube insertion can cause temporary nausea.
- Before administering an intermittent enteral feeding by nasogastric tube (NGT), what is the nurse's FIRST action?
- Measure any residual content
- Place the client in the Low Fowler's position
- Verify proper tube placement
- Assess for active bowel sounds
Correct answer: Verify proper tube placement
Before administering an enteral feeding, the nurse should ensure that the NGT is still properly placed in the stomach. Absent bowel sounds do not necessarily indicate lack of peristalsis. Clients are placed at 30-45 degrees. Residual is measured before each intermittent feeding.
- While providing post-operative care for a 7-year-old who has had a tonsillectomy and adenoidectomy, which is the appropriate nursing action?
- Encourage the child to gargle and spit
- Initiate coughing and deep breathing
- Offer warm liquids as soon as possible
- Observe for signs of post-op bleeding
Correct answer: Observe for signs of post-op bleeding
The nurse should be alert for any signs of post-op hemorrhage. Appropriate actions include direct observation of the throat, checking for vomiting of bright red blood, watching for continuous swallowing, and noting any changes in vital signs. The other options all present a risk of dislodging a blood clot or promoting post-op bleeding.
- The nurse is teaching a client with emphysema how to do pursed-lip breathing. The nurse knows it will help the client because
- It will help the client achieve maximum inhalation
- It helps keep the small airways open and prevents air trapping
- It increases the respiratory rate and oxygenation levels
- It creates negative pressure in the airways
Correct answer: It helps keep the small airways open and prevents air trapping
Decreased elastic recoil results in airway collapse during expiration. Air gets trapped in the lungs, and exhalation becomes difficult. Pursed-lip breathing improves ventilation by keeping the small airways open and releases air that is trapped in the lungs.
- Following a fall from a ladder, a patient is admitted to the ICU with a diagnosis of traumatic brain injury (TBI). The nurse observes that he is increasingly restless and has developed weakness in his right arm. He is also complaining of nausea. What is the nurse's BEST immediate action?
- Elevate the head of the bed to 30 degrees
- Measure the patient's blood pressure
- Increase the IV rate and call the physician
- Administer oxygen by face mask
Correct answer: Elevate the head of the bed to 30 degrees
The patient's symptoms indicate an increase in intracranial pressure (ICP). The best immediate action for the nurse is to relieve the ICP by elevating the head of the bed to 30 degrees. Oxygen therapy will not decrease ICP. Increasing the IV can be harmful. Taking the patient's blood pressure is not an immediate action, but it can be done before contacting the physician about the patient's change in status.
- Seven months after birth, an infant is diagnosed with a persistent patent foramen ovale (PFO). The parents ask the nurse what this means. The nurse explains that before the infant was born, the purpose of the foramen ovale was to bypass
- The superior vena cava
- The pulmonary system
- The left ventricle
- The hepatic system
Correct answer: The pulmonary system
In fetal circulation, the foramen ovale shunts some blood from the right atrium to the left atrium, bypassing the pulmonary system. From the left atrium, blood goes to the left ventricle. Since the fetus receives oxygen from the maternal circulation, the hepatic circulation and superior vena cava are unaffected. Normally, about 75% of foramen ovales seal completely within a few months after birth. If the foramen ovale does not, it's called a patent foramen ovale (PFO). Most PFOs require no treatment.
- A client with a diagnosis of congestive heart failure (CHF) is taking digoxin (Lanoxin) 0.25 mg po qd and furosemide (Lasix) 20 mg po bid. Which is the MOST important laboratory test result for the nurse to monitor?
- Potassium
- Chloride
- Calcium
- Magnesium
Correct answer: Potassium
Furosemide (Lasix) is a non-potassium-sparing loop diuretic. Hypokalemia is a common side effect of furosemide and may enhance digoxin toxicity. While it may affect the excretion rates of all electrolytes, hypokalemia can cause ventricular arrythmias and sudden cardiac death.
- A nurse educates a client who is scheduled for a lipid panel. Which of the client's statements would indicate a lack of understanding?
- This test will check if I have fatty liver disease.
- I won't drink alcohol for 24 hours before this lipid test.
- This test will help check my risk of heart disease.
- I will fast for 8-12 hours before my blood draw.
Correct answer: This test will check if I have fatty liver disease.
Fatty liver disease may be indicated after liver enzymes, alanine aminotransferase test (ALT), and aspartate aminotransferase test (AST), are elevated. Further evaluation by liver biopsy, ultrasound, or CT scan will confirm the diagnosis. The lipid panel measures total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides. Elevated levels can mean an increased risk of atherosclerosis and heart disease. For a lipid panel, the client should avoid alcohol for 24 hours, because it can raise the triglyceride level. Fasting is prescribed, unless the HCP states otherwise.
- The nurse is giving discharge instructions to a male client who had a total hip arthroplasty. Which statement by the client indicates a lack of understanding?
- I shouldn't sit for longer than 45 minutes at a time.
- I'll use a raised toilet seat for about the next six weeks.
- I can bend over to pick up things I've dropped on the floor.
- I'll tell my dentist that I've had a total hip replacement.
Correct answer: I can bend over to pick up things I've dropped on the floor.
Discharge instructions for a client who had a total hip arthroplasty include the following: 1. Don't sit for more than 30 to 45 minutes at a time. 2. For the first 6-12 weeks after surgery, avoid bending the hip beyond 60 to 90 degrees. Don't bend at the waist to put on socks and shoes or pick up items from the floor. 3. Use a raised toilet seat for about 6 weeks. 4. Check the incision daily for redness, swelling, or drainage. Arrange to have the staples removed in two weeks. 5. Don't drive until your provider gives you approval. 6. Sit in chairs with your arms and knees slightly lower than your hips. 7. Don't cross your legs. 8. Notify all your providers - including your dentist - of your surgery.
- For a client receiving chemotherapy, which laboratory value is MOST important for the nurse to monitor?
- Serum creatinine
- Prothrombin time
- Electrolyte panel
- White blood cell count
Correct answer: White blood cell count
White blood cell (WBC) counts should be carefully monitored in a client receiving chemotherapy. If the neutrophil count is below normal (1,500-8,000 (1.5-8.0) neutrophils/mcL), neutropenia can put the client at risk for infection. Mild neutropenia: 1,000-1,500 neutrophils/mcL. Moderate: 500-1,000 neutrophils/mcL. Severe: <500 neutrophils/mcL. The other lab values are part of the client's overall health picture, but not specific to chemotherapy.
- Before administering a dose of furosemide (Lasix) to a 2-year-old with a congenital heart defect, the nurse should confirm the child's identity by checking the hospital ID band and
- Asking the child to state their name
- Verifying the child's identity with a second nurse
- Verifying the child's room number
- Asking the parent for the child's name
Correct answer: Asking the parent for the child's name
Standards of safe medication administration require obtaining two patient identifiers before proceeding. For a child, a parent can give the child's name. Many young children do not know their full name or are accustomed to being called by a nickname. Adults can be asked the child's name and birth date. Room numbers are not a reliable means of verifying identification.
- A patient is prescribed a thiazide diuretic for the treatment of hypertension. When teaching the patient about the medication, which of the following will the healthcare provider include?
- Be sure to include a number of foods in your diet that are rich in potassium.
- I'll teach you how to take your radial pulse before taking the medication.
- Take this medication every day with a large glass of water after your evening meal.
- Stop taking this medication if you notice changes in how much you urinate.
Correct answer: Be sure to include a number of foods in your diet that are rich in potassium.
Because thiazide diuretics produce an increase in urine output, the patient should avoid taking the medication in the evening so that sleep is not interrupted. Potassium is lost in the urine along with sodium and chloride, so the patient should be instructed to include potassium-rich foods in the diet to avoid hypokalemia. Examples of potassium-rich foods include avocados, spinach, sweet potatoes, yogurt, and bananas.
- When a provider prescribes an IV infusion medication to be titrated, which of the following elements is NOT required to be part of the order?
- Objective clinical endpoint or patient response
- Ability of the nurse to determine the units of incremental rate
- Frequency for increasing or decreasing incremental dose
- Initial or starting rate of the infusion (dose/minute)
Correct answer: Ability of the nurse to determine the units of incremental rate
According to the Joint Commission, required elements for medication titration orders include the following: 1. medication name; 2. medication route; 3. initial or starting rate of infusion (dose/min); 4. incremental units the rate can be increased or decreased; 5. frequency for incremental doses (how often the dose (rate) can be increased or decreased); 6. maximum rate (dose) of infusion; 7. objective clinical endpoint or patient response. The nurse follows the titration prescription and does not make independent determinations regarding the infusion.
- A client with a diagnosis of depression is placed on a monoamine oxidase inhibitor (MAOI) medication. When a nurse educates the client, which food should the nurse instruct the client to avoid?
- Grapefruit
- Peanut butter
- Bacon
- Cottage cheese
Correct answer: Bacon
Tyramine is a compound that can affect blood pressure. Tyramine is regulated by the monoamine oxidase (MAO) enzyme, which helps break it down. MAOIs work by restricting the MAO enzyme, reducing the symptoms of depression and anxiety. However, foods and beverages that are high in tyramine can constrict blood vessels and cause life-threatening spikes in blood pressure.
- A client with a urinary tract infection (UTI) is started on sulfamethoxazole/trimethoprim (Bactrim, Septra). When educating the client on the medication, which instruction is most appropriate?
- Expect that urine will be orange
- Drink 6-8 glasses of water every day
- Measure and record urine output.
- Always take the medication with a meal or snack.
Correct answer: Drink 6-8 glasses of water every day
Sulfamethoxazole and trimethoprim combination is used to treat infections such as urinary tract infections, middle ear infections (otitis media), bronchitis, traveler's diarrhea, and shigellosis (bacillary dysentery). Adequate fluid intake is necessary to prevent the adverse effect of crystalluria. The medication does not have to be taken with food. Urine output does not need to be measured. Phenazopyridine, a urinary analgesic, turns urine orange or red.
- When counseling a client with a new diagnosis of hypothyroidism who is starting on levothyroxine (Synthroid), the nurse should inform the client about which possible side effect?
- Weight gain
- Weight loss
- Photophobia
- Hypersomnia
Correct answer: Weight loss
Weight loss is a possible side effect of levothyroxine, because of increased metabolism. Weight gain and photophobia (light sensitivity) are not side effects of levothyroxine. Levothyroxine can cause insomnia, not hypersomnia (excessive daytime sleeping).
- The nurse receives an order to administer 65 mg of acetaminophen solution q 4-6 hrs prn for fever. The pharmacy sends a bottle labeled 80 mg per 5 mL. How much should the nurse administer per dose?
Correct answer: 4 mL
To calculate the correct dose, divide the desired dose by the amount on hand, then multiply by the volume (HD×V). For this question: 80 mg65 mg×5 mL=4 mL.
- A client with Irritable Bowel Syndrome (IBS) tells the nurse that they are using Complementary and Alternative Medicine (CAM) methods, including taking probiotics, peppermint oil, and herbal supplements. What is the nurse's BEST response?
- None of these is harmful, but you're wasting your money.
- There is no proof that these methods will relieve your IBS.
- These are dangerous and you should stop taking them at once.
- Be sure to tell your provider what you're taking.
Correct answer: Be sure to tell your provider what you're taking.
Current drug therapies for IBS are not effective for all clients. CAM can be helpful, but clients should inform their health care providers about any supplements or methods they are using, because they may interact with prescribed medications. Peppermint oil and probiotics are supported by enough evidence to recommend their use. Some herbal formulas are supported by limited evidence, but quality and purity should be considered. Other CAM methods include acupuncture, hypnotherapy, and cognitive-behavioral therapy.
- A client with a diagnosis of bacterial pneumonia is receiving erythromycin 500 mg PO q 6 hr. Which common side effect may be anticipated?
- Nausea and vomiting
- Weight gain
- Muscle weakness
- Brisk tendon reflexes
Correct answer: Nausea and vomiting
Nausea, vomiting, and diarrhea can occur with antibiotic therapy, because the intestinal biodome is disrupted. Clients can be encouraged to eat foods with prebiotics, probiotics, fiber, as well as fermented foods. Other common side effects include abdominal cramping or discomfort, and loss of appetite. Muscle weakness can indicate hyperkalemia. Brisk tendon reflexes (Hyperreflexia) is associated with a lesion above the level of spinal reflex pathways. Weight gain is not a side effect of erythromycin.
- Which of the following medications works by inhibiting platelet aggregation?
- Coumadin
- Warfarin
- Aspirin
- Neomycin
Correct answer: Aspirin
Aspirin inhibits the enzyme COX-1, which produces thromboxane A2, which is necessary for platelet aggregation. Aspirin is one of the oldest drugs in the world, going back to ancient times. Warfarin (Coumadin) blocks Vitamin K-dependent clotting factors. Heparin increases the effect of antithrombin to inhibit thrombin activation. Neomycin is an antibiotic.
- The health care provider (HCP) prescribes 300,000 units Penicillin GIM q 6 hr. Pharmacy dispenses a vial with directions to add 10 mL of sterile water to reconstitute to a concentration of 100,000 units/mL. How many mL will be in each dose?
Correct answer: 3 mL
The nurse will administer 3 mL per dose. To calculate: 300,000 units×100,000 units1 mL=3 mL. NOTE: once the vial is reconstituted, the amount of added diluent is not a factor in calculating the dosage.
- A morphine sulphate injection contains 10 mg/mL. What is the percentage concentration?
Correct answer: 1%
To express the value as a percentage, convert the number of mg in 1mL to grams in 100mL. For this question: 1. 10 mg = 0.01 gm 2. 0.01 gm morphine sulphate is in 1 ml solution. 3. 1 gm morphine sulfate is in 100 mL solution = 1% weight/volume (w/v).
- A pediatric nurse is educating the parents of a child with a new diagnosis of asthma about recognizing food triggers. Of the following, which is MOST likely to cause an allergic reaction?
- Bananas
- French fries
- Apple juice
- Salmon
Correct answer: French fries
Food allergens commonly associated with allergic reactions in asthma include wheat, eggs, dairy products, citrus fruits, corn, tree nuts, and chocolate. Foods fried or cooked in Omega-6 oils can trigger an allergic response. Food allergies can be dangerous for people with asthma. Bananas may actually help children breathe easier; research shows a banana a day reduces asthmatic symptoms by 34%. Apple juice contains Vitamin C and flavonoids, which support lung health and reduce allergy symptoms. Fatty fish, such as salmon, can reduce inflammation.
- A patient who recently quit smoking asks a healthcare provider about the risks of developing lung cancer. Which of the following is the healthcare provider's best response?
- In 8 months, the risk of developing lung cancer will be twice as high as for a nonsmoker
- If lung cancer hasn't developed yet, the ongoing risk is the same as for a non-smoker
- For someone who quits smoking, the risk of developing lung cancer will remain constant and higher than for nonsmokers
- In 15 years, the risk of developing lung cancer will be the same as for a nonsmoker
Correct answer: In 15 years, the risk of developing lung cancer will be the same as for a nonsmoker
Over a long period, the damaged cells in the lungs can be replaced by healthy cells. In 15 years, this patient's risk of developing lung cancer will be no higher than that of a nonsmoker. The benefits of quitting smoking begin within 20 minutes, when the heart rate returns to normal. After one month, cilia in the lungs start to recover. At one year, the risk of developing heart disease will be half that of a smoker.
- A 68-year-old male has a diagnosis of possible abdominal aortic aneurysm (AAA). When the nurse asks about signs and symptoms, which statement by the client would be most accurate?
- I haven't really noticed anything unusual
- My legs and feet always feel numb
- I’m nauseated and sometimes I Vomit
- I have a terrible pain in my stomach
Correct answer: I haven't really noticed anything unusual
Many people with an abdominal aortic aneurysm (AAA) experience no symptoms until the AAA expands or ruptures. Clients may experience no symptoms except for a pulsation in the abdomen when the client is in a reclining position. The other options are all symptoms of an expanding or impending rupture.
- A client presents to the Emergency Department with signs of a myocardial infarction. The client is admitted to the cardiac unit. The next day, the client denies having chest pain. When the nurse reviews the ECG rhythm strip, the PR intervals are 0.16 seconds. How should the nurse interpret this rhythm?
- This is within normal PR interval limits
- The rhythm indicates a first-degree heart block
- The nurse should immediately notify the provider
- This is an early sign of reinfarction
Correct answer: This is within normal PR interval limits
The PR interval is the time from the onset of the P wave to the start of the QRS complex. It reflects conduction through the AV node. The normal PR interval is between 0.12 and 0.20 seconds in duration (three to five small squares). If the PR interval is greater than 0.20 seconds, a first-degree heart block is present.
- When a client suddenly experiences asystole or pulseless electrical activity (PEA), which vasopressor is administered FIRST?
- Dopamine
- Amiodarone
- Epinephrine
- Atropine
Correct answer: Epinephrine
A vasopressor is a medication that produces vasoconstriction and a subsequent rise in blood pressure. Vasoconstriction is important during CPR because it will increase blood flow to the brain and heart. Epinephrine is the first drug to be administered: Epinephrine 1 mg is given STAT, then again every 3-5 minutes. Amiodarone is used for supraventricular and ventricular arrhythmias. Dopamine is given for systolic BP < 100 mmHg or bradycardia. Atropine during asystole or PEA has not been shown to be effective; the AHA removed it from cardiac arrest guidelines.
- A patient who has experienced a stroke is being monitored during the acute management phase. The clinician notes that the patient's intracranial pressure (ICP) is 30 mmHg. Which of the following interventions should be performed first?
- Raise the head of the bed to 30°
- Place the patient in a Sims' position
- Obtain vital signs and measure urine output
- Assess level of consciousness
Correct answer: Raise the head of the bed to 30°
In the acute management phase, stroke patients can develop increased intracranial pressure (ICP), which can complicate recovery and increase the risk of death. An ICP greater than 20 mmHg requires immediate intervention. The head of the bed should be elevated to 30° to allow for an immediate decrease in ICP. Laying the patient flat would decrease venous drainage from the brain and contribute to increased ICP. Vital signs and other neurological assessments should be performed afterward, and the provider should be notified. Assessing the patient's level of consciousness and taking their vital signs are important if a change in ICP is noted, but those are not the priority interventions. Sims' position is used for rectal exams and administering enemas.
- The healthcare provider is assessing a patient admitted with a diagnosis of hemorrhagic stroke affecting the right cranial hemisphere. Which assessment finding is consistent with this diagnosis?
- Kernig's sign
- Bilateral Babinski's sign
- Left-sided flaccidity
- Right-sided spasticity
Correct answer: Left-sided flaccidity
A patient who has sustained damage to the right cranial hemisphere will experience loss of motor function on the left side of the body. Kernig's sign is an indication of meningeal irritation and is not an expected finding. Spasticity is muscle tightness and loss of control over the muscles. Flaccidity is low muscle tone. Flaccid paralysis, a complete lack of voluntary movement, often occurs immediately after the stroke.
- Soon after admission, a patient displays signs of possible pulmonary edema. Which position is most appropriate for this patient?
- Sims'
- Trendelenburg
- Fowler's
- Orthopneic
Correct answer: Fowler's
Fowler's - specifically, High Fowler's at 90 degrees - will decrease venous return to the heart and increase lung expansion. Sims' position places the patient on their left side and is used for rectal examinations. In Trendelenburg position, the patient is supine with the head lowered, which would overload the lungs. Orthopneic position is used when a patient cannot tolerate lying down, but it decreases lung expansion.
- A 52-year-old female client presents to the clinic with symptoms of abdominal swelling accompanied by weight loss. She tells the nurse that when she eats, she feels full quickly; also, sex has become painful. The nurse recognizes these symptoms as clinical indications of
- Heart failure
- Ovarian cancer
- Renal metastases
- Liver disease
Correct answer: Ovarian cancer
Often, ovarian cancer has either no symptoms or vague symptoms such as weight loss, bloating, difficulty eating, painful sex, urinary urgency, and constipation. Then the cancer goes undetected until it has spread within the abdomen and pelvis. Only when a combination of symptoms appear - and are persistent and represent a change from normal - can healthcare providers consider the possibility of ovarian cancer.
- When the nurse observes an isolated premature ventricular contraction (PVC) on a patient's cardiac monitor, which action by the nurse is most appropriate?
- Continue watching the client's rhythm.
- Administer a calcium channel blocker
- Immediately notify the primary care provider
- Move the code cart to the bedside
Correct answer: Continue watching the client's rhythm.
The nurse should continue to monitor the client's rhythm. PVCs are relatively common. Up to 80% of people without heart disease will have at least one PVC during a 24-hour Holter monitor study. At this point, without other information available, no other actions are indicated.
- Which finding accurately describes Grade 3 pitting edema?
- Pressure leaves an indentation of 5-6 mm that takes up to 30 seconds to rebound
- Pressure leaves an indentation of 0-2 mm that rebounds immediately
- Pressure leaves an indentation of 8 mm or deeper. It takes more than 20 seconds to rebound
- Pressure leaves an indentation of 3-4 mm that rebounds in less than 15 seconds
Correct answer: Pressure leaves an indentation of 5-6 mm that takes up to 30 seconds to rebound
Pitting edema is an indentation that remains after pressure is removed. Grade 1: Pressure leaves an indentation of 0-2 millimeters (mm) that rebounds immediately. This is the least severe type of pitting edema. Grade 2: The pressure leaves an indentation of 3-4 mm that rebounds in less than 15 seconds. Grade 3: The pressure leaves an indentation of 5-6 mm that takes up to 30 seconds to rebound. Grade 4: The pressure leaves an indentation of 8 mm or deeper. It takes more than 20 seconds to rebound.
- The nurse reviews the daily lab results for a patient with a serious bacterial infection. When reporting the WBC differential to the patient's physician, the physician notes, "There's been a shift to the left." The nurse knows this means
- The infection is still progressing
- The infection has been resolved
- The patient requires platelets
- The patient has acute leukemia
Correct answer: The infection is still progressing
"Shift to the left" means that there is a shift in the WBC towards more immature neutrophil cells (more bands and blasts). This shift is present in most bacterial infections. In the event of a bacterial infection, large numbers of neutrophils migrate from the blood to the infected site to destroy the invading microorganisms and thus protect the host. "Shift to the right" means that there has been a shift back to the normal differential.
- A 43-year-old client makes an appointment at the OB clinic because she thinks she might be pregnant with her first child. An examination confirms the pregnancy. The client tells the nurse that her last period began on July 12. Using Naegele's Rule, the nurse tells her that her estimated date of delivery (EDD) is
- March 5
- April 19
- March 19
- April 5
Correct answer: April 19
According to Naegele's Rule, the estimated date of delivery (EDD) is calculated by adding 7 days to the first day of the normal menstrual period (July 12 + 7 days = July 19) and then counting back 3 months. (July 19- 3 months = April 19) The other dates are incorrect. NOTE: EDD replaces the former term, estimated date of confinement (EDC).
- A parent brings a 3-year-old to the Emergency Department for a dislocated shoulder. The parent reports that the child fell down the stairs. Which of the following behaviors should raise suspicions that the child may have been abused?
- The child doesn't cry when their shoulder is touched
- The child doesn't make eye contact with the healthcare provider
- The child sobs constantly throughout the examination
- The child pulls away from contact with the healthcare provider.
Correct answer: The child doesn't cry when their shoulder is touched
A characteristic behavior of abused children is the lack of crying when they undergo a painful procedure or are examined by a health care professional. Other signs of physical abuse include: unexplained bruises, burns, bites, or black eyes; has fading bruises or other marks noticeable after an absence from school or day care; seems frightened of the parents and protests or cries when it is time to go home; withdraws from adults. Child abuse is the third leading cause of death in children between ages 1 and 4. The other behaviors are typical for a 3-year-old.
- A client with bipolar disorder, manic phase, says to the nurse, "Hey, beautiful! You're sure looking pretty today." Which is the nurse's best response?
- Stop. Go to your room and relax
- I'm Tina, the nurse for this shift
- Aren't you in a good mood today!
- Thank you. I appreciate the compliment
Correct answer: I'm Tina, the nurse for this shift
The nurse should establish her identity and purpose, so the client has no confusion. Condoning or punishing the behavior are not therapeutic responses and do not establish limits.
- Parents take their 16-year-old daughter to the mental health clinic for treatment of self-harm from cutting. Which of the following statements about Nonsuicidal Self-Injury Disorder (NSSID) is FALSE?
- The client is at a lower risk for suicidal behavior
- The client is at greater risk for disordered eating
- NSSID methods typically damage only the body surface
- The client is trying to deal with unwanted feelings
Correct answer: The client is at a lower risk for suicidal behavior
Nonsuicidal self-injury is not yet recognized by the American Psychiatric Association as a diagnosable mental health condition. However, it is associated with other disorders and should be assessed. Although an act of self-harm differs from a suicide attempt, there is a strong association between self-injury and suicide attempts. It seems that as incidents of self-harm increase, the likelihood of suicide attempts also increases. Clients who have engaged in 20 or more self-harm episodes are about 3.5 times more likely to attempt suicide. The other three statements are true.
- When a healthcare provider is caring for a patient who is having an acute panic attack, which of the following actions by the healthcare provider is most appropriate?
- Offer the patient reassurance of safety and security
- Ask open-ended questions to encourage communication
- Explore common phobias associated with panic attacks
- Use distraction techniques to change the patient's focus
Correct answer: Offer the patient reassurance of safety and security
During a panic attack, the patient experiences intense apprehension and fear. There are often physical symptoms too, such as chest pain, palpitations, and trembling. During the panic attack, the patient's focus is on the distressing physical symptoms caused by the anxiety. Distraction techniques, open-ended questioning, or exploration of phobias will not be helpful during an acute attack. The patient may experience a feeling of impending doom and fear for their life. Therefore, reassurance of safety and security is the best initial intervention for this patient.
- A parent brings their 3-year-old daughter to the pediatric clinic with a fever and cough. While assessing the child, the nurse notes that the girl's genitals are swollen and bruised. The girl also tells the nurse that "it hurts to walk." Which nursing intervention is MOST important?
- Determine if her shoes are fitting properly
- Perform a throat culture and administer Tylenol
- Document all assessment findings
- Notify authorities about suspected child abuse
Correct answer: Notify authorities about suspected child abuse
The nurse is legally obligated to report all suspected child abuse. All 50 states mandate that suspected child abuse be reported. Documentation of findings, including the child's comment, is also important but not the priority. Although the appointment was for a different reason, the nurse must report the case. Signs of sexual abuse in children 0-5 years of age include the following: 1. Pain, itching, bleeding, swelling, or bruises in or around the genital area; 2. Difficulty walking or sitting, caused by genital or anal pain; 3. Urinary tract infections; 4. Reluctance to undress or insistence on wearing multiple pairs of underpants.
- A patient diagnosed with generalized anxiety disorder (GAD) reports ongoing nausea and abdominal bloating. A physical examination fails to confirm a medical illness to explain these symptoms. The healthcare provider suspects these findings are a result of which of the following?
- Dissociation
- Dysthymia
- Somatization
- Derealization
Correct answer: Somatization
Somatization, also known as somatic symptom disorder (SSD), is a form of mental illness that causes physical symptoms, including pain. Somatization is a means of coping with psychosocial distress by developing physical symptoms (soma = body).The physical symptoms that this patient is experiencing are caused by anxiety. The symptoms may or may not be explained by a known medical condition, but they cause unusual levels of distress for the patient. Dysthymia is a persistent depressive disorder that may occur together with anxiety and somatization. Derealization is a sense of detachment from reality. Dissociation is impaired awareness of one's body, self, or environment, and may include derealization.
- A hospice nurse is caring for a client who is actively dying. The client has been receiving high doses of opioids for pain management. When the client becomes unresponsive to verbal stimuli, what is the nurse's BEST action?
- Double the dosage of the opioids
- Continue the opioids at the current dose
- Discontinue the opioids at once
- Begin to wean the client off the opioids
Correct answer: Continue the opioids at the current dose
The nurse should continue the pain medications at the current dose, monitoring for signs that the client's pain is not well managed. Grimacing or moaning will indicate a need to increase the dosage. Clients who have been experiencing pain will continue to do so, even if they aren't able to verbalize. One of the goals of hospice care is to keep the client as pain-free as possible.
- When a female presents to the Emergency Department, stating she has been raped, what is the nurse's first priority?
- Instruct on future legal investigations
- Notify a social worker for counseling
- Initiate a report for the State Health Department
- Get permission to obtain safe shelter
Correct answer: Get permission to obtain safe shelter
After providing medical treatment and collecting evidence, the essential action is to ensure the client's safety. The nurse's first priority is to contact someone who can provide shelter and support for the client. The client may also need counseling and assistance with legal proceedings, but not at this time.
- The nurse is educating parents of a 7year-old girl who is about to start chemotherapy. The nurse tells them that their daughter will likely experience alopecia (loss of hair) from the treatment. The best approach for the nurse is to
- Advise them to get a wig for their daughter prior to starting treatment
- Reassure them that hair falls out gradually and won't be noticeable
- Tell them that they will soon adjust to their daughter's appearance
- Emphasize that children don't really care how they look
Correct answer: Advise them to get a wig for their daughter prior to starting treatment
Children are very aware of their appearance. In hair loss from chemotherapy, the hair tends to come out in clumps, resulting in an uneven appearance. The nurse should advise the parents to get a wig for their daughter so that she can maintain her appearance as much as possible. And never add to the parents' confusion by pretending they still are in their previous situation; they will now be reminded of their daughter's illness by her appearance.
- A client is in a memory care unit because of advanced dementia. The client's spouse is invited to participate in the team meeting to discuss the client's plan of care. The client has recently started to display agitation, confusion, and aggression in the late afternoon. The spouse and team agree that the best INITIAL action is which of the following?
- Involve the client in a new craft activity every afternoon
- Restrict the client to their room each afternoon
- Administer a mild sedative to the client with the afternoon snack
- Allow the spouse to visit the client during late afternoons and evenings
Correct answer: Allow the spouse to visit the client during late afternoons and evenings
Clients who display confusion, anxiety, aggression, or fear in late afternoons or evenings are exhibiting "sundowning" behavior. It can also include pacing or wandering. The exact cause is unknown, but it is seen in clients with dementia or Alzheimer's disease. In a care facility, sundowning may be related to the lack of structured activities later in the day, the staff leaving at change of shift, or reminding the clients of their past, when they used to go home after work. Maintaining a predictable routine and providing familiar people or items may help. Provide adequate lighting and play familiar music to reduce the client's level of anxiety. The other interventions are not appropriate for a client with advanced dementia.
- After a client has completed an inpatient treatment program for alcohol addiction, which statement by the client would indicate an understanding of the disease process?
- From now on, I must avoid alcohol and go to AA meetings
- This isn't really my fault. My father passed his alcoholism on to me
- I have to stick to a couple of drinks so I can stay in control
- If I hadn't lost my job and gotten a DUI, I would have been fine
Correct answer: From now on, I must avoid alcohol and go to AA meetings
Clients who are addicted to alcohol must avoid drinking for the rest of their lives. They are unable to drink socially, because of the loss of control. Alcohol abuse and addiction may run in families, but this does not excuse the client's choices and behaviors. For alcoholics, blaming situations is not an effective coping mechanism.
- A healthcare provider is teaching pursed-lip breathing to a patient with emphysema. Pursed-lip breathing helps patients with emphysema because it
- Helps keep the small airways open and prevents air trapping
- Helps the patient achieve maximum inhalation
- Creates negative pressure in the airways
- Increases the respiratory rate and oxygenation
Correct answer: Helps keep the small airways open and prevents air trapping
Pursed-lip breathing (PLB)is one of the best ways to control shortness of breath. It improves ventilation by keeping the small airways open and releases air that is trapped in the lungs. It also extends the expiratory phase, which slows the breathing rate. Because patients with emphysema have less elastic recoil in their lungs, airways can collapse during expiration, air gets trapped, and exhalation becomes difficult. The Cleveland Clinic suggests the following method to teach PLB: 1. Relax the neck and shoulder muscles. 2. Inhale slowly through the nose for two counts, keeping the mouth closed. Don't take a deep breath; a normal breath will do. It may help to count silently: inhale, one, two. 3. Pucker or "purse" the lips as if whistling. 4. Exhale slowly and gently through the pursed lips for four counts.
- A nurse is instructing a 53-year-old male client with newly diagnosed type 2 diabetes how to care for his feet at home. Which of the following statements would indicate that the client understands?
- Every Sunday evening, I will carefully inspect my feet
- If I cut my foot, I'll just apply antibiotic ointment
- I'll dry my feet very well after every shower
- It's okay to go barefoot in my own home
Correct answer: I'll dry my feet very well after every shower
Diabetics should dry their feet carefully to prevent fungal infections. Feet should be inspected daily and clients should seek professional care for any foot or toe injuries. Proper footwear should be worn at all times to avoid injury and provide support.
- At what age can the pediatric nurse accurately measure a radial pulse in a child?
- Three years
- One year
- Four years
- Two years
Correct answer: Two years
Under the age of two, an apical pulse is most accurate and easy to locate. A radial pulse can be difficult to palpate and count in an infant and young child. Typically, apical pulse rate is taken for a full minute to ensure accuracy; this is particularly important in infants and children due to the possible presence of sinus arrhythmia.
- A teen female client has iron-deficiency anemia. The nurse instructs her to take the prescribed oral iron supplement with
- Orange juice
- Ginger ale
- Whole milk
- Plain water
Correct answer: Orange juice
Of these four options, only orange juice contains vitamin C (ascorbic acid), which enhances iron absorption. Other foods high in vitamin C are also beneficial.
- The nurse is educating a postpartum mother on perineal self-care prior to her discharge to go home with her baby. The nurse should instruct the mother
- To place and adjust the peri-pad from back to front
- To always wear gloves when cleaning the perineum
- That tampons can be used after the first few days
- To clean and wipe the perineum from front to back
Correct answer: To clean and wipe the perineum from front to back
The nurse should teach the mother to wipe from front to back to prevent contamination of the urethra and vagina from the anal area. Perineal self-care is a clean procedure, so the mother does not need to wear gloves. The peri-pad is applied from front to back. The mother should avoid touching the inner surface of the pad to maintain asepsis. The nurse should also instruct the mother not to use tampons, to avoid the risk of infection.
- A 29-year-old primigravida experiencing bleeding at 34 weeks is diagnosed with placenta previa. Which test does the provider perform to assess lung maturity of the fetus?
- Lecithin-sphingomyelin ratio
- Alpha-fetoprotein test
- Transvaginal ultrasound
- Human Chorionic Gonadotropin
Correct answer: Lecithin-sphingomyelin ratio
Placenta Previa is a condition in which the placenta lies low in the uterus and partially or completely covers the cervix. The risk is that the placenta may separate from the uterine wall as the cervix begins to dilate during labor. The test to measure lung maturity is lecithin-sphingomyelin surfactant ratio. A normal ratio is more than 2:1 (lecithin:sphingomyelin). The serum alpha-fetoprotein test is done at about 4 months' gestation to detect neural tube defects, Down syndrome, or other abnormalities. A transvaginal ultrasound is typically performed during the first trimester and does not measure lung maturity. Human Chorionic Gonadotropin is a hormone produced by the placenta after implantation.
- A female client asks her healthcare provider about the benefits of receiving the human papillomavirus (HPV) vaccine. Which statement is the most appropriate response by the healthcare provider?
- The HPV vaccine will protect you from all types of the virus
- You will no longer need to get a routine cervical exam
- You will need to have a booster vaccination each year
- The HPV vaccine can help prevent cervical cancer
Correct answer: The HPV vaccine can help prevent cervical cancer
Over 100 different types of HPV have been identified. HPV is the most common sexually transmitted disease (STD) in the United States. Cancer is the most serious complication of HPV. The vaccine is effective in preventing cervical cancer associated with certain types of HPV, but it does not protect against all HPV types. Regular cervical screenings are recommended. The vaccine is given in a series of three injections over 6 months.
- After assessing their speech development, which of the following children should the nurse refer for further evaluation?
- A 12-month-old girl who can say 3-5 words A month
- An 18-month-old boy who only says "No"
- A 4-month-old girl who laughs out loud
- A 10-month-old boy who says "Dada" and "Mama"
Correct answer: An 18-month-old boy who only says "No"
By 18 months, a child should be able to say several words. The child should also be pointing at objects they want or at pictures in books. Lack of speech development can indicate a lack of social stimulation, a hearing deficiency, or a developmental delay. When a child seems to be lagging in language and cognitive development, further evaluation is recommended.
- The nurse is doing discharge education for a patient with newly diagnosed congestive heart failure (CHF). The nurse tells the client to weigh himself or herself every morning and notify the clinic if they have gained 2 pounds in a 24-hour period. The nurse knows that such a weight gain can indicate
- Impending liver failure
- Poor kidney function
- Decreased cardiac output
- Excessive calorie intake
Correct answer: Decreased cardiac output
Decreased cardiac output can lead to fluid retention because the renin-angiotensin-aldosterone cycle has been stimulated. Excessive calorie intake can lead to weight gain but not usually in a 24-hour period. There is no indication of poor kidney function or impending liver failure.
- The community health nurse is developing a program for clients who are victims of intimate partner violence (IPV). The nurse knows that identifying IPV victims is challenging because
- Victims have no knowledge of IPV
- IPV is a rare occurrence
- Clients worry about the costs of legal action
- Clients only express minor, vague complaints
Correct answer: Clients only express minor, vague complaints
Intimate partner violence (IPV) is physical violence, sexual violence, stalking, or psychological harm by a current or former partner or spouse. This type of violence can occur among both heterosexual and same-sex couples and does not require sexual intimacy. IPV is common: about 1 in 5 females and 1 in 7 males experience severe physical violence from an intimate partner. IPV victims may express only minor complaints, such as headaches, Gl issues, insomnia, or mild muscle aches. However, they seek medical attention more than non-victims. Clients in abusive relationships are usually aware of their situation and possible resources, but they may fear retaliation if they seek help. The cost of legal action is not a factor in lack of identification.
- Before postpartum discharge of a Latina mother and her healthy newborn, the mother tells the nurse that she will soon begin to feed the infant pureed foods. The nurse recognizes that the most likely reason for this is
- The mother has no role models to help her
- The mother cannot afford the expense of baby formula
- The mother is following her cultural beliefs
- The mother has little formal education
Correct answer: The mother is following her cultural beliefs
Studies show that Latinas are more likely not to exclusively breastfeed or give formula. They are also more likely to introduce solid foods earlier than current guidelines. There is a cultural tendency to see chubby babies as healthier and stronger. The nurse may not be able to affect the mother's practices at this time. However, the nurse can offer as much education as possible. The nurse can also explain some risks of offering solid food early, including choking and childhood obesity.
- A nurse has instructed a 63-year-old female with a new prescription for captopril (Capoten) for her hypertension. The nurse realizes that the client needs further teaching when the client states,
- I'll take my blood pressure every week
- I shouldn't stand up too quickly
- I will use a salt substitute
- I'll call if I get a fever or sore throat
Correct answer: I will use a salt substitute
Captopril (Capoten) is an angiotensin-converting enzyme (ACE) inhibitor prescribed for hypertension, congestive heart failure, and diabetic nephropathy. Clients should not use salt substitutes because they contain potassium, and ACE inhibitors cause the body to retain potassium. The other responses are appropriate.
- An 82-year-old patient diagnosed with delirium approaches the nurse, worried that she is late for her dental appointment. "I never miss a check-up," she says. Which of the following is the nurse's most appropriate response?
- You can't leave because the door is locked so you can't get lost
- Let's go to your room, and I'll show you how to brush your teeth
- You're in the hospital right now. My name is _________. I'm one of the nurses
- It's nearly lunch time. You'll want to eat before your appointment
Correct answer: You're in the hospital right now. My name is _________. I'm one of the nurses
Clients diagnosed with delirium are easily confused about time and place. The nurse should calmly orient the client with date, time, and place, and introduce himself or herself. The other options do not address the disorientation. In fact, pretending that the client has an appointment only reinforces the confusion.
- A client with a diagnosis of schizophrenia comes to the mental health clinic for a routine appointment. The client has been compliant with chlorpromazine (Thorazine) therapy for six months. The nurse notifies the physician after observing signs that indicate tardive dyskinesia. Which signs did the nurse observe?
- Blurred vision, drowsiness, constipation
- Dry mouth, photosensitivity, orthostatic hypotension
- Lip-smacking, blinking, lateral jaw movements
- High fever, tachycardia, tachypnea, stupor
Correct answer: Lip-smacking, blinking, lateral jaw movements
Tardive dyskinesia is a side effect of antipsychotic medications. Signs and symptoms include lip smacking, blinking, lateral jaw movements, grunting, and sticking out the tongue unintentionally. Dry mouth, photosensitivity, orthostatic hypotension, blurred vision, drowsiness, and constipation are normal side effects of these drugs. Symptoms of neuroleptic malignant syndrome - a rare occurrence with antipsychotic drugs - usually include very high fever (102 to 104°F), irregular pulse, tachycardia, tachypnea, muscle rigidity, and altered mental status.
- A charge nurse is delegating tasks during a busy shift. Which client may MOST appropriately be assigned to a licensed practical/vocational nurse (LPN/LVN)?
- A stable client requiring reinforcement of previously taught diabetic teaching
- A newly admitted client requiring an initial admission assessment
- A client whose plan of care needs to be evaluated and revised
- A client requiring intravenous push administration of a high-alert medication
Correct answer: A stable client requiring reinforcement of previously taught diabetic teaching
Reinforcing teaching that the RN already provided to a stable client is the correct assignment for the LPN/LVN. Initial assessment, evaluating and revising the plan of care, and the nursing process steps of assessment and evaluation cannot be delegated and remain the RN's responsibility. IV push of high-alert medications is generally outside the LPN/LVN scope in most facilities.
- The RN is determining which task can be delegated to unlicensed assistive personnel (UAP). Which assignment is appropriate?
- Assessing a client's pain level after a dressing change
- Teaching a client how to use an incentive spirometer
- Measuring and recording the intake and output of a stable client
- Determining whether a client is ready for discharge
Correct answer: Measuring and recording the intake and output of a stable client
Measuring and recording intake and output for a stable client is a standardized task with a predictable outcome, making it appropriate for UAP. Assessment, teaching, and clinical judgment about discharge readiness all require nursing knowledge and cannot be delegated to UAP.
- Before delegating a task to unlicensed assistive personnel, the RN should remember that the RN retains accountability for which element?
- Performing the delegated task personally
- The outcome of the delegated task and adequate supervision
- Documenting the task in the UAP's personnel file
- Re-credentialing the UAP for the facility
Correct answer: The outcome of the delegated task and adequate supervision
The RN remains accountable for the outcome of any delegated task and for providing appropriate supervision and follow-up, even though the UAP carries out the task. The RN does not perform an appropriately delegated task personally, and credentialing and personnel documentation are administrative functions outside this responsibility.
- An RN receives report on four clients. Which client should the nurse assess FIRST?
- A client two days post-op reporting incisional pain rated 4 of 10
- A client requesting assistance to the bathroom
- A client awaiting discharge teaching for a new medication
- A client with new-onset shortness of breath and an oxygen saturation of 86%
Correct answer: A client with new-onset shortness of breath and an oxygen saturation of 86%
The client with new-onset shortness of breath and an oxygen saturation of 86% is the priority because airway and breathing problems are immediately life-threatening and rank highest using the ABCs. Incisional pain of 4 of 10, discharge teaching, and toileting assistance are important but do not represent an acute physiologic threat.
- Using Maslow's hierarchy of needs to prioritize care for four clients, which need should the nurse address FIRST?
- A client whose airway is partially obstructed by secretions
- A client expressing fear about an upcoming surgery
- A client who feels isolated from family during hospitalization
- A client asking for spiritual support
Correct answer: A client whose airway is partially obstructed by secretions
The client whose airway is partially obstructed by secretions must be addressed first because airway is a physiologic need at the base of Maslow's hierarchy and takes precedence over psychological needs. Fear, feelings of isolation, and spiritual support reflect higher-level needs that are addressed after physiologic needs are met.
- A client is scheduled for surgery and the surgeon has discussed the procedure. The nurse's responsibility regarding informed consent is to:
- Explain the surgical risks and benefits to the client
- Decide whether the client is competent to consent
- Witness the client's signature and confirm the client understands
- Obtain consent in place of the surgeon if the surgeon is busy
Correct answer: Witness the client's signature and confirm the client understands
Witnessing the client's signature and confirming that the client appears to understand the explanation already given is the nurse's role in informed consent. Explaining the risks, benefits, and alternatives of the procedure is the responsibility of the provider performing it, and the nurse does not independently obtain the consent or determine legal competency.
- A nurse is preparing a client for a procedure when the client says, 'I'm still not sure what they're going to do to me.' What is the nurse's BEST action?
- Reassure the client that the surgeon is very experienced
- Notify the provider that the client needs further explanation before signing
- Have the client sign the consent and proceed
- Explain the procedure details to the client and witness the signature
Correct answer: Notify the provider that the client needs further explanation before signing
Notifying the provider that the client needs further explanation is correct because valid informed consent requires that the client understands the procedure, and only the provider performing it can supply the missing information. Reassurance, proceeding with signing, or having the nurse explain the procedure details do not satisfy the requirement for informed consent.
- A nurse is reviewing practices to protect client confidentiality. Which action violates client privacy under HIPAA?
- Logging off the electronic health record when leaving the workstation
- Sharing information only with team members involved in the client's care
- Verifying a caller's identity before sharing any client information
- Discussing a client's diagnosis with a colleague in a crowded elevator
Correct answer: Discussing a client's diagnosis with a colleague in a crowded elevator
Discussing a client's diagnosis in a crowded elevator violates confidentiality because protected health information can be overheard by people not involved in the client's care. Logging off the record, verifying a caller's identity, and limiting information sharing to the care team are all appropriate measures that protect privacy.
- A family member calls the unit and asks for an update on a hospitalized client. What is the nurse's BEST response?
- Refuse to confirm or share any information until verifying the caller is authorized
- Provide the update because the caller identifies as a relative
- Give general information but withhold the specific diagnosis
- Transfer the call to the provider to share the details
Correct answer: Refuse to confirm or share any information until verifying the caller is authorized
Refusing to confirm or share information until verifying the caller is authorized is correct because protected health information may only be released to individuals the client has designated. Providing an update based solely on a claimed relationship, sharing general information, or transferring the call all risk unauthorized disclosure.
- A competent adult client refuses a blood transfusion for religious reasons despite a low hemoglobin level. The nurse's role as a client advocate is to:
- Persuade the client to accept the transfusion to prevent harm
- Arrange for a family member to override the client's decision
- Support the client's right to refuse and ensure the decision is informed
- Document the refusal and withdraw from the client's care
Correct answer: Support the client's right to refuse and ensure the decision is informed
Supporting the client's right to refuse and ensuring the decision is informed reflects the advocacy role and respects client autonomy. A competent adult may refuse treatment; the nurse does not coerce the client, allow others to override the decision, or abandon the client after a refusal.
- Which situation BEST demonstrates the ethical principle of beneficence?
- The nurse provides identical pain management protocols to all clients
- The nurse repositions a bedbound client to prevent pressure injuries
- The nurse withholds a diagnosis at the family's request
- The nurse tells a client the truth about a poor prognosis
Correct answer: The nurse repositions a bedbound client to prevent pressure injuries
Repositioning a bedbound client to prevent pressure injuries demonstrates beneficence, which is acting to promote the client's good and prevent harm. Treating all clients identically reflects justice, withholding information conflicts with autonomy, and truth-telling reflects veracity.
- A nurse is coordinating discharge for a client who will need wound care, physical therapy, and medication management at home. The BEST approach to ensure continuity of care is to:
- Give the client a list of phone numbers to arrange services independently
- Have the family assume full responsibility without follow-up
- Delay discharge until the client can perform all care alone
- Initiate a referral to home health and communicate the plan to the team
Correct answer: Initiate a referral to home health and communicate the plan to the team
Initiating a referral to home health and communicating the plan to the interdisciplinary team is correct because coordinated referrals ensure the client's ongoing needs are met after discharge. Leaving the client to arrange services alone, delaying discharge unnecessarily, or placing full responsibility on the family without follow-up all fragment continuity of care.
- During a hand-off (SBAR) report, which information belongs in the 'Recommendation' component?
- A request for the provider to evaluate the client's worsening pain
- The current vital signs and assessment findings
- The client's admitting diagnosis and history
- The reason the nurse is calling about the client
Correct answer: A request for the provider to evaluate the client's worsening pain
A request for the provider to evaluate the client's worsening pain is the 'Recommendation' because it states what the nurse needs to happen next. The admitting diagnosis and history are 'Background,' vital signs and assessment are 'Assessment,' and the reason for the call is the 'Situation.'
- A nurse discovers that a medication was given to the wrong client but the client shows no adverse effects. What is the nurse's priority action after assessing the client?
- Avoid reporting it since no harm occurred
- Document the error in the client's chart as an incident report
- Complete an incident/occurrence report
- Ask a coworker not to mention the error
Correct answer: Complete an incident/occurrence report
Completing an incident/occurrence report after assessing the client is the priority because the report supports quality improvement and tracks system problems. The incident report itself is not referenced or filed in the chart, errors are reported regardless of whether harm occurred, and concealing the error is unethical and unsafe.
- A unit identifies a rise in client falls and forms a team to address it. Implementing hourly rounding and reviewing the results afterward is an example of which quality improvement strategy?
- Root cause analysis of a single sentinel event
- A Plan-Do-Study-Act (PDSA) improvement cycle
- Risk management litigation review
- A retrospective chart audit only
Correct answer: A Plan-Do-Study-Act (PDSA) improvement cycle
Implementing hourly rounding and then reviewing the results is a Plan-Do-Study-Act cycle, in which a change is planned, carried out, studied, and acted upon. Root cause analysis investigates a single serious event, litigation review is a legal function, and a retrospective chart audit alone does not include testing a change.
- A nurse realizes that an entry in the electronic health record contains an error. Which action correctly addresses the documentation error?
- Delete the entry so the record looks accurate
- Leave the error and verbally inform the next shift
- Ask another nurse to overwrite the entry
- Use the system's edit function to add a correction noting it is an amendment
Correct answer: Use the system's edit function to add a correction noting it is an amendment
Using the system's edit or amendment function to add a correction and note that it is an amendment is correct because legal documentation must preserve the original entry while showing the change. Deleting entries, having another nurse alter the record, or relying only on verbal communication compromise the integrity of the legal record.
- A provider's order reads 'restrain client as needed.' The nurse recognizes that this order is unacceptable because restraints require:
- A specific order including the type, reason, and time limit, with periodic renewal
- A standing PRN order that the nurse can apply at any time
- Only the family's verbal permission
- No order if the client is confused
Correct answer: A specific order including the type, reason, and time limit, with periodic renewal
A restraint order must be specific, including the type of restraint, the clinical reason, and a time limit, with periodic reassessment and renewal as required. PRN or 'as needed' restraint orders are prohibited, family permission does not substitute for a provider order, and restraints always require an order even for confused clients.
- Before administering medication, the nurse should identify the client using:
- The client's room number alone
- The name on the door of the room
- Two client identifiers, such as name and date of birth
- The client's verbal statement of needing the medication
Correct answer: Two client identifiers, such as name and date of birth
Using two client identifiers, such as the client's name and date of birth, is the standard for safe identification before administering medications or treatments. Room number, the name on the door, and a client's request are not reliable identifiers and can lead to errors.
- Which nursing action BEST prevents a medication error during administration?
- Preparing medications for several clients at once to save time
- Comparing the medication against the order using the rights of medication administration
- Relying on memory for routinely given medications
- Documenting the medication before it is actually given
Correct answer: Comparing the medication against the order using the rights of medication administration
Comparing the medication against the order using the rights of medication administration best prevents errors by verifying the correct client, drug, dose, route, time, and documentation. Preparing medications for multiple clients at once, relying on memory, and documenting before administration all increase the risk of error.
- A confused older adult is identified as a high fall risk. Which intervention is MOST appropriate to reduce the risk of falls?
- Raise all four side rails on the bed at all times
- Place the client in a room far from the nurses' station
- Restrain the client whenever unattended
- Keep the bed in the low position with the call light within reach
Correct answer: Keep the bed in the low position with the call light within reach
Keeping the bed in the low position with the call light within reach is the most appropriate fall-prevention measure because it reduces injury and allows the client to summon help. Raising all four side rails is considered a restraint and can increase injury, routine restraint use is inappropriate, and placing the client far from the nurses' station reduces supervision.
- A nurse discovers a small fire in a client's trash can. Using the RACE acronym, what is the nurse's FIRST action?
- Rescue and remove clients in immediate danger
- Activate the fire alarm
- Confine the fire by closing doors
- Extinguish the fire with an extinguisher
Correct answer: Rescue and remove clients in immediate danger
Rescuing and removing any clients in immediate danger is the first step of the RACE sequence. Activating the alarm, confining the fire by closing doors, and extinguishing the fire follow in the order alarm, confine, extinguish.
- A nurse is setting up seizure precautions for a newly admitted client with a seizure disorder. Which item should be at the bedside?
- A padded tongue blade to insert during a seizure
- Soft wrist restraints to limit movement
- Functioning suction equipment and oxygen
- An ice pack for the client's head
Correct answer: Functioning suction equipment and oxygen
Functioning suction equipment and oxygen at the bedside are essential for seizure precautions to maintain a patent airway during and after a seizure. Nothing should be forced into the mouth during a seizure, the client's movements should not be restrained, and an ice pack is not a seizure precaution.
- According to standard precautions, when should the nurse perform hand hygiene?
- Only after removing gloves
- Before and after every client contact, regardless of glove use
- Only when hands are visibly soiled
- Only before sterile procedures
Correct answer: Before and after every client contact, regardless of glove use
Hand hygiene should be performed before and after every client contact regardless of whether gloves were worn, which is a core element of standard precautions. Limiting hand hygiene to after glove removal, to visibly soiled hands, or to sterile procedures leaves gaps that allow pathogen transmission.
- A nurse's hands are visibly soiled with blood after client care. Which hand hygiene method is appropriate?
- Alcohol-based hand rub only
- Applying additional alcohol gel twice
- Wiping hands on a paper towel
- Washing with soap and water
Correct answer: Washing with soap and water
Washing with soap and water is required when hands are visibly soiled because alcohol-based hand rub does not remove organic material such as blood. Alcohol rub alone, wiping hands on a towel, or repeated gel application do not adequately clean visibly contaminated hands.
- A client is admitted with active pulmonary tuberculosis. Which type of precautions and personal protective equipment does the nurse implement?
- Airborne precautions with a fitted N95 respirator and a negative-pressure room
- Contact precautions with gown and gloves
- Droplet precautions with a surgical mask
- Standard precautions only
Correct answer: Airborne precautions with a fitted N95 respirator and a negative-pressure room
Airborne precautions with a fitted N95 respirator and a negative-pressure (airborne infection isolation) room are required for active pulmonary tuberculosis because the organism is transmitted via small airborne droplet nuclei. Contact precautions, droplet precautions with a surgical mask, and standard precautions alone do not prevent airborne transmission.
- A client with Clostridioides difficile infection requires which infection control measures?
- Airborne precautions and an N95 respirator
- Droplet precautions and a surgical mask
- Contact precautions with gown and gloves and hand washing with soap and water
- Standard precautions with alcohol-based hand rub only
Correct answer: Contact precautions with gown and gloves and hand washing with soap and water
Contact precautions with gown and gloves plus hand washing with soap and water are correct for Clostridioides difficile because the spores are spread by contact and are not killed by alcohol-based hand rub. Airborne and droplet precautions are not indicated, and relying on alcohol rub alone fails to remove the spores.
- A client with pertussis (whooping cough) is placed on which precautions?
- Airborne precautions
- Droplet precautions with a surgical mask
- Contact precautions only
- Protective (reverse) isolation
Correct answer: Droplet precautions with a surgical mask
Droplet precautions with a surgical mask are correct for pertussis because the organism is spread by large respiratory droplets over short distances. Airborne precautions are reserved for tuberculosis, measles, and varicella; contact precautions alone do not cover droplet spread; and protective isolation protects immunocompromised clients rather than containing a contagious disease.
- A client receiving chemotherapy has severe neutropenia. Which action is appropriate for protective (neutropenic) precautions?
- Place the client in a room with a client who has an active infection
- Restrict the client's fluid intake
- Wear an N95 respirator when entering the room
- Avoid bringing fresh flowers and raw fruits or vegetables into the room
Correct answer: Avoid bringing fresh flowers and raw fruits or vegetables into the room
Avoiding fresh flowers and raw fruits or vegetables is appropriate for neutropenic precautions because these items can harbor organisms that endanger an immunocompromised client. Sharing a room with an infected client increases risk, an N95 respirator is not required to protect a neutropenic client, and fluids are not restricted.
- While setting up a sterile field, the nurse recognizes that the field has become contaminated when:
- Moisture soaks through from a nonsterile surface below the field
- A 1-inch border around the edge of the field is treated as unsterile
- Sterile items are placed in the center of the field
- The nurse keeps sterile gloved hands above waist level
Correct answer: Moisture soaks through from a nonsterile surface below the field
Moisture soaking through from a nonsterile surface contaminates the field because moisture provides a pathway for microorganisms (strike-through contamination). Placing items in the center, treating the outer 1-inch border as unsterile, and keeping gloved hands above the waist are all correct sterile technique practices.
- Which action by the nurse maintains surgical asepsis during a sterile dressing change?
- Turning the back to the sterile field briefly to obtain supplies
- Holding sterile items below waist level for convenience
- Keeping all sterile items within view and above the waist
- Reaching across the sterile field to position equipment
Correct answer: Keeping all sterile items within view and above the waist
Keeping all sterile items within view and above the waist maintains surgical asepsis because items out of sight or below the waist are considered contaminated. Turning away from the field, holding items below the waist, and reaching across the field all break sterile technique.
- To prevent a needlestick injury, the nurse should:
- Recap needles using both hands after use
- Activate the safety device and dispose of the needle in a sharps container without recapping
- Bend or break needles before disposal
- Leave used needles on the bedside table until end of care
Correct answer: Activate the safety device and dispose of the needle in a sharps container without recapping
Activating the safety device and disposing of the needle in a sharps container without recapping is the correct practice for preventing needlestick injuries. Two-handed recapping, bending or breaking needles, and leaving used needles on surfaces all increase the risk of injury.
- A nurse notes that a client's electrical bed has a frayed power cord. What is the nurse's BEST action?
- Continue using the bed until a replacement is available
- Wrap the cord with tape and continue using it
- Unplug the bed only when the client is sleeping
- Remove the bed from use and report it for repair
Correct answer: Remove the bed from use and report it for repair
Removing the bed from use and reporting it for repair is the safest action because a frayed cord is an electrical and fire hazard. Continuing to use the equipment, taping the cord, or unplugging it only intermittently leave the hazard in place.
- During a mass-casualty event using START triage, which client is tagged as the HIGHEST priority for immediate treatment?
- A client with a respiratory rate of 36 and delayed capillary refill
- A client with an open fracture but stable breathing and circulation
- A client with no spontaneous respirations even after repositioning the airway
- A client who is ambulatory with minor lacerations
Correct answer: A client with a respiratory rate of 36 and delayed capillary refill
The client with a respiratory rate of 36 and delayed capillary refill is tagged immediate (red) and is the highest priority for treatment because the client has a life-threatening but survivable problem. A client with no respirations after airway repositioning is tagged expectant/deceased, the stable open fracture is delayed, and the ambulatory client with minor injuries is minor/walking wounded.
- In a hospital disaster plan, which action reflects the principle of doing the greatest good for the greatest number?
- Allocating the most resources to the most critically injured regardless of survivability
- Treating clients strictly in the order they arrive
- Treating clients with survivable injuries who will benefit most from immediate care
- Discharging all stable clients before assessing new casualties
Correct answer: Treating clients with survivable injuries who will benefit most from immediate care
Treating clients with survivable injuries who will benefit most from immediate care reflects the disaster principle of doing the greatest good for the greatest number. Concentrating resources on those unlikely to survive, treating strictly by arrival order, and discharging clients before assessment do not align with mass-casualty triage priorities.
- A home health nurse suspects that an older adult client is being financially exploited and neglected by a caregiver. The nurse's legal responsibility is to:
- Confront the caregiver directly and demand it stop
- Report the suspected abuse to the appropriate protective services agency
- Wait until there is definitive proof before taking any action
- Advise the client to find a new caregiver independently
Correct answer: Report the suspected abuse to the appropriate protective services agency
Reporting the suspected abuse to the appropriate protective services agency is required because nurses are mandatory reporters of suspected abuse or neglect of vulnerable adults. Confronting the caregiver, waiting for proof, or simply advising the client do not fulfill the legal duty to report.
- To reduce errors with high-alert medications such as insulin and heparin, a facility implements which safety strategy?
- Storing look-alike, sound-alike drugs next to each other for convenience
- Removing these drugs from the medication formulary
- Allowing verbal orders for all high-alert drugs
- Requiring an independent double-check by a second nurse before administration
Correct answer: Requiring an independent double-check by a second nurse before administration
Requiring an independent double-check by a second nurse before administering high-alert medications such as insulin and heparin is an evidence-based safety strategy. Storing look-alike, sound-alike drugs together increases errors, broad use of verbal orders introduces risk, and removing necessary medications is not a practical safety measure.
- When preparing to assist with moving a heavy, immobile client up in bed, the nurse's safest action is to:
- Use a friction-reducing device and obtain adequate help
- Lift the client alone using the back muscles
- Pull the client up by grasping under the arms
- Raise the bed to its lowest position before moving the client
Correct answer: Use a friction-reducing device and obtain adequate help
Using a friction-reducing device and obtaining adequate help is the safest action because it protects both the client and the nurse from injury. Lifting alone with the back, pulling under the arms, and lowering the bed before the move increase the risk of injury to the nurse and client.
- A client states, 'I want to make sure my wishes are followed if I can't speak for myself.' The nurse should explain that the document naming someone to make health decisions on the client's behalf is a:
- Living will
- Do Not Resuscitate order
- Durable power of attorney for health care
- Standard informed consent form
Correct answer: Durable power of attorney for health care
A durable power of attorney for health care is the document that names another person to make health care decisions when the client cannot. A living will specifies treatment preferences rather than naming a decision-maker, a Do Not Resuscitate order addresses only resuscitation, and an informed consent form authorizes a specific procedure.
- A nurse is caring for a client who speaks limited English and needs to give informed consent. The nurse should:
- Ask a family member to translate the consent discussion
- Use a qualified medical interpreter to facilitate the discussion
- Use gestures and simple words to obtain consent quickly
- Postpone the procedure indefinitely until the client learns English
Correct answer: Use a qualified medical interpreter to facilitate the discussion
Using a qualified medical interpreter ensures accurate communication so the client can give valid informed consent. Relying on a family member risks errors and breaches of privacy, gestures cannot convey complex information, and indefinitely postponing necessary care is inappropriate.
- A medical-surgical nurse is floated to a unit where the nurse lacks specialized competency. The nurse's BEST action is to:
- Refuse the assignment and leave the facility
- Perform unfamiliar procedures by following coworkers' examples
- Accept all assigned clients regardless of complexity
- Inform the charge nurse of the competency limits and request assignment within the nurse's skill set
Correct answer: Inform the charge nurse of the competency limits and request assignment within the nurse's skill set
Informing the charge nurse of the competency limits and requesting an assignment within the nurse's skill set is the best action because nurses must practice within their competence while not abandoning clients. Leaving the facility constitutes abandonment, accepting clients beyond one's competence is unsafe, and imitating coworkers on unfamiliar procedures endangers clients.
- A nurse is caring for four clients. Which client should the nurse assess FIRST after receiving the change-of-shift report?
- A client with chronic stable angina requesting a PRN antacid
- A client one day postoperative who reports incisional pain rated 4 out of 10
- A client with pneumonia whose oxygen saturation has dropped from 94% to 86%
- A client awaiting discharge teaching for a new prescription
Correct answer: A client with pneumonia whose oxygen saturation has dropped from 94% to 86%
The nurse should assess the client with pneumonia whose oxygen saturation dropped from 94% to 86% first, because a sudden decline in oxygenation reflects an unstable airway/breathing problem (ABCs) that is potentially life-threatening. The other clients are stable and their needs are predictable and non-urgent.
- The charge nurse is making assignments for the shift. Which client is MOST appropriate to assign to a licensed practical/vocational nurse (LPN/LVN)?
- A newly admitted client requiring an initial admission assessment
- A stable client recovering from pneumonia who needs reinforcement of teaching
- A client receiving the first dose of a blood transfusion
- A client requiring development of an individualized plan of care
Correct answer: A stable client recovering from pneumonia who needs reinforcement of teaching
The stable pneumonia client who needs reinforcement of teaching is most appropriate for the LPN/LVN, because LPNs/LVNs care for stable clients with predictable outcomes and may reinforce teaching. Initial assessments, starting blood transfusions, and developing the plan of care require the assessment and judgment of the registered nurse.
- A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is OUTSIDE the UAP's scope and should NOT be delegated?
- Recording a client's oral intake and urinary output
- Assisting a stable client with ambulation in the hallway
- Evaluating a client's response to a newly administered analgesic
- Obtaining a routine set of vital signs on a stable client
Correct answer: Evaluating a client's response to a newly administered analgesic
Evaluating a client's response to a newly administered analgesic should not be delegated to a UAP, because evaluation is a nursing-process step reserved for the registered nurse. Recording intake and output, assisting a stable client to ambulate, and obtaining routine vital signs are appropriate UAP tasks.
- A nurse identifies a client at high risk for falls. Which intervention is the MOST appropriate to reduce this client's fall risk?
- Keep all four side rails of the bed raised at all times
- Instruct the client to remain in bed and avoid getting up alone
- Apply a vest restraint whenever the client is in bed
- Place the call light within reach and keep the bed in the lowest position
Correct answer: Place the call light within reach and keep the bed in the lowest position
Keeping the call light within reach and the bed in the lowest position is the most appropriate fall-prevention measure, because it lets the client summon help and minimizes injury if a fall occurs. Raising all four side rails is considered a restraint, applying a vest restraint is not a first-line measure, and simply telling the client to stay in bed does not address the actual risk.
- A nurse is reviewing a client's medication orders and finds an entry written in pencil with no date or time. What should the nurse do FIRST?
- Trace over the pencil entry in ink so it cannot be erased
- Contact the prescriber to clarify and have the order entered correctly
- Administer the medication and document the order after the fact
- Ignore the order because it is not legally valid
Correct answer: Contact the prescriber to clarify and have the order entered correctly
The nurse should contact the prescriber to clarify and have the order entered correctly, because a pencil-written, undated order is not a valid, legally acceptable order and must be corrected before any action is taken. Tracing over it, administering the drug, or ignoring it without clarification all create safety and documentation risks.
- During a hand-off using the SBAR communication tool, which information belongs in the 'Recommendation' component?
- The client's admitting diagnosis and code status
- The most recent set of vital signs and assessment findings
- The client's name, room number, and reason for admission
- A request for the prescriber to evaluate the client and consider new orders
Correct answer: A request for the prescriber to evaluate the client and consider new orders
A request for the prescriber to evaluate the client and consider new orders belongs in the Recommendation component, because SBAR ends with what the nurse wants done or suggests. The admitting diagnosis and identifying data fit Background/Situation, while vital signs and assessment findings fit Assessment.
- A nurse is preparing to care for a client with active pulmonary tuberculosis. Which personal protective equipment is required when entering the room?
- A surgical mask and clean gloves
- A gown, gloves, and goggles only
- A fit-tested N95 respirator (or higher) and placement of the client in a negative-pressure room
- Standard precautions with no additional protective equipment
Correct answer: A fit-tested N95 respirator (or higher) and placement of the client in a negative-pressure room
A fit-tested N95 respirator (or higher) with the client in a negative-pressure airborne-isolation room is required, because tuberculosis is transmitted by the airborne route. A surgical mask does not filter the small droplet nuclei, and gown/gloves/goggles or standard precautions alone are insufficient for airborne pathogens.
- A nurse witnesses a coworker remove an opioid from the automated dispensing cabinet but later notices the medication was never documented as administered or wasted. What is the nurse's MOST appropriate action?
- Confront the coworker privately and agree to keep it confidential
- Document the concern only if the client complains of unrelieved pain
- Report the discrepancy to the nurse manager according to facility policy
- Wait to see if the same situation happens again before acting
Correct answer: Report the discrepancy to the nurse manager according to facility policy
Reporting the discrepancy to the nurse manager according to facility policy is the most appropriate action, because nurses have a legal and ethical duty to report suspected controlled-substance diversion to protect clients and the public. Keeping it confidential, waiting for harm, or delaying a report fail that duty.
- A client placed on contact precautions for Clostridioides difficile infection is being cared for by the nurse. Which action is correct?
- Use alcohol-based hand rub after removing gloves and gown
- Wear an N95 respirator when entering the room
- Reuse the same gown for the next room to conserve supplies
- Wash hands with soap and water after providing care
Correct answer: Wash hands with soap and water after providing care
Washing hands with soap and water after providing care is correct, because C. difficile spores are not reliably killed by alcohol-based hand rub and must be removed by mechanical washing. Gowns are single-use, and an N95 respirator is unnecessary because C. difficile is not airborne.
- A nurse is about to administer a medication and the client states, "That doesn't look like the pill I usually take." What should the nurse do FIRST?
- Withhold the medication and verify the order against the medication record
- Reassure the client and administer the medication as ordered
- Tell the client that the pharmacy must have changed the brand
- Ask the client to take the pill and report any side effects
Correct answer: Withhold the medication and verify the order against the medication record
The nurse should withhold the medication and verify the order against the medication record, because a client's concern is a safety cue that must be investigated before administration. Reassuring the client, assuming a brand change, or proceeding anyway could lead to a medication error.
- A nurse is caring for a client with a latex allergy. Which intervention best protects the client during care?
- Ensure latex-free gloves and supplies are used and post a latex-allergy alert
- Keep the client's door closed at all times
- Premedicate the client with an antihistamine before each contact
- Place the client in a negative-pressure isolation room
Correct answer: Ensure latex-free gloves and supplies are used and post a latex-allergy alert
Ensuring latex-free gloves and supplies are used and posting a latex-allergy alert best protects the client, because preventing exposure is the priority for an allergy. Closing the door, premedicating, or using isolation rooms do not remove the latex from the care environment.
- A nurse discovers a medication error after a client has received the wrong dose. What is the nurse's priority action?
- Complete the incident report before doing anything else
- Assess the client and notify the prescriber
- Document the error only in the nurse's personal log
- Wait to see whether the client develops adverse effects
Correct answer: Assess the client and notify the prescriber
Assessing the client and notifying the prescriber is the priority, because client safety comes first and the prescriber may need to order interventions. The incident report is completed afterward, errors are documented in the official record, and waiting for symptoms delays needed care.
- A nurse is delegating to a UAP the care of a client receiving an enteral tube feeding. Which instruction is essential for the nurse to give?
- Keep the head of the bed elevated at least 30 to 45 degrees during the feeding
- Assess the client's bowel sounds before each feeding
- Adjust the feeding pump rate if the client reports nausea
- Evaluate the client's tolerance of the feeding and modify the plan
Correct answer: Keep the head of the bed elevated at least 30 to 45 degrees during the feeding
Instructing the UAP to keep the head of the bed elevated 30 to 45 degrees is essential, because this aspiration-prevention task is within the UAP's scope. Assessing bowel sounds, adjusting the pump rate, and evaluating tolerance require nursing judgment and cannot be delegated.
- A client tells the nurse, "I've decided I don't want the surgery anymore," minutes before transport to the operating room. What is the nurse's BEST action?
- Tell the client it is too late to cancel because the team is ready
- Administer the preoperative sedative to help the client relax
- Notify the surgeon and document the client's withdrawal of consent
- Proceed with transport since consent was already signed
Correct answer: Notify the surgeon and document the client's withdrawal of consent
Notifying the surgeon and documenting the client's withdrawal of consent is the best action, because a client may revoke consent at any time and the procedure cannot proceed without it. Telling the client it's too late, sedating the client, or proceeding violates the client's right to autonomy.
- A nurse is reviewing infection-control practices for inserting an indwelling urinary catheter. Which technique is required?
- Sterile technique throughout the procedure
- Clean technique with clean gloves
- Standard precautions only
- Contact precautions with a gown and gloves
Correct answer: Sterile technique throughout the procedure
Sterile technique throughout the procedure is required for indwelling urinary catheter insertion, because the catheter enters a normally sterile body cavity and breaks in technique cause catheter-associated urinary tract infections. Clean technique, standard precautions alone, or contact precautions do not maintain the needed sterile field.
- A nurse is caring for a client who needs an interpreter to give informed consent. Which approach is MOST appropriate?
- Use a qualified medical interpreter provided by the facility
- Ask the client's adult family member to interpret
- Use written translation software on a personal phone
- Have a bilingual UAP from another unit translate
Correct answer: Use a qualified medical interpreter provided by the facility
Using a qualified medical interpreter provided by the facility is most appropriate, because accurate, unbiased interpretation is required for valid informed consent and to meet legal standards. Family members, software, and untrained staff may introduce errors, bias, or breaches of confidentiality.
- A nurse is assigning client care for the shift and must consider the principle of 'right circumstance' in delegation. Which factor best reflects this principle?
- The UAP has completed competency training for the task
- The nurse provides clear, concise directions for the task
- The client is stable and the task outcome is predictable
- The nurse evaluates the outcome of the delegated task
Correct answer: The client is stable and the task outcome is predictable
The client being stable with a predictable task outcome best reflects the right circumstance, because that principle focuses on the appropriateness of the client's situation for delegation. Competency relates to the right person, clear directions to the right communication, and evaluation to the right supervision.
- A nurse notes that a client's wrist restraint is secured to the side rail of the bed. What should the nurse do?
- Leave it because securing to the side rail is acceptable
- Reattach the restraint to the movable part of the bed frame
- Tie the restraint to the stationary headboard
- Remove the restraint and substitute all four side rails up
Correct answer: Reattach the restraint to the movable part of the bed frame
The nurse should reattach the restraint to the movable part of the bed frame, because securing a restraint to a side rail can injure the client when the rail is lowered. The side rail and headboard are not appropriate attachment points, and raising all four side rails is itself a restraint and does not correct the hazard.
- A nurse accidentally accesses the electronic health record of a client who is not assigned to the nurse, out of curiosity. This action represents a violation of which standard?
- The Emergency Medical Treatment and Labor Act (EMTALA)
- The Health Insurance Portability and Accountability Act (HIPAA)
- The Patient Self-Determination Act
- The Americans with Disabilities Act (ADA)
Correct answer: The Health Insurance Portability and Accountability Act (HIPAA)
Accessing the record of a non-assigned client out of curiosity violates HIPAA, because clinicians may access protected health information only on a need-to-know basis for clients in their care. EMTALA governs emergency treatment, the Patient Self-Determination Act addresses advance directives, and the ADA addresses disability rights.
- A nurse is teaching a UAP about standard precautions. Which statement by the UAP indicates correct understanding?
- "I only need to wear gloves when I know a client has an infection."
- "I can skip hand hygiene if I wore gloves during the task."
- "I treat all clients' blood and body fluids as potentially infectious."
- "Standard precautions apply only in isolation rooms."
Correct answer: "I treat all clients' blood and body fluids as potentially infectious."
"I treat all clients' blood and body fluids as potentially infectious" indicates correct understanding, because standard precautions apply to every client regardless of diagnosis. Limiting gloves to known infections, skipping hand hygiene after gloves, or restricting precautions to isolation rooms are all incorrect.
- A nurse is caring for a client who has just been told of a poor prognosis and wishes to create an advance directive. The nurse's role is to:
- Decide which treatments the client should accept or refuse
- Encourage the client to choose a full-code status
- Provide information and ensure the client's wishes are documented
- Complete the directive on the client's behalf to save time
Correct answer: Provide information and ensure the client's wishes are documented
Providing information and ensuring the client's wishes are documented is the nurse's role, because the nurse supports the client's autonomy and self-determination regarding advance directives. The nurse does not decide treatments, steer code status, or complete the directive for the client.
- A nurse is preparing to perform sterile dressing changes on two clients. To prevent cross-contamination, the nurse should:
- Change the dressing of the infected wound first to save supplies
- Change the dressing of the client with the clean wound first
- Use the same sterile field for both clients to save time
- Wear the same pair of sterile gloves for both clients
Correct answer: Change the dressing of the client with the clean wound first
Changing the dressing of the client with the clean wound first prevents cross-contamination, because care progresses from least to most contaminated to avoid transferring organisms to a clean site. Treating the infected wound first, sharing a sterile field, or reusing gloves all spread pathogens between clients.
- A nurse is supervising a graduate nurse who is documenting care. Which entry requires the supervising nurse to intervene?
- The graduate nurse charts findings immediately after providing care
- The graduate nurse leaves a blank line and charts the next entry later
- The graduate nurse draws a single line through an error and initials it
- The graduate nurse signs each entry with name and credentials
Correct answer: The graduate nurse leaves a blank line and charts the next entry later
Leaving a blank line to chart a later entry requires intervention, because blank spaces allow falsified or out-of-sequence entries and must be avoided in legal documentation. Charting promptly, correcting errors with a single line and initials, and signing with credentials are all correct documentation practices.
- During a disaster triage situation using the START system, which client would be tagged as the HIGHEST priority for immediate treatment?
- A client who is walking, alert, and following commands
- A client with a closed ankle fracture who can wait for care
- A client with no respirations after the airway is repositioned
- A client with a respiratory rate of 36 and a weak, rapid pulse
Correct answer: A client with a respiratory rate of 36 and a weak, rapid pulse
The client with a respiratory rate of 36 and a weak, rapid pulse is the highest priority (tagged red/immediate), because abnormal respirations and perfusion indicate a life-threatening but salvageable condition. The ambulatory client is minor, the ankle fracture is delayed, and a client with no respirations after airway repositioning is tagged expectant in mass-casualty triage.
- A nurse is caring for a client in protective (neutropenic) precautions. Which action is appropriate?
- Allow fresh flowers and potted plants in the client's room
- Restrict visitors who have signs of active infection
- Place the client in a negative-pressure room
- Reuse the client's meal tray for the next service
Correct answer: Restrict visitors who have signs of active infection
Restricting visitors with signs of active infection is appropriate, because protective precautions aim to shield the immunocompromised client from outside pathogens. Fresh flowers and plants can harbor organisms, neutropenic clients need positive-pressure rather than negative-pressure rooms, and reusing trays is unsanitary.
- A nurse on a busy unit must prioritize follow-up. Which laboratory result requires the nurse to notify the prescriber IMMEDIATELY?
- A serum potassium of 6.8 mEq/L in a client on a potassium-sparing diuretic
- A hemoglobin A1c of 6.2% in a client with diabetes
- A fasting blood glucose of 105 mg/dL
- A white blood cell count of 7,500/mm3
Correct answer: A serum potassium of 6.8 mEq/L in a client on a potassium-sparing diuretic
A serum potassium of 6.8 mEq/L requires immediate notification, because severe hyperkalemia can cause life-threatening cardiac dysrhythmias and demands prompt intervention. The A1c, fasting glucose, and white blood cell count shown are within or near normal limits and are not emergencies.
- A nurse is reviewing the chain of command after identifying an unsafe staffing assignment. What is the nurse's FIRST step?
- File a formal complaint with the state board of nursing
- Contact the hospital's chief executive officer directly
- Refuse the assignment and leave the unit
- Discuss the concern with the immediate supervisor or charge nurse
Correct answer: Discuss the concern with the immediate supervisor or charge nurse
Discussing the concern with the immediate supervisor or charge nurse is the first step, because the chain of command begins at the lowest appropriate level before escalating. Going to the board of nursing or chief executive first bypasses the chain, and abandoning the assignment could constitute client abandonment.
- A nurse is caring for a client with a draining wound colonized with methicillin-resistant Staphylococcus aureus (MRSA). Which precautions are required?
- Airborne precautions with an N95 respirator
- Standard precautions only
- Droplet precautions with a surgical mask
- Contact precautions with gown and gloves
Correct answer: Contact precautions with gown and gloves
Contact precautions with gown and gloves are required for a draining MRSA wound, because MRSA spreads by direct and indirect contact. Airborne and droplet precautions address respiratory transmission, and standard precautions alone are insufficient for a multidrug-resistant organism.
- A nurse hears a UAP tell a confused, wandering client, "If you get out of bed again, I'll tie you down." What should the nurse do?
- Address the UAP, as threatening restraint constitutes false imprisonment
- Support the UAP because the client is a safety risk
- Apply restraints immediately to keep the client safe
- Document only that the client is uncooperative
Correct answer: Address the UAP, as threatening restraint constitutes false imprisonment
The nurse should address the UAP, because threatening to restrain a client can be charged as false imprisonment, an intentional tort. Supporting the threat, applying restraints without an order, or mischaracterizing the situation as the client being uncooperative all fail to protect the client's rights.
- A nurse is verifying a client's identity before administering medication in accordance with National Patient Safety Goals. Which method is correct?
- Use the client's room number as one identifier
- Confirm identity using the bed location on the assignment sheet
- Ask the client, "Are you Mr. Smith?" and proceed if he nods
- Use two client identifiers such as name and date of birth
Correct answer: Use two client identifiers such as name and date of birth
Using two client identifiers such as name and date of birth is correct, because National Patient Safety Goals require at least two identifiers that are not location based. Room number and bed location can change, and asking a leading yes/no question is unreliable for confirming identity.
- A nurse is caring for a client who has a code status of Do Not Resuscitate (DNR). The client suddenly develops chest pain and shortness of breath. What should the nurse do?
- Provide comfort and treatment measures for the symptoms
- Withhold all interventions because the client is a DNR
- Begin chest compressions and call a code
- Wait for the family to arrive before taking any action
Correct answer: Provide comfort and treatment measures for the symptoms
Providing comfort and treatment measures for the symptoms is correct, because a DNR order only prohibits resuscitation in the event of cardiac or respiratory arrest, not ongoing care or symptom management. Withholding all care, starting CPR, or waiting for family neglects the client's current needs.
- A nurse is implementing a new fall-prevention bundle as part of a continuous quality improvement initiative. Which outcome measure best evaluates the bundle's effectiveness?
- The number of staff who attended the fall-prevention in-service
- The amount of money spent on nonslip socks
- The number of fall-risk signs posted on doors
- The rate of client falls per 1,000 patient-days on the unit
Correct answer: The rate of client falls per 1,000 patient-days on the unit
The rate of client falls per 1,000 patient-days best evaluates effectiveness, because an outcome measure reflects the actual result the initiative aims to change. Attendance counts, posted signs, and supply costs are process or structure measures that do not directly demonstrate improved client safety.
- A 67-year-old client with no contraindications asks the nurse which routine immunizations are recommended at this stage of life. Following current CDC adult immunization guidance, which vaccine should the nurse identify as specifically recommended for healthy adults beginning at age 65 to prevent severe lower respiratory infection?
- Pneumococcal (PCV) vaccine
- Human papillomavirus (HPV) series
- Meningococcal conjugate vaccine
- A second measles-mumps-rubella (MMR) dose
Correct answer: Pneumococcal (PCV) vaccine
The pneumococcal (PCV) vaccine is correct because current CDC guidance recommends pneumococcal vaccination for all adults 65 and older to prevent invasive pneumococcal disease and pneumonia, which carry high morbidity in older adults. The HPV series is routinely targeted to adolescents and young adults through age 26, not 65-year-olds. Meningococcal conjugate vaccine is recommended for specific high-risk groups and adolescents, not routinely for healthy 65-year-olds. A repeat MMR dose is not indicated for an older adult presumed to have prior immunity, so it is not the age-based recommendation.
- During a well-child visit, the nurse evaluates the developmental progress of a 12-month-old. Which finding should the nurse recognize as an expected gross motor milestone for a typically developing child of this age?
- Rides a tricycle independently
- Pulls to a stand and may take first steps
- Skips on alternating feet
- Jumps with both feet off the floor
Correct answer: Pulls to a stand and may take first steps
Pulling to a stand and taking first steps is correct because around 12 months of age a child typically pulls to stand, cruises along furniture, and begins independent walking. Riding a tricycle is a gross motor skill expected closer to age 3, well beyond a 1-year-old's capability. Skipping on alternating feet is a skill that emerges around age 5 to 6. Jumping with both feet off the floor is generally seen around age 2, so it is not yet expected at 12 months.
- A 50-year-old female client tells the nurse she has had irregular menstrual periods and occasional hot flashes for the past several months and asks what to expect as she approaches menopause. Which response by the nurse provides accurate health maintenance teaching about perimenopause?
- "You should expect your periods to stop abruptly and completely with no warning."
- "Menstrual irregularity and hot flashes are common, and menopause is confirmed after 12 consecutive months without a period."
- "Because pregnancy is no longer possible during this stage, contraception is unnecessary."
- "Hormone changes during this time eliminate any need for ongoing bone density monitoring."
Correct answer: "Menstrual irregularity and hot flashes are common, and menopause is confirmed after 12 consecutive months without a period."
The statement that menstrual irregularity and hot flashes are common and that menopause is confirmed after 12 consecutive months without a period is correct because perimenopause involves fluctuating estrogen producing irregular cycles and vasomotor symptoms, with menopause defined retrospectively after a full year of amenorrhea. Telling the client periods stop abruptly is inaccurate, as perimenopause is typically a gradual transition. Saying contraception is unnecessary is unsafe because ovulation can still occur intermittently until menopause is confirmed. Claiming bone monitoring is unneeded is incorrect because declining estrogen increases osteoporosis risk, making bone health surveillance more important.
- A client with hyperkalemia (serum potassium 6.8 mEq/L) and peaked T waves is prescribed IV calcium gluconate. What is the primary purpose of this medication in this situation?
- It rapidly shifts potassium from the blood into the cells
- It stabilizes the cardiac cell membrane to prevent dysrhythmias
- It promotes excretion of potassium through the kidneys
- It binds potassium in the gastrointestinal tract for elimination
Correct answer: It stabilizes the cardiac cell membrane to prevent dysrhythmias
Calcium gluconate stabilizes the cardiac cell membrane to prevent life-threatening dysrhythmias; it does not lower the serum potassium itself. It antagonizes the effect of high potassium on the myocardium, buying time while other therapies (insulin/glucose, kayexalate, dialysis) actually reduce the potassium level.
- A nurse is caring for a client receiving a continuous IV infusion of regular insulin for diabetic ketoacidosis (DKA). Which laboratory value is MOST important for the nurse to monitor frequently to prevent a dangerous complication of treatment?
- Serum sodium
- Serum calcium
- Serum magnesium
- Serum potassium
Correct answer: Serum potassium
Serum potassium is the most critical value to monitor, because insulin drives potassium into the cells and can cause life-threatening hypokalemia during DKA treatment even when the initial level appears normal or high. Frequent monitoring guides potassium replacement and prevents cardiac dysrhythmias.
- A client is admitted with arterial blood gas values of pH 7.30, PaCO2 55 mmHg, and HCO3 24 mEq/L. The nurse interprets these results as which acid-base imbalance?
- Metabolic acidosis
- Respiratory alkalosis
- Respiratory acidosis
- Metabolic alkalosis
Correct answer: Respiratory acidosis
These values indicate uncompensated respiratory acidosis: the pH is low (acidic) and the PaCO2 is elevated, while the HCO3 remains normal. A low pH with a high CO2 and normal bicarbonate points to a respiratory cause that has not yet been buffered by the kidneys.
- A client receiving total parenteral nutrition (TPN) through a central line suddenly develops shortness of breath, chest pain, and a drop in blood pressure during a bag change. The nurse suspects an air embolism. Which action should the nurse take FIRST?
- Place the client in Trendelenburg position on the left side
- Administer supplemental oxygen by face mask
- Notify the health care provider immediately
- Obtain a stat set of vital signs
Correct answer: Place the client in Trendelenburg position on the left side
Placing the client in Trendelenburg position on the left side is the first action, because it traps air in the right atrium and away from the pulmonary outflow tract, preventing it from entering the lungs. Oxygen, notification, and vital signs follow this immediate positioning intervention.
- A client with chronic kidney disease has a serum phosphorus level of 6.5 mg/dL. The nurse anticipates teaching the client about which class of medication, and when it should be taken?
- A loop diuretic taken in the morning
- A phosphate binder taken with meals
- A potassium supplement taken between meals
- An iron supplement taken at bedtime
Correct answer: A phosphate binder taken with meals
A phosphate binder taken with meals is correct, because it binds dietary phosphorus in the gastrointestinal tract so it is excreted in stool rather than absorbed. Taking it with food is essential; taking it between meals would not control the phosphorus from the meal.
- A client with myasthenia gravis is experiencing increasing muscle weakness, difficulty swallowing, and respiratory distress. The nurse cannot determine whether this is a myasthenic crisis or a cholinergic crisis. Which finding would specifically indicate a CHOLINERGIC crisis?
- Increased salivation, lacrimation, and abdominal cramping
- Improvement of symptoms after a dose of pyridostigmine
- Dry mouth and tachycardia
- Symptoms that worsen with physical exertion
Correct answer: Increased salivation, lacrimation, and abdominal cramping
Increased salivation, lacrimation, and abdominal cramping indicate a cholinergic crisis, which results from excess anticholinesterase medication and produces muscarinic effects (SLUDGE symptoms). A myasthenic crisis, by contrast, comes from too little medication and improves with cholinergic drugs.
- A client returns to the unit after a thyroidectomy. Which assessment finding requires the nurse's IMMEDIATE attention?
- A sore throat and hoarse voice
- A small amount of serosanguineous drainage on the dressing
- Tingling around the mouth and muscle twitching
- Discomfort when swallowing
Correct answer: Tingling around the mouth and muscle twitching
Tingling around the mouth and muscle twitching require immediate attention because they signal hypocalcemia from inadvertent parathyroid gland damage during surgery, which can progress to laryngospasm and tetany. A sore throat, hoarseness, and minimal drainage are expected postoperative findings.
- A nurse is caring for a client with cancer who has a platelet count of 18,000/mm3. Which intervention is the priority for this client?
- Place the client in protective (reverse) isolation
- Encourage increased fluid intake to prevent dehydration
- Restrict visitors who have signs of infection
- Implement bleeding precautions and avoid invasive procedures
Correct answer: Implement bleeding precautions and avoid invasive procedures
Implementing bleeding precautions and avoiding invasive procedures is the priority, because a platelet count of 18,000/mm3 is severe thrombocytopenia that places the client at high risk for spontaneous hemorrhage. Protective isolation and visitor restrictions address neutropenia, not low platelets.
- A client is receiving an IV infusion of heparin. The nurse reviews the most recent activated partial thromboplastin time (aPTT), which is 92 seconds, with a control of 30 seconds. Which action should the nurse take?
- Stop the infusion and prepare to administer protamine sulfate
- Increase the heparin infusion rate as ordered
- Continue the current rate and recheck in 6 hours
- Administer vitamin K subcutaneously
Correct answer: Stop the infusion and prepare to administer protamine sulfate
Stopping the infusion and preparing protamine sulfate is correct because an aPTT of 92 seconds is far above the therapeutic range of about 1.5 to 2.5 times the control (45 to 75 seconds), indicating excessive anticoagulation and bleeding risk. Protamine sulfate is the antidote for heparin; vitamin K reverses warfarin.
- A client with Parkinson's disease is prescribed carbidopa-levodopa. The nurse should teach the client to avoid taking the medication with a meal high in which nutrient?
- Protein
- Carbohydrates
- Fiber
- Vitamin C
Correct answer: Protein
The client should avoid taking carbidopa-levodopa with a high-protein meal, because dietary amino acids compete with levodopa for absorption across the intestinal wall and the blood-brain barrier, reducing the drug's effectiveness. Carbohydrates, fiber, and vitamin C do not have this competitive interaction.
- A nurse is monitoring a client who is 4 hours post-cardiac catheterization performed via the right femoral artery. Which finding indicates a complication requiring immediate intervention?
- The client reports mild discomfort at the insertion site
- The right pedal pulse is absent and the foot is cool and pale
- A small ecchymotic area is noted around the insertion site
- The client's urine output is 60 mL in the past hour
Correct answer: The right pedal pulse is absent and the foot is cool and pale
An absent right pedal pulse with a cool, pale foot indicates arterial occlusion or thrombus formation at the catheter site, compromising distal circulation and requiring immediate intervention. Mild discomfort, a small bruise, and adequate urine output are expected or normal findings.
- A client with severe hypovolemia from gastrointestinal bleeding is being treated for shock. Which set of vital sign changes would the nurse expect to find in compensated (early) hypovolemic shock?
- Increased heart rate with normal or slightly decreased blood pressure
- Decreased heart rate with elevated blood pressure
- Decreased heart rate with bounding peripheral pulses
- Normal heart rate with widened pulse pressure
Correct answer: Increased heart rate with normal or slightly decreased blood pressure
An increased heart rate with normal or slightly decreased blood pressure characterizes compensated hypovolemic shock, because the body increases heart rate and vasoconstricts to maintain perfusion before blood pressure falls significantly. A falling blood pressure with bradycardia is a late, decompensated sign.
- A client is admitted with acute pancreatitis. Which laboratory result would the nurse expect to be significantly elevated to support this diagnosis?
- Serum albumin
- Serum creatinine
- Serum bilirubin only
- Serum lipase
Correct answer: Serum lipase
Serum lipase is expected to be significantly elevated in acute pancreatitis and is more specific than amylase for pancreatic injury, remaining elevated longer. Albumin and creatinine are not diagnostic for pancreatitis, and isolated bilirubin elevation points to biliary obstruction rather than the inflammatory pancreatic process.
- A client receiving a unit of packed red blood cells develops a fever, chills, flank pain, and red-tinged urine 15 minutes into the transfusion. After stopping the transfusion, which action should the nurse take NEXT?
- Slow the transfusion rate and continue monitoring
- Administer an antihistamine and restart the transfusion
- Keep the IV line open with normal saline using new tubing
- Remove the IV catheter and apply a warm compress
Correct answer: Keep the IV line open with normal saline using new tubing
Keeping the IV line open with normal saline using new tubing is the next action, because these findings indicate an acute hemolytic transfusion reaction, and maintaining venous access with saline preserves renal perfusion and allows emergency medications. The blood tubing is removed to avoid infusing more incompatible blood, and the line must not be removed.
- A client with end-stage liver disease is at risk for hepatic encephalopathy. The nurse anticipates administering lactulose. The nurse knows the medication is effective when which finding is observed?
- Improved level of consciousness and orientation
- Decreased number of daily bowel movements
- Increased serum potassium level
- Resolution of jaundice
Correct answer: Improved level of consciousness and orientation
Improved level of consciousness and orientation indicate that lactulose is effective, because the drug lowers blood ammonia by trapping it in the colon and promoting its elimination through increased stooling. Lactulose should increase, not decrease, bowel movements, and it does not affect jaundice.
- A nurse is caring for a client immediately after a bronchoscopy with topical anesthesia to the throat. Which assessment must the nurse complete BEFORE allowing the client to eat or drink?
- Ability to ambulate independently
- Stable blood pressure reading
- Presence of a gag reflex
- Absence of throat soreness
Correct answer: Presence of a gag reflex
The presence of a gag reflex must be verified before oral intake, because topical anesthesia suppresses the gag reflex and the client is at high risk for aspiration until it returns. Ambulation, blood pressure, and throat soreness do not protect the airway from aspiration.
- A client with chronic obstructive pulmonary disease (COPD) and chronic carbon dioxide retention is receiving oxygen therapy. The nurse should set the oxygen flow rate to maintain the oxygen saturation within which range?
- 94% to 98%
- 98% to 100%
- 80% to 85%
- 88% to 92%
Correct answer: 88% to 92%
An oxygen saturation of 88% to 92% is the target for a COPD client who retains carbon dioxide, because excessive oxygen can blunt the hypoxic respiratory drive and worsen carbon dioxide retention. Higher targets risk suppressing respiration, and a target of 80% to 85% is dangerously hypoxic.
- A client is prescribed a continuous bladder irrigation (CBI) after a transurethral resection of the prostate (TURP). The nurse notes the urine is bright red with numerous clots and the drainage is slowing. Which action should the nurse take FIRST?
- Clamp the catheter and notify the provider
- Remove the indwelling catheter and reinsert a new one
- Increase the irrigation flow rate to maintain catheter patency
- Decrease the irrigation rate to reduce bleeding
Correct answer: Increase the irrigation flow rate to maintain catheter patency
Increasing the irrigation flow rate is the first action, because bright red urine with clots and slowing drainage suggests active bleeding and obstruction, and a faster flow keeps the catheter patent and flushes clots. Clamping would worsen obstruction and clot retention, and the catheter should not be removed.
- A nurse reviews the morning laboratory results for a client receiving digoxin and notes a serum potassium of 2.9 mEq/L. Why is this finding significant?
- Hypokalemia decreases the effectiveness of digoxin
- Hypokalemia increases the risk of digoxin toxicity
- Hypokalemia is an expected effect of digoxin therapy
- Hypokalemia indicates the client needs a higher digoxin dose
Correct answer: Hypokalemia increases the risk of digoxin toxicity
Hypokalemia increases the risk of digoxin toxicity, because low potassium enhances digoxin binding to cardiac cells and potentiates its effects, predisposing the client to dangerous dysrhythmias. This combination requires prompt potassium correction rather than a higher digoxin dose.
- A client with a spinal cord injury at the T4 level suddenly develops a pounding headache, blood pressure of 210/110 mmHg, profuse sweating above the injury, and bradycardia. After raising the head of the bed, which action should the nurse take NEXT?
- Administer an oral analgesic for the headache
- Lay the client flat and elevate the legs
- Assess for and remove the cause, such as a distended bladder
- Apply oxygen and obtain an electrocardiogram
Correct answer: Assess for and remove the cause, such as a distended bladder
Assessing for and removing the cause, such as a distended bladder, is the next action because these findings indicate autonomic dysreflexia, a life-threatening response to a noxious stimulus below the injury. Eliminating the trigger (often a full bladder or bowel) resolves the crisis; laying the client flat would worsen the dangerous hypertension.
- A nurse is administering enoxaparin (a low-molecular-weight heparin) subcutaneously. Which technique is correct?
- Inject into the abdomen without expelling the air bubble in the prefilled syringe
- Aspirate before injecting to confirm placement
- Massage the site vigorously after injection
- Insert the needle at a 45-degree angle into the thigh
Correct answer: Inject into the abdomen without expelling the air bubble in the prefilled syringe
Injecting into the abdomen without expelling the air bubble is correct, because the bubble in the prefilled syringe ensures the full dose is delivered and clears the needle to reduce bruising. The nurse should not aspirate or massage the site, as both increase the risk of hematoma.
- A client with acute respiratory distress syndrome (ARDS) is intubated and mechanically ventilated. Which nursing intervention best reduces the risk of ventilator-associated pneumonia?
- Keep the client in a supine position to optimize ventilation
- Perform routine saline lavage with every suctioning
- Change the ventilator circuit tubing every 8 hours
- Maintain the head of the bed elevated 30 to 45 degrees
Correct answer: Maintain the head of the bed elevated 30 to 45 degrees
Maintaining the head of the bed at 30 to 45 degrees best reduces ventilator-associated pneumonia, because semi-Fowler's positioning decreases the aspiration of secretions into the lungs. Supine positioning increases aspiration risk, routine saline lavage is discouraged, and frequent unnecessary circuit changes can introduce contamination.
- A nurse is caring for a client receiving a continuous infusion of a vasopressor through a peripheral IV. Which finding indicates extravasation requiring immediate intervention?
- A brisk blood return when the line is aspirated
- Blanching, coolness, and swelling at the IV site
- Warmth and redness tracking up the vein
- The infusion pump alarming for an occlusion downstream
Correct answer: Blanching, coolness, and swelling at the IV site
Blanching, coolness, and swelling at the IV site indicate extravasation of the vasopressor into surrounding tissue, which can cause severe tissue ischemia and necrosis and requires the infusion to be stopped immediately. Warmth and redness tracking the vein suggest phlebitis, a different complication.
- A client is scheduled for a paracentesis to relieve tense ascites. Which action should the nurse take immediately BEFORE the procedure?
- Place the client in a supine, flat position
- Have the client void to empty the bladder
- Withhold all oral fluids for 12 hours
- Administer a cleansing enema
Correct answer: Have the client void to empty the bladder
Having the client void to empty the bladder immediately before paracentesis is correct, because an empty bladder reduces the risk of accidental puncture when the needle is inserted into the abdomen. The client is typically positioned upright or sitting, not flat, to allow fluid to pool in the lower abdomen.
- A client with Cushing's syndrome is admitted to the unit. Based on the pathophysiology of this disorder, which laboratory finding would the nurse expect?
- Hypoglycemia and hyperkalemia
- Hyponatremia and hypercalcemia
- Hypoglycemia and hyponatremia
- Hyperglycemia and hypokalemia
Correct answer: Hyperglycemia and hypokalemia
Hyperglycemia and hypokalemia are expected in Cushing's syndrome, because excess cortisol raises blood glucose and promotes potassium excretion along with sodium and water retention. This contrasts with Addison's disease, which produces hypoglycemia, hyperkalemia, and hyponatremia.
- A nurse is caring for a client in sickle cell crisis. Which intervention is the priority for managing this client?
- Administer IV fluids and prescribed analgesics
- Restrict fluids to reduce vascular congestion
- Apply cold compresses to painful joints
- Encourage vigorous ambulation to improve circulation
Correct answer: Administer IV fluids and prescribed analgesics
Administering IV fluids and prescribed analgesics is the priority during a sickle cell crisis, because hydration reduces blood viscosity and helps reverse the sickling and vaso-occlusion that cause severe pain and tissue hypoxia. Fluid restriction and cold compresses worsen sickling by promoting vasoconstriction and dehydration.
- A client recovering from a myocardial infarction is started on metoprolol. Which assessment finding would cause the nurse to hold the dose and notify the provider?
- Blood pressure of 128/78 mmHg
- Respiratory rate of 18 breaths per minute
- Oxygen saturation of 96% on room air
- Apical heart rate of 48 beats per minute
Correct answer: Apical heart rate of 48 beats per minute
An apical heart rate of 48 beats per minute would cause the nurse to hold metoprolol, because this beta blocker slows the heart rate and giving it during bradycardia could cause dangerous further slowing. A normal blood pressure, respiratory rate, and oxygen saturation are not contraindications to the dose.
- A nurse is reviewing arterial blood gas results for a client with prolonged vomiting: pH 7.52, PaCO2 42 mmHg, HCO3 32 mEq/L. The nurse interprets these values as which imbalance?
- Respiratory alkalosis
- Metabolic alkalosis
- Metabolic acidosis
- Respiratory acidosis
Correct answer: Metabolic alkalosis
These values indicate metabolic alkalosis: the pH is elevated (alkalotic), the bicarbonate is high, and the PaCO2 is normal. The loss of gastric acid through prolonged vomiting raises the bicarbonate level, producing an alkalosis of metabolic origin.
- A client with a chest tube connected to a water-seal drainage system is being monitored. The nurse observes continuous, vigorous bubbling in the water-seal chamber. What does this finding most likely indicate?
- Normal functioning of the drainage system
- Re-expansion of the lung
- An air leak in the system
- Obstruction of the chest tube
Correct answer: An air leak in the system
Continuous, vigorous bubbling in the water-seal chamber most likely indicates an air leak in the system, which must be located and corrected. Intermittent bubbling during exhalation or coughing is normal, whereas continuous bubbling signals air entering the system through a leak in the tubing or connections.
- A nurse is administering phenytoin IV to a client for seizure control. Which precaution is essential when giving this medication intravenously?
- Administer slowly and flush the line with normal saline, not dextrose
- Mix the medication in dextrose 5% in water for infusion
- Give the full dose as a rapid IV push
- Administer through the same line as other IV medications
Correct answer: Administer slowly and flush the line with normal saline, not dextrose
Administering phenytoin slowly and flushing the line with normal saline is essential, because rapid administration can cause hypotension and cardiac dysrhythmias, and phenytoin precipitates when mixed with dextrose solutions. The drug requires a dedicated line flushed with saline before and after.
- A client with severe preeclampsia is receiving an IV magnesium sulfate infusion. The nurse assesses absent deep tendon reflexes, a respiratory rate of 10 breaths per minute, and decreased urine output. After stopping the infusion, which medication should the nurse prepare to administer?
- Potassium chloride
- Naloxone
- Calcium gluconate
- Sodium bicarbonate
Correct answer: Calcium gluconate
Calcium gluconate is the antidote the nurse should prepare, because absent reflexes, respiratory depression, and decreased urine output indicate magnesium toxicity, and calcium directly antagonizes magnesium's effects. Naloxone reverses opioids, not magnesium, and would not address this emergency.
- A client recovering from abdominal surgery suddenly reports a 'popping' sensation at the incision, and the nurse observes loops of bowel protruding through the wound. After calling for help, which action should the nurse take?
- Attempt to gently reinsert the bowel into the abdomen
- Apply a tight abdominal binder over the protruding tissue
- Position the client in high Fowler's with knees extended
- Cover the wound with sterile gauze moistened with normal saline
Correct answer: Cover the wound with sterile gauze moistened with normal saline
Covering the wound with sterile gauze moistened with normal saline is correct, because this is an evisceration, and keeping the exposed organs moist prevents drying and tissue damage until surgical repair. The nurse should never push the bowel back in, and the client is positioned with knees flexed to reduce abdominal tension.
- A nurse is caring for a client with acute kidney injury in the oliguric phase. Which dietary modification should the nurse anticipate teaching the client?
- Increase potassium-rich foods to replace losses
- Restrict potassium, sodium, and protein intake
- Encourage a high-protein, high-phosphorus diet
- Liberalize fluid intake to flush the kidneys
Correct answer: Restrict potassium, sodium, and protein intake
Restricting potassium, sodium, and protein is correct during the oliguric phase, because the failing kidneys cannot excrete these substances, leading to dangerous accumulation such as hyperkalemia and rising nitrogenous wastes. Fluids are also restricted, not liberalized, because of impaired excretion.
- A client is prescribed a fentanyl transdermal patch for chronic cancer pain. Which instruction should the nurse include in the teaching?
- Apply the patch and expect immediate pain relief
- Cut the patch in half if the dose is too strong
- Avoid applying external heat sources over the patch
- Apply the patch to a freshly shaved, irritated area
Correct answer: Avoid applying external heat sources over the patch
Avoiding external heat over the patch is correct, because heat increases drug absorption and can cause life-threatening opioid overdose. The patch is not cut, takes hours to reach effect, and should be applied to clean, intact, non-irritated skin to ensure predictable absorption.
- A nurse is assessing a client 6 hours after a total knee arthroplasty. Which finding indicates compartment syndrome and requires immediate provider notification?
- Severe pain unrelieved by opioids and pain with passive stretching of the foot
- Mild swelling and bruising around the surgical knee
- Serosanguineous drainage on the surgical dressing
- Reports of incisional pain rated 4 on a 0-to-10 scale
Correct answer: Severe pain unrelieved by opioids and pain with passive stretching of the foot
Severe pain unrelieved by opioids combined with pain on passive stretching indicates compartment syndrome, a surgical emergency caused by increased pressure within a muscle compartment that compromises circulation and can cause permanent damage. Mild swelling and expected drainage are normal postoperative findings.
- A client with hypothyroidism is being treated but presents with hypothermia, bradycardia, hypotension, and a decreasing level of consciousness. The nurse recognizes these as signs of which complication?
- Thyroid storm
- Hypoglycemic shock
- Myxedema coma
- Adrenal crisis
Correct answer: Myxedema coma
Hypothermia, bradycardia, hypotension, and a declining level of consciousness indicate myxedema coma, a severe, life-threatening complication of untreated or undertreated hypothyroidism. Thyroid storm, in contrast, produces hyperthermia and tachycardia from excess thyroid hormone.
- A nurse is caring for a client receiving IV potassium chloride for hypokalemia. Which prescription would the nurse question to ensure client safety?
- Dilute potassium chloride in IV fluid and infuse via pump
- Monitor cardiac rhythm during the infusion
- Assess urine output before administering the dose
- Administer potassium chloride 20 mEq IV push over 2 minutes
Correct answer: Administer potassium chloride 20 mEq IV push over 2 minutes
The nurse would question the order to give potassium chloride by IV push, because rapid undiluted IV potassium can cause fatal cardiac dysrhythmias and arrest. Potassium must always be diluted and infused slowly via pump, with cardiac monitoring and adequate urine output confirmed.
- A client is admitted with a diagnosis of acute exacerbation of multiple sclerosis. The nurse anticipates administering which class of medication to reduce the inflammatory response during the exacerbation?
- Anticoagulants
- Corticosteroids
- Antihypertensives
- Loop diuretics
Correct answer: Corticosteroids
Corticosteroids are anticipated during an acute multiple sclerosis exacerbation, because they reduce the inflammation and edema affecting the demyelinated nerves, helping to shorten the duration of the relapse. Anticoagulants, antihypertensives, and diuretics do not address the autoimmune inflammatory process.
- A nurse is monitoring a client who received epidural anesthesia for surgery. Which finding is the priority to address?
- Numbness and tingling in the lower extremities
- A sudden drop in blood pressure to 84/50 mmHg
- Inability to move the legs voluntarily
- A sensation of warmth in the lower body
Correct answer: A sudden drop in blood pressure to 84/50 mmHg
A sudden drop in blood pressure to 84/50 mmHg is the priority, because epidural anesthesia causes sympathetic blockade and vasodilation that can lead to severe hypotension and compromised perfusion. Numbness, motor block, and warmth in the lower body are expected effects of the epidural.
- A client receiving chemotherapy develops a temperature of 101.4 F (38.6 C) and an absolute neutrophil count of 480/mm3. Which action is the priority for this client?
- Administer acetaminophen and recheck the temperature in 4 hours
- Encourage oral fluids and apply a cooling blanket
- Document the finding and continue routine monitoring
- Obtain cultures and prepare to administer broad-spectrum antibiotics promptly
Correct answer: Obtain cultures and prepare to administer broad-spectrum antibiotics promptly
Obtaining cultures and administering broad-spectrum antibiotics promptly is the priority, because fever with an absolute neutrophil count below 500/mm3 is neutropenic fever, a medical emergency with a high risk of overwhelming sepsis. Delaying treatment to recheck the temperature could be fatal in this immunocompromised client.
- A nurse is administering IV potassium chloride to a client with a serum potassium of 2.9 mEq/L. Which action is essential before initiating the infusion?
- Confirm the client has adequate urine output
- Administer the potassium by rapid IV push
- Place the client on a fluid restriction
- Withhold all oral potassium-rich foods
Correct answer: Confirm the client has adequate urine output
Confirming adequate urine output is essential because potassium is primarily excreted by the kidneys; administering IV potassium to a client with poor renal output risks dangerous hyperkalemia. IV potassium must never be given by push, which can cause fatal cardiac arrest, but always diluted and infused slowly. Fluid restriction and withholding dietary potassium are not indicated for a hypokalemic client.
- A client receiving a continuous heparin infusion has an aPTT that is more than three times the control value. Which medication should the nurse anticipate administering?
- Vitamin K (phytonadione)
- Calcium gluconate
- Protamine sulfate
- Aminocaproic acid
Correct answer: Protamine sulfate
Protamine sulfate is the specific antidote for heparin and should be anticipated when the aPTT is excessively prolonged, indicating overanticoagulation and bleeding risk. Vitamin K reverses warfarin, not heparin. Calcium gluconate treats hyperkalemia or magnesium toxicity, and aminocaproic acid is used for fibrinolysis-related bleeding, not heparin reversal.
- A nurse is caring for a client with chronic kidney disease who reports muscle cramps and has an ECG showing peaked T waves. Which laboratory value should the nurse address first?
- Serum sodium of 138 mEq/L
- Serum potassium of 6.8 mEq/L
- Serum calcium of 9.2 mg/dL
- Serum chloride of 102 mEq/L
Correct answer: Serum potassium of 6.8 mEq/L
A serum potassium of 6.8 mEq/L must be addressed first because the peaked T waves confirm hyperkalemia, which can progress to lethal ventricular dysrhythmias. The sodium, calcium, and chloride values are all within normal limits and pose no immediate threat. Hyperkalemia is the priority physiological adaptation problem in this client.
- A nurse is monitoring a client receiving total parenteral nutrition (TPN). Which finding most likely indicates the client is developing a complication of the therapy?
- Urine output of 60 mL/hr
- Blood glucose of 280 mg/dL
- Heart rate of 78 beats per minute
- Temperature of 98.6 degrees Fahrenheit
Correct answer: Blood glucose of 280 mg/dL
A blood glucose of 280 mg/dL most likely indicates hyperglycemia, a common metabolic complication of the high dextrose content in TPN. Urine output of 60 mL/hr, a heart rate of 78, and a normal temperature are all within expected limits and do not signal a complication. Frequent glucose monitoring is required during TPN administration.
- A client with diabetic ketoacidosis is receiving an IV insulin infusion. The nurse should monitor most closely for which electrolyte disturbance as the blood glucose falls?
- Hypernatremia
- Hypercalcemia
- Hypokalemia
- Hyperphosphatemia
Correct answer: Hypokalemia
Hypokalemia is the disturbance to monitor most closely because insulin drives potassium back into the cells along with glucose, causing serum potassium to drop rapidly. This can precipitate cardiac dysrhythmias if not corrected. Insulin therapy does not characteristically cause hypernatremia, hypercalcemia, or hyperphosphatemia in this setting.
- A nurse is preparing to administer digoxin to a client. The client's apical heart rate is 52 beats per minute. Which action should the nurse take?
- Administer the dose and recheck in one hour
- Give half of the prescribed dose
- Withhold the dose and notify the provider
- Administer the dose with a full glass of water
Correct answer: Withhold the dose and notify the provider
Withholding the dose and notifying the provider is correct because an apical rate below 60 beats per minute is a contraindication to administering digoxin, as the drug further slows the heart rate. Giving the dose, halving it, or administering it with water would all expose the client to symptomatic bradycardia and possible toxicity.
- A client is admitted with severe vomiting for three days. Arterial blood gases show pH 7.52, PaCO2 42 mmHg, and HCO3 32 mEq/L. The nurse interprets these results as which acid-base imbalance?
- Respiratory acidosis
- Metabolic acidosis
- Respiratory alkalosis
- Metabolic alkalosis
Correct answer: Metabolic alkalosis
These results indicate metabolic alkalosis: the elevated pH with an elevated bicarbonate and a normal PaCO2 reflects a metabolic (nonrespiratory) origin, consistent with the loss of gastric acid from prolonged vomiting. Respiratory acidosis and respiratory alkalosis would show abnormal PaCO2 values, and metabolic acidosis would present with a low pH and low bicarbonate.
- A nurse is caring for a client with a chest tube connected to a water-seal drainage system. The nurse notes continuous bubbling in the water-seal chamber. Which is the most appropriate initial action?
- Assess the tubing connections for an air leak
- Clamp the chest tube near the insertion site
- Increase the suction pressure on the unit
- Strip the entire length of the drainage tubing
Correct answer: Assess the tubing connections for an air leak
Assessing the tubing connections for an air leak is the most appropriate initial action because continuous bubbling in the water-seal chamber suggests air is entering the system, often from a loose connection. Clamping the tube can cause a tension pneumothorax, increasing suction does not fix a leak, and routine stripping of tubing is no longer recommended due to dangerously high pressures.
- A nurse is teaching a client newly prescribed warfarin. Which client statement indicates the need for further teaching?
- I will keep my intake of green leafy vegetables consistent
- I will use a soft toothbrush and an electric razor
- I will take extra doses if I notice any swelling
- I will report any blood in my urine or stool
Correct answer: I will take extra doses if I notice any swelling
The statement about taking extra doses for swelling indicates the need for further teaching because clients must never self-adjust warfarin dosing, which is titrated by INR results, and doubling doses dramatically increases bleeding risk. Keeping vitamin K intake consistent, using a soft toothbrush and electric razor, and reporting bleeding are all correct safety practices.
- A nurse is monitoring a client who is two hours post-thyroidectomy. Which finding requires immediate intervention?
- A sore throat when swallowing
- Hoarseness of the voice
- A small amount of serosanguineous drainage
- Stridor and a sensation of throat tightness
Correct answer: Stridor and a sensation of throat tightness
Stridor with a sensation of throat tightness requires immediate intervention because it signals airway obstruction, possibly from hematoma or laryngeal edema, a life-threatening post-thyroidectomy emergency. A sore throat, mild hoarseness, and a small amount of serosanguineous drainage are expected findings that can be monitored.
- A nurse is caring for a client receiving a unit of packed red blood cells. Fifteen minutes after the transfusion begins, the client reports chills, lower back pain, and a feeling of apprehension. What is the nurse's priority action?
- Slow the transfusion rate and continue monitoring
- Document the findings as an expected response
- Administer an antipyretic and reassess in 15 minutes
- Stop the transfusion and keep the IV line open with normal saline
Correct answer: Stop the transfusion and keep the IV line open with normal saline
Stopping the transfusion and maintaining the IV line with normal saline is the priority because chills, back pain, and apprehension suggest an acute hemolytic transfusion reaction, which can be fatal. Slowing the rate still exposes the client to incompatible blood, antipyretics do not address hemolysis, and these findings are never expected.
- A nurse is providing nutrition guidance to a client with cirrhosis and elevated ammonia levels. Which dietary recommendation is most appropriate?
- Increase intake of high-protein animal foods
- Restrict fluids to less than 500 mL daily
- Eliminate all carbohydrates from the diet
- Moderate protein intake and ensure adequate calories
Correct answer: Moderate protein intake and ensure adequate calories
Moderating protein intake while ensuring adequate calories is most appropriate because excess protein increases ammonia production, contributing to hepatic encephalopathy, yet some protein is needed to prevent muscle breakdown. Increasing animal protein worsens ammonia load, eliminating carbohydrates promotes protein catabolism, and severe fluid restriction is not the standard intervention for elevated ammonia.
- A client is receiving IV vancomycin. During the infusion, the nurse notes flushing and redness of the client's face, neck, and upper torso. Which is the nurse's best action?
- Administer the next dose by rapid IV push
- Stop the medication and discard the IV catheter
- Apply cool compresses and continue at the same rate
- Slow the rate of the vancomycin infusion
Correct answer: Slow the rate of the vancomycin infusion
Slowing the infusion rate is the best action because the flushing and redness describe vancomycin infusion reaction (formerly red man syndrome), which is rate-related and typically resolves when the drug is infused more slowly. The IV catheter does not need removal, continuing at the same rate worsens the reaction, and vancomycin must never be given by rapid push.
- A nurse is caring for a client in the oliguric phase of acute kidney injury. Which intervention is most important for the nurse to implement?
- Encourage a diet high in potassium-rich foods
- Monitor for signs of fluid volume overload
- Administer IV fluids at 200 mL per hour
- Restrict the client's daily caloric intake
Correct answer: Monitor for signs of fluid volume overload
Monitoring for fluid volume overload is most important because during the oliguric phase the kidneys excrete little urine, causing fluid retention that can lead to pulmonary edema and heart failure. High-potassium foods are dangerous due to hyperkalemia risk, aggressive IV fluids worsen overload, and caloric restriction is not indicated.
- A nurse is calculating an IV medication dose. The order is for 750 mg, and the available vial contains 1 g in 4 mL. How many milliliters should the nurse administer?
Correct answer: 3 mL
The nurse should administer 3 mL. Converting 1 g to 1000 mg gives a concentration of 1000 mg per 4 mL: 1000 mg750 mg×4 mL=3 mL. The other volumes result from miscalculating the concentration or omitting the gram-to-milligram conversion.
- A nurse is caring for a client with a nasogastric tube set to low intermittent suction. Which arterial blood gas abnormality should the nurse anticipate if drainage is excessive?
- Metabolic acidosis
- Respiratory acidosis
- Metabolic alkalosis
- Respiratory alkalosis
Correct answer: Metabolic alkalosis
The nurse should anticipate metabolic alkalosis because nasogastric suction removes hydrochloric acid from the stomach, depleting hydrogen ions and raising the blood pH. Loss of gastric acid does not produce metabolic acidosis, and because the imbalance is nonrespiratory in origin, neither respiratory acidosis nor respiratory alkalosis applies.
- A nurse is assessing a client receiving morphine via patient-controlled analgesia. Which assessment finding is the priority concern?
- Urinary output of 50 mL per hour
- Report of constipation
- Complaint of mild itching
- Respiratory rate of 8 breaths per minute
Correct answer: Respiratory rate of 8 breaths per minute
A respiratory rate of 8 breaths per minute is the priority concern because respiratory depression is the most dangerous adverse effect of opioids such as morphine and can be life-threatening. Constipation and pruritus are common, manageable side effects, and a urinary output of 50 mL per hour is within normal limits.
- A nurse is caring for a client after a cardiac catheterization performed through the right femoral artery. Which assessment finding requires immediate notification of the provider?
- Bruising at the insertion site the size of a quarter
- A diminished, weak right pedal pulse
- Mild discomfort at the catheter insertion site
- Blood pressure of 124 over 78 mmHg
Correct answer: A diminished, weak right pedal pulse
A diminished, weak right pedal pulse requires immediate notification because it may indicate arterial occlusion or compromised circulation distal to the femoral insertion site, threatening the limb. Small bruising and mild site discomfort are expected after catheterization, and the blood pressure is within normal limits.
- A nurse is monitoring a client receiving magnesium sulfate IV for preterm labor. Which finding indicates magnesium toxicity?
- Brisk, 3+ deep tendon reflexes
- Respiratory rate of 18 breaths per minute
- Blood pressure of 130 over 84 mmHg
- Absent deep tendon reflexes
Correct answer: Absent deep tendon reflexes
Absent deep tendon reflexes indicate magnesium toxicity because rising magnesium levels progressively depress neuromuscular transmission, with loss of reflexes being an early warning before respiratory depression and cardiac arrest. Brisk reflexes suggest a subtherapeutic level, and the listed blood pressure and respiratory rate are normal findings.
- A nurse is providing care for a client with a new ileostomy. Which characteristic of the stoma output should the nurse expect?
- Loose, liquid to semi-liquid stool
- Formed, solid brown stool
- Clear, mucus-only drainage
- Dark, tarry stool
Correct answer: Loose, liquid to semi-liquid stool
Loose, liquid to semi-liquid stool is expected from an ileostomy because the output exits before the large intestine can absorb most of the water, leaving the effluent watery. Formed brown stool is characteristic of a colostomy in the distal colon, mucus-only drainage is abnormal, and dark tarry stool suggests upper GI bleeding rather than normal ileostomy output.
- A nurse is administering enoxaparin subcutaneously to a client. Which technique is correct?
- Expel the air bubble from the prefilled syringe before injecting
- Massage the injection site vigorously after administration
- Inject into the abdomen without aspirating or rubbing the site
- Insert the needle at a 15-degree angle into the deltoid
Correct answer: Inject into the abdomen without aspirating or rubbing the site
Injecting into the abdomen without aspirating or rubbing the site is correct because the air bubble in the prefilled syringe should be retained to deliver the full dose, and aspirating or massaging increases bruising and hematoma risk with this anticoagulant. Expelling the bubble, massaging the site, and using a shallow deltoid injection are all incorrect techniques.
- A nurse is caring for a client with acute pancreatitis. Which intervention best supports the goal of resting the pancreas?
- Maintaining the client NPO with IV hydration
- Providing a high-fat, high-protein diet
- Encouraging frequent small carbohydrate snacks
- Administering oral pancreatic enzymes with meals
Correct answer: Maintaining the client NPO with IV hydration
Maintaining the client NPO with IV hydration best rests the pancreas because withholding food reduces pancreatic enzyme stimulation while fluids prevent dehydration during the acute phase. A high-fat diet and carbohydrate snacks stimulate enzyme secretion, and oral pancreatic enzymes are used for chronic insufficiency, not to rest an acutely inflamed pancreas.
- A nurse is reviewing morning labs for a client receiving furosemide. Which result is most important to report to the provider?
- Creatinine of 0.9 mg/dL
- Sodium of 140 mEq/L
- Hemoglobin of 13.5 g/dL
- Potassium of 2.8 mEq/L
Correct answer: Potassium of 2.8 mEq/L
A potassium of 2.8 mEq/L is most important to report because furosemide is a loop diuretic that causes potassium wasting, and this hypokalemic level increases the risk of cardiac dysrhythmias. The sodium, hemoglobin, and creatinine values are all within normal limits and do not require urgent reporting.
- A nurse is caring for a client in sickle cell crisis. Which intervention is the highest priority?
- Applying cold compresses to painful joints
- Administering IV fluids and prescribed analgesia
- Encouraging vigorous ambulation in the hallway
- Restricting the client's oral fluid intake
Correct answer: Administering IV fluids and prescribed analgesia
Administering IV fluids and prescribed analgesia is the highest priority because hydration reduces blood viscosity and improves perfusion to ischemic tissue while analgesia manages the severe pain of vaso-occlusion. Cold compresses cause vasoconstriction and worsen sickling, vigorous activity increases oxygen demand, and restricting fluids promotes further sickling.
- A nurse is preparing to administer phenytoin IV. Which solution should the nurse use to dilute or flush the line?
- Lactated Ringer's solution
- 5% dextrose in water
- 0.9% normal saline
- 0.45% half-normal saline
Correct answer: 0.9% normal saline
0.9% normal saline should be used because phenytoin precipitates when mixed with dextrose-containing solutions, so saline is the compatible diluent and flush. Using 5% dextrose in water causes crystallization, while lactated Ringer's and half-normal saline are not the recommended compatible solutions for IV phenytoin administration.
- A nurse is caring for a client with a deep wound healing by secondary intention. Which dressing approach best supports moist wound healing?
- Applying a moisture-retentive dressing to the wound bed
- Allowing the wound to air dry between dressing changes
- Packing the wound tightly with dry gauze
- Cleansing the wound with full-strength antiseptic each shift
Correct answer: Applying a moisture-retentive dressing to the wound bed
Applying a moisture-retentive dressing best supports healing because a moist wound environment promotes granulation tissue formation and epithelial cell migration. Letting the wound air dry and packing it with dry gauze dehydrate the wound bed, and full-strength antiseptics can be cytotoxic to the new tissue needed for repair.
- A nurse is monitoring a client receiving IV regular insulin for hyperkalemia. Which additional medication is typically given with the insulin and why?
- Heparin, to prevent clotting
- Calcium carbonate, to bind potassium
- Furosemide, to enhance insulin action
- Dextrose, to prevent hypoglycemia
Correct answer: Dextrose, to prevent hypoglycemia
Dextrose is given with insulin to prevent hypoglycemia, because the insulin shifts potassium into the cells but also lowers blood glucose, so concurrent dextrose protects against a dangerous drop. Calcium carbonate does not bind potassium in this context, furosemide does not enhance insulin action, and heparin has no role in this treatment.
- A nurse is caring for a client with increased risk of aspiration during enteral feeding. Which intervention best reduces this risk?
- Keeping the head of the bed flat during feeding
- Positioning the client in the left lateral recumbent position
- Administering the feeding as a rapid bolus
- Elevating the head of the bed 30 to 45 degrees during and after feeding
Correct answer: Elevating the head of the bed 30 to 45 degrees during and after feeding
Elevating the head of the bed 30 to 45 degrees during and after feeding best reduces aspiration risk because the upright position uses gravity to keep formula in the stomach and prevent reflux into the airway. A flat position and rapid bolus increase reflux, and the left lateral position is not the recommended antireflux measure for enteral feeding.
- A nurse is assessing a client with hypocalcemia. Which finding supports this diagnosis?
- Constipation and abdominal distention
- Decreased deep tendon reflexes
- Positive Trousseau's sign
- Bone pain with pathologic fractures
Correct answer: Positive Trousseau's sign
A positive Trousseau's sign supports hypocalcemia because low calcium increases neuromuscular excitability, producing carpal spasm when a blood pressure cuff is inflated on the arm. Decreased reflexes, constipation, and bone pain with pathologic fractures are associated with hypercalcemia rather than hypocalcemia.
- A nurse is teaching a client about home oxygen therapy at 2 L/min via nasal cannula. Which instruction is most important for safety?
- Avoid open flames and smoking near the oxygen source
- Increase the flow rate whenever feeling short of breath
- Apply petroleum jelly to the nares to prevent dryness
- Remove the cannula during all meals
Correct answer: Avoid open flames and smoking near the oxygen source
Avoiding open flames and smoking near the oxygen source is most important because oxygen vigorously supports combustion and creates a serious fire hazard. Increasing the flow rate without an order can be dangerous, petroleum-based products are flammable and should not be used near oxygen, and the cannula should generally stay in place during meals.
- A nurse is caring for a client with Addisonian crisis. Which IV therapy should the nurse anticipate administering first?
- Potassium chloride bolus
- Regular insulin infusion
- Hydrocortisone and normal saline
- Furosemide and fluid restriction
Correct answer: Hydrocortisone and normal saline
Hydrocortisone and normal saline should be anticipated first because Addisonian crisis results from acute cortisol deficiency with hypotension and volume depletion, requiring immediate glucocorticoid replacement and fluid resuscitation. An insulin infusion, a potassium bolus, and diuresis with fluid restriction would all worsen the client's life-threatening hypovolemia and electrolyte status.
- A nurse is monitoring a client receiving IV nitroglycerin for chest pain. Which finding requires the nurse to decrease the infusion rate?
- Blood pressure of 84 over 50 mmHg
- Heart rate of 72 beats per minute
- Report of a mild headache
- Oxygen saturation of 96 percent
Correct answer: Blood pressure of 84 over 50 mmHg
A blood pressure of 84 over 50 mmHg requires decreasing the rate because nitroglycerin is a potent vasodilator and hypotension is a dose-limiting adverse effect that can reduce coronary perfusion. A heart rate of 72 and an oxygen saturation of 96 percent are normal, and a mild headache is an expected, manageable effect of the vasodilation.
- A nurse is caring for a client with a fluid volume deficit. Which assessment finding best supports this diagnosis?
- Crackles auscultated in the lung bases
- Urine specific gravity of 1.035
- Bounding peripheral pulses
- Jugular vein distention
Correct answer: Urine specific gravity of 1.035
A urine specific gravity of 1.035 best supports fluid volume deficit because concentrated urine reflects the kidneys conserving water in response to dehydration. Crackles, bounding pulses, and jugular vein distention are all signs of fluid volume excess rather than deficit.
- A nurse is administering eye drops and an eye ointment to the same eye. Which sequence and spacing is correct?
- Apply the ointment first, then the drops immediately after
- Instill the drops first, then the ointment, waiting about five minutes between
- Apply both medications at the exact same time
- Instill the drops directly onto the cornea, then the ointment on the lid
Correct answer: Instill the drops first, then the ointment, waiting about five minutes between
Instilling the drops first, then the ointment, waiting about five minutes, is correct because the ointment would otherwise create a barrier preventing the drops from being absorbed, and spacing allows each to take effect. Applying ointment first blocks the drops, simultaneous application is ineffective, and medications should be placed in the conjunctival sac, not directly on the cornea.
- A nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which laboratory finding does the nurse expect?
- Serum sodium of 152 mEq/L
- Serum sodium of 122 mEq/L
- Serum potassium of 6.5 mEq/L
- Serum glucose of 320 mg/dL
Correct answer: Serum sodium of 122 mEq/L
A serum sodium of 122 mEq/L is expected because SIADH causes excessive water retention that dilutes the blood, producing dilutional hyponatremia. A high sodium of 152 reflects dehydration or diabetes insipidus, while elevated potassium and glucose are not characteristic of SIADH.
- A nurse is preparing to give a client an intramuscular injection in the ventrogluteal site. Which technique reduces the risk of tissue damage and ensures correct placement?
- Using the Z-track method and a needle long enough to reach muscle
- Selecting the dorsogluteal site to avoid major nerves
- Injecting at a 45-degree angle into the subcutaneous tissue
- Choosing the smallest available needle regardless of body size
Correct answer: Using the Z-track method and a needle long enough to reach muscle
Using the Z-track method with a needle long enough to reach the muscle reduces tissue damage and medication tracking back into subcutaneous tissue while ensuring deposition in muscle. The dorsogluteal site is no longer preferred because of nerve injury risk, a 45-degree angle delivers to subcutaneous tissue rather than muscle, and an undersized needle may not reach the muscle in larger clients.
- A nurse is caring for a client experiencing severe diarrhea for several days. Which acid-base imbalance is the client most at risk for developing?
- Metabolic acidosis
- Metabolic alkalosis
- Respiratory acidosis
- Respiratory alkalosis
Correct answer: Metabolic acidosis
The client is most at risk for metabolic acidosis because severe diarrhea causes loss of bicarbonate-rich intestinal fluids, lowering the blood's buffering capacity and pH. Metabolic alkalosis results from acid loss such as vomiting, and the respiratory imbalances arise from ventilation problems rather than gastrointestinal bicarbonate loss.
