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Question 1

1. A nurse is caring for a client who is 2 days following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression to independence and mobility for the client?

A. Keep loose absorbent dressing around incision site.
B. Encourage the client to use the overhead trapeze.
C. Caution the client to avoid a prone position while in bed.
D. Maintain abduction of the client’s limb with a pillow.

Answer 1

B. Encourage the client to use the overhead trapeze.

Question 2

A nurse at a pediatric clinic is checking the vital signs of a 2 month old infant prior to administering immunization. The nurse should recognize respiratory rate is 30/min. This indicates that the respiratory rate is?

A. Respiratory rate is a manifestation of respiratory infection

B. Within the expected range

C. Result of cold stress

D. Manifestation respiration depression

Answer 2

B. Within the expected range

Question 3

A nurse is reinforcing discharge teaching with a family of a client who has dependent personality disorder. What action should the nurse take?

Answer 3

Encourage the client to be assertive

Question 4

A charge nurse in the long-term care facility notices the smell of alcohol from one of the nurse’s breath. Which oc the following actions should the nurse take first?

A. Assign the client to the remaining staff

B. Remove the nurse from the client care area

C. Document objective findings from the situation

D. Call the supervisor to ask for another nurse

Answer 4

B. Remove the nurse from the client care area

Question 5

A nurse in a clinic is collecting data with a client who had a vaginal birth 6 weeks ago. Which of the following findings should the nurse expect?

A. Increase growth of fine body hair

B. Fundus is halfway palpable

C. White Blood Cells are elevated

D. Reported Lochia Alba

Answer 5

D. Reported Lochia Alba

Question 6

A nurse is supervising an assistive personnel. Which of the following actions by the AP indicates an effective use of client care materials?

A. Wears clean gloves when assisting client with oral care

B. Empty sharp container when it is full

C. Wearing an N95 when bathing a client who has C-Diff

D. Returns unopened food items from the clients tray to the client

Answer 6

A. Wears clean gloves when assisting client with oral care

Question 7

A nurse is preparing to administer spironolactone and lisinopril to a client who reports anxiety, dyspnea, and weakness of the leg. Which of the following actions should the nurse take first?

A. Withhold the prescribed medication

B. Document the client’s manifestations

C. Administer insulin per facility rules

D. Call the provider

Answer 7

A. Withhold the prescribed medication

Question 8

A nurse is assisting with the care of a client who is receiving chemotherapy and radiation for advanced breast cancer. The client states, “I’m thinking of stopping the treatment.” Which of the following responses should the nurse make?

A. “Why do you think that would be a good choice?”

B. “Tell me more about what you are thinking.”

C. “I would feel the same way if I were you.”

D. “You’ll be cancer-free after you complete your treatment.”

Answer 8

B. “Tell me more about what you are thinking.”

Question 9

The nurse is caring for a client who reports having a decreased in fetal movement following an external cephalic version 6 hours ago. The nurse identifies the fetus in Right Occipital Anterior position. Where should the nurse place the fetal heart monitor?

Answer 9

The nurse should put the fetal heart rate monitor above the umbilicus and to the right of thew abdomen.

Question 10

A nurse is RT with a client who is 35 weeks gestation who will undergo a contraction stress test. WOTF information should the nurse include in the teaching?

A. We will apply warm, moist cloths to your breasts

B. We will perform internal monitoring of your baby

C. You should expect the test to take 2 hours

D. You will lie flat on your back for the test

Answer 10

D. You will lie flat on your back for the test

Question 11

A nurse is collecting data from a client who represents the facility and who reports vomiting. WOTF findings indicate that the client is experiencing Fluid Volume deficit?

A. Orthostatic hypotension

B. Brisk Capillary Refill

C. Bradycardia

D. Polyuria

Answer 11

A. Orthostatic hypotension

Question 12

A nurse is reinforcing dietary teaching for a client who is 37 weeks gestation and has gestational hypertension. WOTF foods should the nurse recommend? (SATA)

A. Sourkauret

B. Raw apple

C. Ham

B. Cooked carrots

E. Lettuce salad

Answer 12

B. Raw apple, B. Cooked carrots

Question 13

A client who has cancer is being discharged to home with hospice services. The client has a
prescription for oxycodone for pain control. WOTF medications should the nurse remind the client to take regularly to prevent a common adverse effect of this medication?

A. Ranitidine

B. Docusate Sodium

C. Lorazepam

D. Gabapentin

Answer 13

B. Docusate Sodium

Question 14

A nurse is caring for an adolescent client who has been hospitalized for several weeks. WOTF actions should the nurse take relative to the client’s developmental stage?

A. Arrange for uninterrupted visitations with friends

B. Invite the patient’s parents to stay overnight in the daughter’s room

C. Encourage the client’s friends to being favorite books to read

D. Provide the client with a variety of jigsaw puzzles

Answer 14

A. Arrange for uninterrupted visitations with friends

Question 15

A nurse is RT with a parent of a preschool age child who has a new diagnosis of varicella. WOTF statements indicate an understanding of the teaching?

A. I will give my child a bubble-bath every day

B. I will apply an antipruritic cream to my child’s skin

C. I will give my child an antibiotic for 10 days

D. I will apply alcohol to my child’s skin to dry out the lesions

Answer 15

B. I will apply an antipruritic cream to my child’s skin

Question 16

A nurse is caring for a client who is experiencing urge incontinence and limited dexterity. WOTF
actions should the nurse take?

A. Establishing urinary habit program

B. Instruct the client about bladder compression

C. Instruct the client about self catheterization

D. Limit daily fluid intake

Answer 16

A. Establishing urinary habit program

Question 17

A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. WOTF information should the nurse include in the teaching?

A. You will feel pressure when I inflate the catheter balloon

B. You cannot drink fluids for hour hours after the procedure

C. You will have a leg bag to collect the urine

D. You will need to urinate before

Answer 17

D. You will need to urinate before

Question 18

A nurse at a long-term care facility is reviewing the PoC of a client who has a prescription for mitten restraints. WOTF tasks does the nurse assign to the assistive personnel?

A. Instruct the client’s family about the purpose of the restraints

B. Determine the circulatory status of the affected extremity every 2 hours

C. Evaluate the need for the client to remain in restraints

D. Assist with ROM of the hand

Answer 18

D. Assist with ROM of the hand

Question 19

A nurse is RT with a client who has primary open-angle glaucoma and a new prescription for Timolol eye drops. WOTF statements by the client indicates an understanding of the teaching?

This medication will darken the color of my eyes

I should check my heart rate while taking this medication

I should take iron supplements with this medication

This medication will improve my vision

Answer 19

I should check my heart rate while taking this medication

Question 20

A nurse is obtaining a health history from a client who wants to take oral contraceptives. WOTF
findings is the nurse’s priority?

Irregular periods

Smoking

Asthma

Obesity

Answer 20

Smoking

Question 21

A home health nurse is preparing to set up a continuous passive motion machine for a client who
is post-op following a total knee replacement. WOTF actions should the nurse respond to take first?

Align the knee joint with the frame joint of the CPM machine

Inspect the CPM machine and electrical cords for possible damage

Place the CPM machine in extension and pad the surface with sheep skin

Set the degree of flexion and extension on the CPM machine

Answer 21

Inspect the CPM machine and electrical cords for possible damage

Question 22

A nurse is preparing to administer morphine 30mg to a client who reports pain. Available
morphine is 20mg/mL

Answer 22

1.5mL

Question 23

A nurse is RT about hand hygiene to a newly licensed nurse. WOTF information should the nurse include in her teaching?

Dry hands starting from forearm to fingers

Use hot water to wash hands

Interlace the fingers while rubbing hands together

Apply friction to hands for 10 seconds

Answer 23

Interlace the fingers while rubbing hands together

Question 24

A nurse is reinforcing dietary teaching with a client who experienced a myocardial infarction. The nurse should encourage the client to limit WOTF?

Saturated fats

Dietary fiber

Omega-3 Fatty Acids Complex

carbohydrates

Answer 24

Saturated fats

Question 25

A nurse is RT with the family of a client who is terminally ill about the grief process. WOTF information should the nurse include in the teaching? Anger towards the health care staff is expected Anticipatory grieving prolongs the grief process The grieving process should be complete within a year The stages of grief occur in sequential order

Answer 25

Anger towards the health care staff is expected

Question 26

A nurse is collecting data from a client who has diabetic Ketoacidosis. WOTF should the nurse expect?

Answer 26

Fruity breath

Question 27

A nurse in the long term facility is caring for an older adult client who has a history of hypertension. WOTF findings should the nurse recognize as an indicative sign of a Transient Ischemic Attack? Epigastric Pain Seizure activity Sudden loss of vision in one eye Pain radiating down the left arm

Answer 27

Sudden loss of vision in one eye

Question 28

A nurse is planning care for a client who recently attempted suicide. WOTF actions should the nurse plan to take? Keep the client’s door closed when he is in the room Limit the client’s personals to room only cologne Observe the client’s behavior every 2 hours Ensure the client swallows each dose of medicine

Answer 28

Ensure the client swallows each dose of medicine

Question 29

A nurse is caring for a client who has upper gastrointestinal bleed. WOTF actions should the nurse take first? Prepare the client for an upper endoscopy Obtain a prescription for blood transfusion Insert an NGT for lavage Check bowel sounds

Answer 29

Check bowel sounds

Question 30

A nurse is assisting with the admission of an adolescent client who is suspected of having bacterial meningitis.

Answer 30

Nuchal rigidity

Question 31

A nurse is transcribing a prescription from the provider. The prescription reads Gentamicin 2 gtt OD q4h. WOTF information should the nurse clarify with the provider? Time Medication Route Dosage

Answer 31

Dosage

Question 32

A nurse is reinforcing discharge teaching with a client whose post-op and who has a prescription of oxycodone. WOTF information should the nurse include to prevent constipation? Take a stool softener at bedtime Reduce daily fiber intake Limit water to 4 glasses per day Decrease physical activity

Answer 32

Take a stool softener at bedtime

Question 33

A nurse is reinforcing teaching with a parent of a child who has a new prescription for ferrous sulfate in liquid form. WOTF statements by the parent indicates an understanding of the teaching? I will notify the provider if my child becomes nauseated I will give the iron through a straw I will notify the provider if my child’s stools are tarry I will give the iron with milk

Answer 33

I will give the iron through a straw

Question 34

A nurse is collecting data from a client who has cholecystitis. WOTF findings should the nurse expect? Pain radiating to the jaw Pain in the right upper abdomen Increased abdominal discomfort prior to meals Discomfort with urination

Answer 34

Pain in the right upper abdomen

Question 35

A nurse is caring for a 3 year old child at a well-child visit. The parents report that their son has been playing with imaginary friends. WOTF responses should the nurse make? How many hours per day does your child watch TV? This is a common behavior for children at this age You should seek family counseling if this behavior continues Children have imaginary friends to gain attention

Answer 35

This is a common behavior for children at this age

Question 36

A nurse is assisting with the physical examination on a 7-year-old child. WOTF options should the nurse take? Have a parent remove the child’s outer clothing Perform the most invasive procedures first Explain the purpose of the equipment used Explain findings during the examination

Answer 36

Explain the purpose of the equipment used

Question 37

A nurse is delegating client care assignments. WOTF tasks should the nurse assign to the assistive personnel? Reinforce teaching on how to use the glucometer for a client who has diabetes Monitor a client’s sacral pressure ulcer to determine need for dressing Reposition client who is experiencing increased ICP Apply an antiembolic stocking for a client who is 2 days post-op

Answer 37

Apply an antiembolic stocking for a client who is 2 days post-op

Question 38

A nurse is caring for a client who had a femoral popliteal bypass graft 2 days ago. When monitoring peripheral pulses, the nurse is unable to locate the pulses in the affected leg. WOTF actions should the nurse take? Place the client in high-fowler’s position Implement passive ROM Notify the charge nurse about the findings Apply a warm, moist pad to the extremity

Answer 38

Notify the charge nurse about the findings

Question 39

A nurse is caring for a client who has multiple sclerosis and has a new prescription for baclofen. WOTF indicates that the medication is having its desired effect? Improved alertness Improved dexterity Increased appetite Increased blood pressure

Answer 39

Improved dexterity

Question 40

A nurse is assisting with the prenatal examination of a client who is at 8 weeks gestation. The nurse notices a purplish color of the vagina

Answer 40

Chadwick’s sign

Question 41

A nurse is caring for a client who recently gave birth to her first child. The baby is crying and the client states, “I can’t seem to do anything right, what should I do?” What is the nurse’s best response? Let me show you how to swaddle and cuddle him, then you try I’ll take him back to the nursery If I turn him on his side maybe it’ll go to sleep Babies need to cry soon after they are born to develop their hormones

Answer 41

Let me show you how to swaddle and cuddle him, then you try

Question 42

A charge nurse is observing a newly licensed nurse perform suction on a tracheostomy. Which of the following should the charge nurse intervene?

Answer 42

Suctioning for 30 seconds

Question 43

A nurse is reinforcing teaching to the support person of the client who has early stage labor. Which of the following instructions should the nurse include regarding effleurage? Help her not to move early Breathe in deeply at the beginning of contractions. Gently stroke her abdomen at the start of her contractions Apply steady pressure with her pubis to her sacral area

Answer 43

Apply steady pressure with her pubis to her sacral area

Question 44

A nurse is reinforcing discharge teaching to the family of the client who has Alzheimer’s Disease. The client has wandering behaviour and the family is concerned about safety at home. Which of the following instructions should the nurse include? Replace door knobs with ones containing simple locks Keep the client’s shoes at the front door Contact Law enforcements if unable to locate the client Obtain a medical bed with side rails to use at night.

Answer 44

Replace door knobs with ones containing simple locks

Question 45

A nurse is reinforcing teaching with a mother who is breastfeeding her 3 week old newborn. Which of the following instructions should the nurse include in the teaching? Encourage the newborn to take a pacifier Offer the newborn supplemental formula twice daily Feed the newborn every 2-3 hours Feed the newborn for 30 minutes.

Answer 45

Feed the newborn every 2-3 hours

Question 46

A nurse is collecting data from a child during a well child visit. Which of the following actions should the nurse take when checking the child’s oculomotor function? Pupils are equal and react to light.

Answer 46

Pupils are equal and react to light.

Question 47

A nurse is caring for a client who delivered by C-section 1 day ago. The client requests non pharmacological interventions to manage pain when changing position. Which of the following responses should the nurse make? Use breathing techniques when changing positions Splint incisions with pillow when changing position Change positions as little as possible You can apply counter pressure to your back with each position

Answer 47

Use breathing techniques when changing positions

Question 48

A nurse is caring for a client who has a new diagnosis of heart failure and has a new prescription for digoxin. The nurse should monitor which of the following for an adverse effect? Insomnia Hyperkalemia Seizures Visual Changes

Answer 48

Visual Changes

Question 49

. A nurse is caring for a client who has anorexia nervosa. At home the client exercises frequently each day. Which of the following interventions should the nurse implement? Encourage the client to continue on an exercise routine Monitor the difference in weight before and after exercise Allow the client to snack throughout the day Observer during meals.

Answer 49

Observer during meals.

Question 50

A nurse is reinforcing teaching to a client who is to start taking ferrous sulfate elixir. Which of the following statements shows client understanding of teaching? I will mix medication with water I will report tarry stools to my doctor I can prevent nausea if I take the medication on an empty stomach I can prevent constipation if I take milk with this medication

Answer 50

I will mix medication with water

Question 51

A charge nurse at Emergency Department recommends that a client should be discharged in response to mass casualty disaster. Which of the following clients should the nurse recommend? A client who is 3 days post-op of knee arthroplasty and requires knee rehabilitation A client who has Diabetes and ketonuria A client who has hypertension and a new onset of slurred speech A client who has aortic stenosis and 2 kg weight gain

Answer 51

A client who is 3 days post-op of knee arthroplasty and requires knee rehabilitation

Question 52

A nurse is caring for a mother who is breastfeeding her newborn 1 week after delivery. Which of the following types of stools from the newborn should the nurse expect? Watery Firm Seedy Gelatinous

Answer 52

Seedy

Question 53

A nurse is reinforcing teaching about foot care of a client who has Diabetes. Which of the following statements indicates an understanding of the teaching? I should not use moisturizers on my feet I should wear the same shoes all day I can remove my own callus with a pumice stone I should shake out my shoes before I put them on

Answer 53

I should shake out my shoes before I put them on

Question 54

A charge nurse is discussing about confidentiality of a client; about sharing the client’s medical record. Which of the following people should the nurse identify as an appropriate person to share client’s information with? Client’s partner Social Worker Client’s Employer Nurse from another unit

Answer 54

Social Worker

Question 55

A nurse is assisting to monitor a client who has preeclampsia and is receiving an infusion of Magnesium Sulfate. Which of the following findings should the nurse expect to stop the infusion and report to the charge nurse? Diaphoresis Facial Flushing Urine Output 40 mL/hr Respiratory rate 10/min

Answer 55

Respiratory rate 10/min

Question 56

A nurse is providing skin care for a 14-year-old adolescent who is in skeletal traction for a fractured femur. Which of the following actions should the nurse take? Select all that apply. Massage reddened bony prominences Check skin every 2 hours Cleanse skin with soap-free agents Use a draw sheet to move client Elevate the HOB to a 90 degree angle

Answer 56

Check skin every 2 hours Cleanse skin with soap-free agents Use a draw sheet to move client

Question 57

A nurse is caring for a client who has prescription for Warfarin. What laboratory values should the nurse check?

Answer 57

INR

Question 58

A nurse in a mental health facility is observing two clients playing cards in the day room. One of the clients becomes agitated and throws the cards on the ground. Which of the following actions should the nurse take first? Encourage client to express their feelings. Assist the client to resolve the issue Administer haloperidol Place the client into a quiet area

Answer 58

Place the client into a quiet area

Question 59

A nurse is reviewing the medical record for a child who is scheduled for a Varicella Immunization. Which of the following findings should the nurse recognize as a contraindication.

Answer 59

Chemotherapy

Question 60

A nurse is reinforcing teaching about sterile technique with a newly licensed nurse. The nurse should include in the teaching. Which of the following procedures requires sterile technique?

Answer 60

Suctioning Tracheostomy

Question 61

A nurse is reinforcing teaching to a client who has Hypertension about dietary measures to control blood pressure. Which of the following food selection shows an understanding of teaching? Grilled cheese Ham sandwich Baked chicken Tomato soup

Answer 61

Baked chicken

Question 62

A nurse is caring for a client following an electroconvulsive therapy. What action should the nurse monitor?

Answer 62

15 minutes disorientation

Question 63

A nurse is reinforcing teaching with a client who is planning on becoming pregnant about the dietary intake need to reduce the risk of neural tube defect. Which of the following foods is a priority to include in the teaching? Rice Cooked Spinach Orange juice Eggs

Answer 63

Cooked Spinach

Question 64

A nurse is caring for a client who has new prescription for ferrous sulfate. Which of the following findings should the nurse monitor the client? Orthostatic Hypotension Gastrointestinal Distress Decreased Clotting Time Orange Urine

Answer 64

Gastrointestinal Distress

Question 65

A nurse is providing care for a client who has cystic fibrosis. Which of the following effects is a therapeutic effect of administering pancreatic enzymes? Reduced fat in the stools Decreased sodium excretions Improved respiratory function Improved absorption of vitamin B and C

Answer 65

Improved respiratory function

Question 66

A nurse is reinforcing discharge teaching with a parent of a newborn. Which of the following statements indicates an understanding of the teaching? “I will use hydrogen peroxide on the cord during each diaper change.” “I will fold the diaper just below my baby’s cord.” “I will wash the cord with warm soapy water.” “I will apply petroleum jelly daily to my baby’s cord.”

Answer 66

“I will fold the diaper just below my baby’s cord.”

Question 67

A nurse is preparing to administer acetaminophen 50 mg PO to an infant. Available is 80 mg/0.8 mL. How many mL should the nurse administer to the infant?

Answer 67

0.5 mL

Question 68

A nurse is caring for a client who is in Buck’s traction. Which of the following actions should the nurse take?

Answer 68

Ensure the weights are hanging freely

Question 69

A nurse is caring for a client who is receiving continuous bladder irrigation following a Transurethral resection of the prostate. Which of the following findings should the nurse report immediately to the provider? The client suddenly develops bladder spasms The nurse observes continuous bright, red urinary output The client passes small clots in drainage bag The nurse notes drainage flow rate has slowed

Answer 69

The nurse observes continuous bright, red urinary output

Question 70

Anurseiscollectingdatafromanadolescentclientwhoisexperiencingsexualabuse.Whichof the following shows that the client is using the defense mechanism of suppression? “My mother is the real reason for it all because she doesn’t live in the real world.” “Sometimes, I get angry about it.” “I drink beer as often as I can so I don’t have to think about it.” “I have to take some of the blame because of the way me and my friends dress.”

Answer 70

“I drink beer as often as I can so I don’t have to think about it.”

Question 71

A nurse is assisting with discharge planning for a group of clients. Which of the following clients should the nurse recommend for a home care referral. Adolescent who has tibial fracture and requires crutches. Older adult client who has heart failure and lives alone. Young adult who has a substance abuse disorder Middle age adult who has a mastectomy and requires radiation

Answer 71

Older adult client who has heart failure and lives alone.

Question 72

A nurse is caring for a client who is taking multiple medications about the possible interactions. Which of the following members of the interdisciplinary team should the nurse make a referral to? Advance practice nurse Psychologist Social worker Patient-care technician

Answer 72

Advance practice nurse

Question 73

A nurse on the postpartum unit is reinforcing teaching with a client whose baby is 1 day old about the development of sensory behavior. Which of the following statements by the client indicates an understanding of teaching? “My baby can hear my voice when I talk to him.” “My baby will recognize the odor of my breath within couple of weeks.” “My baby will gradually feel me touching his skin.” “My baby’s eye prefer bright light.”

Answer 73

“My baby can hear my voice when I talk to him.”

Question 74

A nurse is caring for a client who has an indwelling catheter for a urinary drainage. Which of the following actions should the nurse take? Instruct the client to hold the draining bag at waist height. Coil the tube on the bed above the drainage bag. Secure the tubing to the lower abdomen with adhesive tape. Collect a sterile specimen from the drainage bag.

Answer 74

Coil the tube on the bed above the drainage bag.

Question 75

A nurse is on a mental health unit is caring for a client who expresses anxiety. The nurse promises to walk with the client everyday. Which of the following ethical principles is the nurse displaying?

Answer 75

Fidelity

Question 76

A charge nurse is monitoring a group of assistive personnel regarding the use of gloves in contact isolation. Which of the following actions by the AP should the charge nurse intervene?

Answer 76

Remove gloves last when taking off PPE

Question 77

A nurse is reinforcing discharge instructions with a client who had a myocardial infarction. Which of the following statements indicates an understanding of the teaching? “I should refrain from sexual activity until I can walk 1 mile without stopping.” “I can have 2.5 g of Sodium each day.” “I can swallow nitroglycerin pill on the first onset of chest pain.” “I can take a nitroglycerin pill every 5 minutes up to 3 times to relieve chest pain.”

Answer 77

“I can take a nitroglycerin pill every 5 minutes up to 3 times to relieve chest pain.”

Question 78

A nurse is caring for a client who has an AV Shunt in his right arm. Which of the following actions should the nurse take? Check bruit over the shunt on a regular basis Give IV fluids through the AV Shunt. Obtain Blood Pressure from the right arm. Avoid Range-Of-Motion on the right arm

Answer 78

Check bruit over the shunt on a regular basis

Question 79

A nurse is collecting data from a client who is 12 hour post-op following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to client ambulation? Oral temperature of 99.7F Apical Pulse 88/min Respiratory Rate 20/min Oxygen Saturation of 90%

Answer 79

Oxygen Saturation of 90%

Question 80

A nurse is collecting data from a client who is in his third trimester pregnancy, having her routine prenatal visit. The client reports she is dizzy,clammy, and becomes pale lying down. Which of the following actions should the nurse instruct the client to take? Lie on her left side Take a brisk walk Check her temperature Drink a glass of orange juice

Answer 80

Lie on her left side

Question 81

A nurse is assisting a client move up in bed. Which of the following action should the nurse take? Place the bed in the lowest position Stand with feet together Ask the client to flex her hips and knees Raise the head of the bed

Answer 81

Raise the head of the bed

Question 82

A nurse is reinforcing teaching from a client who has a Urinary Tract Infection and a prescription for antibiotic. Which of the following instructions should the nurse include in teaching? Take the medication until the manifestations subside Wear nylon undergarments until manifestations are present Limit alcohol intake to one beverage per day Empty bladder every 4 hours.

Answer 82

Empty bladder every 4 hours.

Question 83

A nurse is performing nasopharyngeal suctioning on an adult client. Which of the following techniques should the nurse use? Wait one minute between suctioning Perform inter catheterization of 20cm or 8 inches Apply intermittent suctioning for 30 seconds Apply suction while inserting the catheter.

Answer 83

Wait one minute between suctioning

Question 84

A nurse is caring for a client who has a follow up visit for bipolar disorder and a new prescription for Lithium Therapy. Which of the following indicates Lithium Toxicity? Urinary retention Dysrhythmias Excessive salivation Hypoglycemia

Answer 84

Dysrhythmias

Question 85

A nurse is reinforcing teaching for a 36 year old client who is 16 weeks gestation and who is scheduled for amniocentesis. What is the purpose of amniocentesis?

Answer 85

To determine chromosomal abnormalities

Question 86

A nurse in a long term care facility has just received change of shift. Which of the following clients should the nurse attend to first? Client who has a spinal cord injury and needs a dressing change Client who has a temperature of 101.4 and appears confused Client who is receiving enteral tube feeding and has a blood glucose of 155 mg/dL Client who had a hip arthroplasty and is requesting pain medication

Answer 86

Client who has a temperature of 101.4 and appears confused

Question 87

A nurse is collecting data from a parent of a school age child who is allergic to bee venom. What should the nurse administer?

Answer 87

Epinephrine (muscle relaxant)

Question 88

A nurse is caring for a client who has increased ICP following a closed head injury. Which of the following actions should the nurse take? Place the client in lateral Sim’s position Monitor the client’s temperature every 4 hours Wake the client every 6-8 hours Elevate the Head of the Bed 30 degrees

Answer 88

Elevate the Head of the Bed 30 degrees

Question 89

A nurse is planning a health promotion program for high school students. Which of the following about cigarette smoking would be the most appropriate to get the students to stop smoking? Smoking can lead to substance use disorders Smoking is the no. 1 preventable cause of death Quitting smoking can help save money for other things Smoking cause unattractive stain on the teeth and hands

Answer 89

Smoking cause unattractive stain on the teeth and hands

Question 90

A nurse is preparing to administer intermittent enteral feeding to a client who has a small dour NGT. Which of the following actions should the nurse plan to take? Chill the formula before administration Hang the feeding 6 inches above the insertion site Flush the tubing with 5 mL of water Elevate the Head of Bed 45 degree

Answer 90

Flush the tubing with 5 mL of water

Question 91

A nurse is caring for a preschool age child who recently experienced the death of a parent. Which of the following should the nurse expect? Child curious about funeral service States everyone dies eventually States death is punishment for bad behavior. Recognizes the parent will never wake up

Answer 91

States death is punishment for bad behavior.

Question 92

A nurse manage is taking measures to increase cost effective. In which of the following client situations should the nurse manager intervene? An AP dons a mask when providing an oral care to a client who has staphylococcal infection A nurse uses sterile gauze pads to place a dressing on a surgical wound. A nurse discards a bottle of saline after it has been opened for 24 hours An AP is wearing clean gloves when feeding a client who has Hepatitis B

Answer 92

A nurse uses sterile gauze pads to place a dressing on a surgical wound.

Question 93

A nurse is contributing to the plan of care to a client who has delirium. Which of the following interventions should the nurse recommend? Provide the client with four food choices at each meal Vary the client’s activities daily. Assist the client to the bathroom every 2 hours.

Answer 93

Assist the client to the bathroom every 2 hours.

Question 94

A home health nurse is reinforcing teaching with a client about safe food handling to prevent food poisoning. Which of the following instructions should the nurse include in the teaching? Allow leftover food to cool before refrigerating Defrost frozen foods in the refrigerator Set refrigerator to 46.4 degrees Fahrenheit Cook poultry to 140 degrees Fahrenheit

Answer 94

Allow leftover food to cool before refrigerating

Question 95

A nurse on a hospice unit is caring for a client that has cancer and is in the active phase of dying. Which of the following findings indicates intervention from the nurse? Oxygen is in use Assistive Personnel is encouraging intake of fluids Benzodiazepines are administered every 4 hours A family member remains at the client’s bedside for 24 hours

Answer 95

Assistive Personnel is encouraging intake of fluids

Question 96

A nurse is caring for an adolescent who had a child and is requesting the most reliable method of birth control. Which of the following should the nurse recommend? Spermicide Injectable progesterone Oral contraceptives Condoms

Answer 96

Injectable progesterone

Question 97

A client is collecting nutritional data from a group of adult clients. Which of the following clients should the nurse recommend an interprofessional conference with a dietitian? Patient with serum albumin of 4.5 Patient with sodium intake of 1200 mg per day Patient has a total fat intake 25% BMI of 32

Answer 97

BMI of 32

Question 98

A nurse is assisting a client to ambulate when the client begins to have a generalized seizure. What action should the nurse take? (I don’t know the answer for this one) Place on the side Supply Oxygen Oral hygiene Reorient

Answer 98

Place on the side

Question 99

A nurse is caring for a client who is 34 weeks gestation. Which of the following statements is the nurse priority to report to the provider? “Palms of my hands are red and blotchy” “My heart feels like it skips a beat.” “Acetaminophen is not working on my persistent headaches” “I have nosebleeds once a week.”

Answer 99

“Acetaminophen is not working on my persistent headaches”

Question 100

What is the use/effect of protamine?

Answer 100

Decreasing clotting time

Question 101

What does it mean when a client is pacing back? Move the client cards Client is participating to group therapy Client returns to the room Walks to the recreation room

Answer 101

Client returns to the room

Question 102

What is the adverse effect of the postoperative opioid medication? Urinary retention Tachycardia Diaphoresis Hypotension

Answer 102

Urinary retention

Question 103

What is the adverse effect of methylphenidate? Tachycardia Ringing of the ears Metallic taste Decreased appetite

Answer 103

Decreased appetite

Question 104

What should be done when the nurse sees a mid-abdominal incision? Reinforce Dressing Apply pressure for 30 seconds Cleanse with normal saline Notify the provider

Answer 104

Reinforce Dressing

Question 105

What must be done when the nurse is not sure of calculating the medication dosage correctly? Call another nurse to verify the calculation Recalculate the dosage Document the incident Administer the medication

Answer 105

Call another nurse to verify the calculation

Question 106

What is the adverse effect of Enoxaparin? Epistaxis Nausea Muscle weakness Hyperglycemia

Answer 106

Epistaxis

Question 107

What progress must be seen in a four year old child? Eat vegetables Familiarize with shapes Speaking using only 20 to 50 words Thumb sucking

Answer 107

Eat vegetables

Question 108

What is the adverse effect of furosemide? Hypotension Urinary retention Fatigue Hypokalemia

Answer 108

Hypokalemia

Question 109

What safety measures must be implemented for a 12 month old infant? Lock the doors and cabinets Turn pot handles inward Provide finger foods Provide a non skid soles

Answer 109

Turn pot handles inward

Question 110

What action must be done when the nurse finds out that there is a gastric residual prior to providing bolus feeding? Notify the provider Withhold the bolus feeding and check again in an hour Flush the tube with 240 cc of water Document the incident

Answer 110

Withhold the bolus feeding and check again in an hour

Question 111

A nurse is caring for a Asian client who is admitted 2 days ago. Which of the following practices should the nurse must be mindful of? Avoid eye contact Bow Separate the content of each meals in the tray Raising the voice

Answer 111

Avoid eye contact

Question 112

When a nurse is caring for a client who has a terminal cancer, this should be followed strictly. Treatment times Isolation precautions Negative pressure airflow Advance Directives

Answer 112

Advance Directives

Question 113

Which of the following tasks the nurse can delegate to the Assistive Personnel to perform? Catheter care Dressing change Fingerstick prior to insulin administration Performing a head-to-toe assessment

Answer 113

Catheter care

Question 114

A nurse is caring for a client who is terminally ill, sees the patient’s partner crying and seemed to be upset. What action should the nurse take? Ignore the patient’s partner Encourage the partner to express feelings Lecture the patient Call the supervisor

Answer 114

Encourage the partner to express feelings

Question 115

What should be the action taken when a client is suspected with the manifestations of Bulimia Nervosa? Observe the condition and manifestations Reinforce teaching about proper dietary intake Notify the provider Send to the emergency department

Answer 115

Observe the condition and manifestations

Question 116

The nurse from the morning shift is turning over the reports to the afternoon shift. Which of the following clients must be seen first? A client who is diagnosed of Guillain-Barre syndrome A client who has current blood pressure of 165/92 mm Hg A client who has small laceration on the right thigh A client who has temperature of 38.5 degrees Celsius

Answer 116

A client who is diagnosed of Guillain-Barre syndrome

Question 117

Withhold doxycycline if the client is manifesting this symptom. Crackles Abdominal distention Wheezing Bradycardia

Answer 117

Crackles

Question 118

What intervention must be implemented for a client who has kidney failure with peripheral edema? Decrease water intake Infuse IV normal saline 0.9% Ambulate the client to the hallway Apply antiembolic stockings

Answer 118

Decrease water intake

Question 119

4 months infant?

Answer 119

Cool mist vaporizer

Question 120

The LPN/LVN cares for the client after a plaster cast has been applied to the left leg due to a fractured femur. The LPN/ LVN should take which action?

Answer 120

Turn the client every 2 hours

Question 121

The client has attempted to manage 6 month history of severe joint pain in both knees and hip joints with over-the-counter-medications. The client states these have not completely resolved the pain. The HCP orders Diclofenac Sodium. When reinforcing teaching about this medication, it is important that the client understands which concern?

Answer 121

Do not take with Aspirin

Question 122

The family relates having difficulty coping with the emotional outbursts of the family member diagnosed with Alzheimer’s disease. The family members ask the LPN/LVN what they can do about the outbursts. Which response, if made by the LPN/LVN is the best?

Answer 122

Provide a calm, non-chaotic environment

Question 123

The nursing assistive personnel approaches the LPN/LVN and says, “You need to help my client with morning care because I am not going to be able to get it done.” The LPN/LVN identifies this is an example of which type of delegation?

Answer 123

Reverse delegation

Question 124

The client diagnosed with colitis, type 1 diabetes, and cholelithiasis describes experiencing pain when chewing and relates the food doesn’t have any flavor. Which response is most appropriate by the LPN/LVN?

Answer 124

“It is normal as a person ages to have osteoarthritis in the jaw and the loss of taste buds.”

Question 125

Which statement by the LPN/LVN to the client who is receiving dextroamphetamine (Dexedrine) for daytime sleepiness and fatigue, is the most important?

Answer 125

“Call the healthcare provider’s office immediately if your heart seems to be skipping beats.”

Question 126

The LPN/LVN identifies the nursing assistive personnel is using appropriate body mechanics if which finding is observed?

Answer 126

The AP keeps the head erect when lifting a heavy object.

Question 127

The client has a nasogastric (NG) and T-tube is placed following an open (classic) cholecystectomy. The LPN/LVN understands the purpose of the T-tube is which statement>

Answer 127

To ensure patency of the common bile duct.

Question 128

The LPN/LVN determines teaching is effective if the client makes which statement about the proper use of nitroglycerin sublingual tablets?

Answer 128

“I should take 1 nitroglycerin tablet and repeat the dose in 5 minutes if the chest pain is unrelieved.”

Question 129

The client with chronic bronchitis says to the LPN/LVN “I do okay until my wife starts smoking, then my bronchitis gets bad again.” Which statement by the LPN/LVN would be most appropriate?

Answer 129

“It is very important for your medical condition that your wife not smoke.”

Question 130

The client is in active labor and says, “Help me! I have to push! I have to push now!” Which is the best response?

Answer 130

“​Take a deep breath and bear down like you are having a bowel movement.”

Question 131

The LPN/LVN obtains vital signs from the client: oral temperature of 97.6F (36.4C), radial pulse of 80 bpm, Respiration rate is 28, and B/P 110/60. Which action should the LPN/LVN take next?

Answer 131

Report the vital signs to the registered nurse in charge.

Question 132

132. The client diagnosed with cancer of the pancreas reports mild to moderate pain within the past week. Based on this, the LPN/LVN should recommend which to the client?

Answer 132

Continue with non-opioid analgesics as your were doing.

Question 133

The LPN/LVN cares for the 4 year old child with cast on his left arm due to a fractured wrist. The child states “The cast feels funny over my wrist bone”. Which is the best response from the LPN/LVN?

Answer 133

“I will talk with the health care provider.”

Question 134

The nurse cares for the client who just underwent through an abdominal surgery. To increase the client’s comfort level, it is most important for the nurse to place the client in which position?

Answer 134

Sitting upright in a chair. Prone with knees straight Left side-lying Supine with knees flexed Prone trendelenburg lithotomy

Question 135

Which explanation about a thoracentesis by the nurse would be most appropriate?

Answer 135

“The HCP will be removing fluid from your pleural space.”

Question 136

The client who is having frequent diarrhea is diagnosed with methicillin-resistant staphylococcus aureus (MRSA) and is placed on contact precautions. The nurse should intervene if the nurse observes the AP performing which action?

Answer 136

The AP takes the blood pressure cuff out of the client’s room

Question 137

The nurse finds the client unresponsive on the floor, what should the nurse take first?

Answer 137

Check respirations and pulse

Question 138

The nurse knows that a modifiable risk factor related to reducing the possibility of a second myocardial infarction would be which factor?

Answer 138

Change of diet to reduce fat intake

Question 139

The nurse cares for the client who returned from a traditional cholecystectomy 45 minutes ago. Since that time, the client’s NG tube has been draining 75-100 mL per hour and the fluid appears to be slightly blood tinged. The nurse must take which action first?

Answer 139

Report the condition to the RN immediately

Question 140

The nurse begins to prepare the deceased body for viewing by the family due to arrive in 20 minutes. The nurse is paged to assist a client to eat breakfast and to help another with morning care and transfer to the chair. Which action by the nurse is most appropriate?

Answer 140

Delegate the clients requiring help with breakfast and morning care to the nursing assistive personnel and continue to prepare the body

Question 141

The nurse observes the client falling out of a chair; which action should the nurse take first?

Answer 141

Stay with the client and ask the AP to get the RN

Question 142

The nurse should offer the client which food for a clear liquid diet?

Answer 142

1⁄2 cup of strawberry gelatin

Question 143

The nurse observes an AP place a hot water bottle directly on the skin of an elderly patient. Which of the following action should the nurse take first?

Answer 143

Immediately remove the hot water bottle

Question 144

The client insist that the nurse remove her vest restraint “immediately”. What action by the nurse is best?

Answer 144

Check the health care provider’s order to determine the criteria for removing the restraint.

Question 145

The nurse knows that the treatment for pleurisy is which implementation?

Answer 145

An anti inflammatory medication

Question 146

The nurse works with the client taking phenytoin for seizure prevention. Which instruction is the most essential for the nurse to reinforce regarding this medication?

Answer 146

Notify the health care provider immediately if a skin rash develops

Question 147

The RN mentions that the client diagnosed with borderline personality disorder uses the defense mechanism of splitting. The nurse recognizes which presentation exemplifies splitting?

Answer 147

Views other as either all good or all bad

Question 148

The elderly client is admitted with severe substernal chest pain, tachypnea and tachycardia. The client’s skin is cool and clammy. The client becomes listless and has decrease in level of consciousness. The nurse correctly identifies the cause of the client’s symptoms as which process?

Answer 148

Cardiogenic shock

Question 149

The nurse cares for the client diagnosed with a tension pneumothorax. The client asks the nurse, “which is the most serious complication?”.

Answer 149

Mediastinal shift

Question 150

The nurse identifies which position is the best for the client immediately post liver biopsy? Right side-lying

Answer 150

Right side-lying

Question 151

Following a tornado, the nurse assists a disaster team by gathering data for victims who are not physically injured. Which interview question is the best?

Answer 151

Please share with me what help you need at this time.

Question 152

The client diagnosed with asthma currently takes beclomethasone dipropionate. The nurse is aware that the most serious side effect of this medication are which findings?

Answer 152

Bronchospasm and angioedema

Question 153

The nurse cares for an elderly client diagnosed with type 2 DM and partial-thickness burns of unknown origin on the lower legs and feet. Which reason if stated by the nurse is most likely cause of the burns?

Answer 153

Diabetes not being managed appropriately

Question 154

The client reports a sad mood, loss of pleasure in usually pleasurable things, and an inability to sleep through the night. No manic episodes or psychotic behavior is noted in the outpatient clinic. The nurse correctly understands that which diagnosis matches this client’s presentation?

Answer 154

Major depression

Question 155

For three weeks, the client with a spinal cord injury at C7 and has had intensive sessions with PT TID. the nurse determines the client is making expected progress if which finding is observed?

Answer 155

The client is able to independently complete ADL

Question 156

The HCP orders alprazolam 0.5 mg tablet PO TID. the available tablet contains 0.25 mg. How many tablets should the nurse give?

Answer 156

6 tabs

Question 157

The client states “I just haven’t felt the best lately, I don’t know what it is, I am not feeling like my usual self.” Based on the client’s hx of two previous MI and HF, which question should the nurse ask?

Answer 157

Have you had any swelling in your feet or lower legs?

Question 158

The middle aged adult reports fatigue, insomnia, and difficulty focusing on tasks. The client has three teenagers in the home and is the primary caregiver for the client’s elderly mother with significant health problems. The nurse knows that one of the difficulties in this situation is what?

Answer 158

Being a member of sandwich generation

Question 159

The 3 month old infant was brought to the emergency room with a dx of SIDS. which question is the most appropriate for the nurse to ask?

Answer 159

What did the baby look like when you found him/her

Question 160

The nurse suctions the client’s trache, what is the most important action?

Answer 160

Apply suction no longer than 10 seconds

Question 161

The nurse instructs the AP to complete a bath for the client. The AP claims that they do not have enough time. What action should the nurse take?

Answer 161

Report to supervisor

Question 162

Which instruction is essential for the nurse to give the client who has venous thromboembolism of the left leg?

Answer 162

Bed rest must be maintained until the anticoagulant therapy is begun

Question 163

Client has COPD and pulmonary edema. Action

Answer 163

Raise the head of the bed

Question 164

Living Will

Answer 164

1. Client’s wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues. 2. Example: CPR, Mechanical ventilation, feeding by artificial means. 3. HCP who follow the health care directive in a living will are protected from liability.

Question 165

Durable Power of Attorney

Answer 165

1. Designates an individual authorized to make health care decisions for a client who is unable. 2. Proxy must be very familiar with the client’s wishes. 3. DNR or AND is written: nurse should initiate CPR when a client has no pulse or respirations. 4. Provider consults the client and the family prior administering a DNR or AND. Client’s decisions are priority.

Question 166

Requesting Reassignment of a Client

Answer 166

1. Negotiate with the charge nurse 2. No resolution: concern up the chain of command 3. Failure to accept the assignment without following the proper channels may be considered abandonment.

Question 167

Plan of Care for a client who has bulimia nervosa

Answer 167

1. Therapeutic communication 2. Encourage client in decision making 3. Promote cognitive reframing, relaxation techniques, journal writing, desensitization exercises 4. Support groups 5. Work with the dietitian 6. Small frequent meals 7. Diet high in fiber 8. Diet low in sodium 9. Limit high-fat and gassy foods 10. Multivitamin and mineral supplement 11. Avoid caffeine 12. Meds: SSRI (fluoxetine [Prozac]) Schedule a dental exam ←- this is the answer

Question 168

Monitoring the performance of Assistive Personnel

Answer 168

1. Right task, circumstance, person, communication/direction, supervision/evaluation Tasks that can be delegated to APs: ➔ ADLs ➔ Feeding without swallowing precautions ➔ Specimen collection ➔ I and O ➔ V/S for stable clients Task that cannot be delegated to APs: ➔ TEA: teaching, evaluation, Assessment

Question 169

Client safety versus breach of Confidentiality

Answer 169

1. Right to privacy 2. Information about the client, verbal and in writing, must be shared only with those who are responsible for implementing the client’s treatment plan. 3. Others who are not involved need the client’s consent. 4. Patient in mental hospital have the right to refuse meds and make decision, even if admitted against will. There has to be a court order to say other wise.

Question 170

Guidelines for Documenting Client Care

Answer 170

1. Factual 2. Accurate and concise 3. Complete and current 4. Organized 5. Show trends in v/s, b/g levels, pain levels, and others 6. Narrative documents = storylike manner 7. Subjective-Objective-Assessment-Plan 8. Problem-Intervention-Evaluation 9. Data-Action-Response

Question 171

Care following a tracheostomy

Answer 171

1. Keep the following at the bedside: two extra tracheostomy tubes (one same size and one smaller), o2 source, suction catheters and source, and BVM 2. Provide methods to communicate with staff (pen, paper, dry-erase board) 3. Adequate humidification and hydration 4. Oral care q2h 5. Trache care q8h 6. Suction/yankauer 7. Remove soiled dressings and excess secretions 8. O2 source loosely - if O2 sat decreases 9. Remove and clean the inner cannula 10. Clean the stoma site and trache plate 11. Place fresh dressing under and around the tracheostomy holder and plate 12. Replace ties if they are wet or soiled. 13. Two fingers fit between the tie and neck 14. Replace non disposable trach tubes per 6 to 8 weeks 15. Do not shake bedding 16. Position the client upright and tip his chin to his chest during meal time.

Question 172

Reinforcing teaching about Ostomy Care

Answer 172

1. Hand hygiene 2. Stoma: moist, shiny, and pink; peristomal area must be intact 3. Use mild soap and water to cleanse the skin, gently dry a. No moisturizing soaps 4. Apply paste/ skin barrier and pouch 5. Measure and draw where to cut the skin barrier, allowing only the stoma to appear through the opening.

Question 173

Obtaining a Telephone Prescription from a provider

Answer 173

1. Have a second nurse listen to a telephone prescription 2. Repeat the order back, making sure to include the medication’s name, dosage, time, and route. 3. Question any prescription that may seem inappropriate for the client. 4. Make sure the provider signs the prescription in person within the time frame the facility specifies, typically 24 hr.

Question 174

Evidence-Based Practice

Answer 174

1. Always check the information from the Patient’s Chart.

Question 175

Client Advocacy

Answer 175

1. A person who publicly supports or recommends the client’s rights.

Question 176

Managing Client care: responding to an assistive personnel who refuses an assigned task

Answer 176

- Discuss with the AP upon the behavior - Report to the charge nurse

Question 177

Postoperative Care: Prioritizing client care

Answer 177

- Priorities: - Bleeding - Report to the provider STAT - Airway and breathing - Monitor o2 sat - Assist with coughing and deep breathing at least every 2 hr - Provide pillows or folded blanket - Use of Incentive spirometer at least every 2 hour - Repositioning - Circulation - Do not put pillows under knees or elevate the knee gatch on the bed - Encourage early ambulation - Fluid status - Push IV solution of dextrose 5% in 0.45% NaCl - Ice chips and fluids as prescribed/tolerated - Frequent oral hygiene - Pain - Monitor clients who receive pain medications via PCA pump - Assess pain level frequently - Observe manifestations (increased pulse, respirations, b/p, restlessness, moaning during movement) - Monitor adverse effects of opioids (respiratory depression, nausea, urinary retention, and rconstipation) - Provide analgesia 30 minutes before ambulation or other painful procedures - Kidney function - Monitor and report urinary outputs of less than 30 ml/hr - Palpate bladder - Use bladder scan if necessary - SeeDuring a bladder scan, pt should not feel any discomfort - Bowel function - Maintain NPO until gag reflex and peristalsis returns - Irrigate NG suction tubes with saline - Do not move the NG tubes in clients who are postoperative gastric surgery as order by surgeon - Monitor bowel sounds - Advance diet as prescribed and tolerated (clear liquids to regular)

Question 178

Guidelines for documenting client care

Answer 178

- Trends in v/s, blood glucose levels, pain level, and other frequent assessments - Narrative with sequence of events

Question 179

Delegating tasks to an assistive personnel

Answer 179

- AP’s do not drink TEA (T-Teach, E-Evaluate, A-Assess) - Everything that does not involve any medical - ADLs

Question 180

Conflict negotiation

Answer 180

- Avoiding/withdrawing - Both parties know there is a conflict; refuse to face it or work - Smoothing - One party attempts to “smooth” another party; trying to satisfy the other - Competing/coercing - One party pursues a desired solution - Party who loses may experience anger - Cooperating/accommodating - One party sacrifices something, allowing the other party to get what it wants - Original problem may not actually be resolved - Compromising/negotiating - Each party gives up something

Question 181

Vital signs: Evaluating assistive personnel measuring tympanic temperature

Answer 181

- Pull the ear up and back (ADULT); down and back (CHILD YOUNGER THAN 3) - Place the thermometer probe snugly into the client’s outer ear canal and press the scan button. - Leave it in place until you hear the signal - Carefully remove the thermometer from the ear canal and read the temperature - Earwax can alter the reading - Room temperature can also alter readings

Question 182

Ethical principle of Autonomy

Answer 182

- Client has the right to make his/her own decisions.

Question 183

Maintaining Client’s Safety

Answer 183

- Client has orthostatic hypotension: - Instruct the client to avoid getting up too quickly, sit on the side of the bed for 30-60 seconds prior to standing, and stand at the side of the bed for a few seconds prior to walking. - Ensure that the client knows how to use the call light and it is within reach - Responds to call lights asap - Orient the client - Place them near the nursing station - Bedside tables are within reach - Bed in low position - Keep bed rails up - Avoid full side bed rails - Nonskid footwear - Keep the floor free from clutter - Keep assistive device nearby - Lock wheels on beds, w/c, and carts - Use chair or bed sensors to alert staff

Question 184

Emergency management of an evisceration

Answer 184

- Risk for deep-vein thrombosis - Prophylactic measures: administration of lower-molecular-weight or low-dose heparin or low-dose warfarin (Coumadin), anti embolism stockings, pneumatic compression devices, range of motion exercises, and early ambulation - Avoid any form of pressure behind the knee with a pillow or blanket, which can cause constriction of blood vessels and decreased venous return - Avoid dangling client for long periods of time - Provide adequate hydration by administering IV fluids or encouraging increased oral fluid intake

Question 185

Providing cost-effective care

Answer 185

- Using all levels of personnel to their fullest when making assignments - Providing necessary equipment and properly changing clients - Returning uncontaminated, unused equipment to the appropriate department for credit - Using equipment properly to prevent wastage - Providing training to staff unfamiliar with equipment - Returning equipment (IV, kangaroo pumps) to the proper department as soon as it is no longer needed

Question 186

Reporting client care issues to an interprofessional team

Answer 186

1. Place the client in private room with private bathroom 2. Delegation and Supervision: Tasks for an assistive personnel 3. Increased intracranial pressure disorders: Prioritizing client care 4. Airway management: required equipment for home suctioning-yanker 2) Safe and Infection Control

Question 187

Alzheimer’s Disease: Maintaining a Safe Environment

Answer 187

1. check the Pt's skin weekly for breakdown 2. put a bed alarm or mat sensor alarm 3. Remove clutters 4. Cables along the wall

Question 188

Hygiene: Assisting with a tub bath

Answer 188

1. Gather all necessary supplies 2. place a rubber mat on the tub floor 3. assist the patient into the bathroom 4. Instruct the patient on using safety bars when getting in and out of the tub 5. Instruct the patient to remain in the tub for no longer than 20 min

Question 189

Neurocognitive Disorders: Planning Care in an Adult Day Care Setting

Answer 189

1. Check Mental Status 2. Introduce age-appropriate activities

Question 190

Safe Medication Administration and Error Reduction: Clarifying Prescription Information

Answer 190

A. The Patient 1. compare the name on the client's wristband with the name on the MAR 2. ask the client to state his DOB 3. ask the client to state his name 4. use the bar-code scan to ID the client B. Prescription 1. Compare prescriptions with MAR 2. Question unclear prescriptions and call the provider for clarifications 3. Repeat back when taking prescriptions by phone

Question 191

Discharging Clients During a Mass Casualty Incident

Answer 191

1. casualties are separated in relation to their potential for survival, and treatment is allocated accordingly

Question 192

Maintaining a Safe Environment: Caring for a client who has MRSA

Answer 192

Have specialized equipment for patient. Own room and bathroom The AP keeps the blood pressure cuff inside the client’s room

Question 193

Transmission precautions:

Answer 193

Contact precautions for wound, skin, and urine infection; droplet precautions for sputum infection No treatment needed for patients with colonization only. Provide emotional support to the patient and family members. Consider grouping infected patients together and having the same nursing staff care for them. Use meticulous hand-washing technique. Use standard precautions and contact precautions, droplet precautions, or both as indicated. Provide skin and wound care as indicated; inspect wound and skin for changes and evidence of healing. Administer antibiotics as ordered; if I.V. route is used, ensure patent I.V. access and provide I.V. site care according to facility policy. Obtain cultures of wound as ordered

Question 194

Home Safety: Home Inspection for a Client Education regarding home oxygen

Answer 194

Teach the patient and family to place an oxygen in use sign on the door at home and to keep oxygen delivery systems at least 10 feet away from any open flames. Record the method of oxygen delivery and flow rate. Document the patient's response to oxygen therapy. Record the dates of your patient teaching sessions about safe home oxygen therapy. Review the medical prescription for delivery method and flow rate. review the delivery method and flow rate specified on the medical order. Inspect all electrical equipment in the patient's room for the presence of safety-check tags.

Question 195

Client safety: Equipment Malfunction

Answer 195

remove the equipment with frayed cord or missing part report equipment having malfunction or misuse issues ensure that equipment is safe and if not working appropriately, have it sent for repair within the facility

Question 196

Applying restraints to a client

Answer 196

Applying the restraints after the order is written by the HCP Client complains of tingling in the fingers on the right hand require immediate attention tie restraints: -tie to the bed frame (not side rail) -never tie a true knot (quick release buckle) -check for 2 finger looseness Documentation -ongoing assessment required -include behavior that necessitated need, procedure used, condition of body part, client response side rails restraint -most commonly used physical restraint -clients can become trapped or fall from when trying to exit a bed -the FDA cautions use

Question 197

Safety Hazard for a Client who has an Immune Deficiency

Answer 197

1. clean up blood spills immediately with chlorine bleach 2. Use standard precautions

Question 198

Interventions for a client who has herpes simplex

Answer 198

1. Implement contact precautions 2. Discourage the use of Over-the-Counter products

Question 199

Home inspection for a client

Answer 199

- Too long to type but: - Prioritize: Airway, fall risk, risk for aspirations, burns, poisoning, injury, drowning

Question 200

Monitor client for adverse effects of cyclosporine

Answer 200

- primarily occurs in the kidneys, with up to 75% of pts experiencing reduction in urine output - Over 50% of pts: hypertension and tremor - Other common: headache, gingival hyperplasia, elevated hepatic enzymes - Periodic blood counts are necessary to ensure WBC's don't fall below 4,000 or platelets below 75,000 - Long-term therapy increases risk of malignancy - especially lymphomas and skin cancers

Question 201

Health promotion of infants (2 Days to 1 Year): Reinforcing teaching about home safety

Answer 201

1. Parents must make sure that there is only one finger between the crib and the railing.

Question 202

Home safety: Setting up medical equipment

Answer 202

- Oxygen: - Place no smoking sign - Smoke outside the house - Ensure that electrical equipment is in good repair and well grounded - Keep flammable materials such as heating oil and nail polish remover away from the client

Question 203

Tuberculosis: Patient teaching about infection precautions

Answer 203

-Wear a mask or respirator prior to room entry, depending on the disease-specific recommendations. ( Most disease will require N95 or higher respiratory protection.) -Place patient in an airborne infection isolation room ( AII)- single room that is equipped with special air handling and ventilation capacity. -AAIR room (negative pressure room). -When transferring the patient, have the patient to wear surgical mask prior to being transferred

Question 204

Diabetes mellitus management and complications: Evaluating client understanding about foot care

Answer 204

- Check for bruises or sores - Always wear socks or slippers as protection - Use lotion to prevent cracks and skin dryness - Never cut the toenails - Podiatrist will do it for elder clients - Use nail file, not nail cutter

Question 205

IV Therapy: Patient teaching about a peripherally inserted central catheter line Neurologic diagnostic procedures: Caring for a client who has a prescription for cerebral angiogram Ergonomic principles: Using correct body mechanics to move a client

Answer 205

1. The wider the base of support, the more stable the object, within limits. (The feet must not be too wide apart, as this would cause instability.) The feet are spread sidewise when lifting, to give side-to-side stability. 2. Get the patient close to your body when moving 3. The AP keeps the head erect when lifting a heavy object.

Question 206

Arthroplasty: Caring for a client using a continuous passive motion device Cancer treatment options: Caring for a client who is immunocompromised

Answer 206

3) Health Promotion and Maintenance

Question 207

1. Complications of the Newborn: Findings to report to the provider during phototherapy

Answer 207

a. Notify provider if jaundice is worsen

Question 208

2. Phototherapy nursing care:

Answer 208

a. Maintain an eye mask over the newborn’s eyes for protection of corneas and retinas b. Keep the newborn undressed with the exception of male newborn. A surgical mask should be placed like a bikini over the genitalia to prevent possible damage to the testicles during the therapy. Be sure to remove the metal strip from the mask to prevent burning c. Avoid applying lotions or ointments to the skin because they can cause burns d. Remove the newborn from the light ever 4 hours and unmask the newborn’s eyes. Check the eyes for damages or injury e. Reposition the newborn every 2 hours to expose all of the body f. Turn off the lights before drawing blood g. Bronze, maculopapupular skin rash are not serious complications h. Monitor elimination and daily weight. Encourage breastfeeding to help with excretion of bilirubin in the stools i. Maintain adequate fluid intake to prevent dehydration

Question 209

Newborn data collection: Findings to report

Answer 209

a. Jaundice b. Low heart rate

Question 210

Responding to the caregiver of a client who has Alzheimer’s Disease

Answer 210

a. Provide verbal and nonverbal ways to communicate with the client b. Reminisce c. Stimulate the memory by repeating the client’s statement d. Orient to reality e. Do not argue f. Speak directly with concise sentences g. Use calm tone

Question 211

Reinforcing teaching about breastfeeding

Answer 211

a. Allow 20-30 mins for each breast to be completely emptied b. If the baby is falling asleep, the baby is full. Do not force feed because it could lead to overweight

Question 212

Hospitalization, Illness, and Play: Developmentally appropriate activities for an adolescent

Answer 212

a. Nonviolent video games b. Nonviolent music c. Sports d. Caring for a pet e. Career training programs f. Reading g. Social events (going to movies, school dances)

Question 213

Immunization: Contraindication to receiving varicella immunization

Answer 213

a. If the client is allergic to gelatin b. Immunosuppressed patients c. Is or may be pregnant d. Received blood products (whole blood, plasma, etc) during the previous 3-1 months

Question 214

Contraception: Appropriate use of contraception

Answer 214

a. Ensure that the rim is outside so it looks like a little hat. If you accidentally put it inside out, get a new one. DO NOT flip it. b. Pinch the tip of the condom and place it on the head, leaving a little space at the top c. Roll to the shaft d. Have fun e. Take it off after the party

Question 215

Hypertension: Low-Sodium food recommendations

Answer 215

a. Fish or shellfish b. Chicken or turkey breast without skin c. Lean cuts of beef or pork d. AVOID: i. Salty snack food ii. Canned soups and vegetables iii. Baked goods that contains baking powder or baking soda iv. Processed meat (bologna, ham, bacon) v. Dairy products, especially cheese vi. Pickles vii. Olives viii. Soy sauce, steak sauce ix. Salad dressings

Question 216

Preparing a client for a colposcopy

Answer 216

a. Avoid scheduling it during your period b. No vaginal intercourse the day or two before your colposcopy c. Don’t use vaginal medications for the two days before d. Take OTC pain reliever before going to the appointment

Question 217

Sources of nutrition: Increasing fiber intake

Answer 217

a. Foods high in fiber: i. Raspberries, strawberries ii. Pear and apple with skin iii. Orange iv. Whole wheat v. Brown rice, rye, bread

Question 218

Thorax, heart, and abdomen: Identifying understanding of health promotion

Answer 218

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Question 219

Older Adults (65 and +): Health promotion behaviors

Answer 219

a. Recommend herpes zoster immunization b. Exercise c. Social interactions

Question 220

Expected findings with an acetaminophen overdose

Answer 220

1. Diarrhea 2. Change in renal hormones (ALT/AST > 1000 uL/d) 3. Monitor change in BUN/Creatinine level

Question 221

Depressive Disorders: Priority finding to report

Answer 221

a. depressed mood b. difficulty sleeping or excessive sleeping c. Indecisiveness d. -decreased ability to concentrate e. -suicidal ideation f. -increase or decrease in motor activity g. -inability to feel pleasure (anhedonia) h. -increase or decrease in weight of more than 5% of total body weight over 1 month

Question 222

Psychotic Disorders: Identifying negative symptoms of schizophrenia

Answer 222

a. Apathy b. Affect -: blunted or flat expressions c. Alogia-: poverty of thought or speech d. Anergia-: lack of energy e. Anhedonia-: lack of pleasure or joy f. Avolition-: lack of motivation

Question 223

Characteristics of perpetrators of child abuse

Answer 223

a. age b. gender c. step parent d. single parent e. psychological characteristics

Question 224

Reinforcing teaching about oppositional defiant disorder

Answer 224

a. Assessment-: Hx, environmental, symptoms b. Provide psychoeducation to orient parents c. Establish nurturing and positive parent-child interactions d. Increase authoritative parenting and child compliance e. Improve parental use of personal anger management and problem solving skills

Question 225

Reinforcing rules with a client who has antisocial personality disorder

Answer 225

a. Use therapeutic communication (don’t yell) b. Calm the patient and prevent self harm and to others.

Question 226

Anger management: Responding to escalating aggression

Answer 226

a. Respond quickly b. Remain calm an in control c. Encourage client to express feelings verbally (use therapeutic communication) d. Allow the client as much as personal space as possible e. Maintain eye contact by sitting or facing the client f. Communicate with honesty, sincerity, and non aggressively g. Avoid accusatory or threatening statement h. Reassure the client staff member are present to prevent loss of control

Question 227

Appropriate Therapeutic Response

Answer 227

a. Use calm tone b. Never ask why c. Encourage to open up feelings d. Never give false assurance

Question 228

Identifying culture-bound syndromes

Answer 228

a. These are mental disorders that affect a single cultural group, therefore, are often unknown outside their own regions.

Question 229

Kosher Diet

Answer 229

a. Milk(Dairy) and meat cannot be served on a same meal tray. b. Pig and camel are avoided

Question 230

Multiple Sclerosis: Priority Action for a client who has Multiple Sclerosis

Answer 230

a. Prevent injury. (No Tx but aimed at relieving symptoms) b. Pt. should avoid stressors that exacerbate the condition. During exacerbation, administer corticosteroids. c. Teach self-catheterization if needed

Question 231

Benign Prostatic Hyperplasia: Postoperative care following transurethral

Answer 231

1. During this immediate postoperative period your doctors will monitor closely for post-TURP syndrome, a rare but serious condition that occurs when too much fluid is absorbed during the TURP procedure. The initial symptoms include dizziness, headache, and a slow heartbeat, and it can progress to shortness of breath, seizures, and even coma. 2. A catheter placed through your penis into your bladder will remove urine until your prostate heals. The catheter will stay in place for a few days after surgery. If you go home with your catheter, the nurse will show you how to clean around it with soap and water. Cleaning your catheter twice a day will prevent infection.

Question 232

Planning postoperative care for above the knee amputation

Answer 232

1. Encourage to use overhead trapeze 2. Give medication for phantom pain 3. Monitor cap refill by comparing extremities 4. Observe for edema, necrosis, and lack of hair distribution of the extremity due to inadequate peripheral circulation 5. Prevent postoperative complications (hypovolemia, pain, infection) 6. Assess surgical site for bleeding. MOnitor VS frequently 7. Monitor tissue perfusion of end of residual limb 8. Monitor and treat pain 9. Monitor for signs of infection and/or non healing of incision. Infection can lead to osteomyelitis. 10. Client's perception and feelings regarding amputation of body part. 11. Residual limb preparation and prosthesis fitting. 12. Client Education

Question 233

Atopic Dermatitis; manifestations, treatment, and interventions

Answer 233

1. Type of eczema that is characterized by pruritus (itching) and associated 2. With a history of allergies that are of an inherited tendency (atopy) 3. Lesions disappear if the scratching is stopped 4. Cannot be cured but can be well controlled 5. Antihistamines - Hydroxyzine (Atarax) or diphenhydramine (Benadryl)- teach about sedating effect, safety measures 6. Antihistamines - Loratadine (Claritin) or fexofenadine (Allegra), oral for antipruritic effect, preferred for use during the day time 7. Antibiotics should be used to treat secondary infections 8. Topical corticosteroids- to reduce or control flare ups 9. NSAIDs- decrease inflammation during flare ups- older than 2 years old, at start of exacerbation 10. Keep skin hydrated with tepid baths (with/without mild soap or emulsifying oil), then apply 11. an emollient within 3 min of bathing. -Two or three baths may be given daily with one prior to bedtime. 12. Dress the child in cotton clothing. 13. Avoid wool and synthetic fabrics. 14. Avoid excessive heat and perspiration, which increases itching. 15. Avoid irritants (bubble baths, soaps, perfumes, fabric softeners). 16. Provide support to the child and family. 17. Wash skin folds and genital area frequently with water

Question 234

Reinforcing teaching about range-of-motion exercises

Answer 234

1. Range-of-motion exercises help patients who are unable to ambulate or exercise maintain joint mobility and muscle strength. They are usually performed once or twice daily, or according to the provider’s order and can be performed independently or with assistance. 2. Active range-of-motion exercises are those the patient performs, with a nurse or a physical therapist supervising to ensure that the patient is doing them correctly. They involve moving each joint through its complete range of motion. These exercises maintain and increase muscle strength and help keep joint problems and contractures from developing. 3. Passive range-of-motion exercises are performed for patients by a nurse or a physical therapist. They also involve moving each joint through its complete range of motion. These exercises are performed so that patients who are completely immobilized can retain as much joint range of motion as possible. Because muscles do not contract during passive range-of-motion exercises, muscle strength is neither maintained nor increased.

Question 235

Interventions following knee arthroplasty

Answer 235

1. Pulses and circulation checks should be done every one (1) to two (2) hours postoperatively. 2. Weight-bearing limits on the affected Knee with an immobilizer on the affected joint to provide stability. 3. Continuous Passive Motion (CPM) is used only while the patient is in bed and ordered with support from Physical Therapy. Sheepskin is used to prevent injury on skin. 4. Rationale for continuous passive motion (CPM) machine and frequency of use 8-12 hours/day. 5. Cryopak therapy or Ice packs to reduce swelling and inflammation. 6. 1st Line intervention is Ice Not directly on joints 7. Encourage to use overhead trapeze <~ this is the answer

Question 236

Stroke: assisting a client with meals

Answer 236

1. Elevate the head of bed 45 to 90 degrees 2. Add thickener 3. Place food on non affected side of the mouth 4. AP can help them feed

Question 237

Patient teaching about music therapy

Answer 237

1. Music therapy can help her verbally express emotions 2. Music therapy works as a distraction and can help alleviate her pain 3. Music therapy can help facilitate mvmt in some clients who have mobility limitations

Question 238

Osteoarthritis and Low-Back Pain: Teaching about exercise

Answer 238

1. Water aerobics, water exercises

Question 239

Mobility and Immobility: Using an Aquathermia Pad

Answer 239

A waterproof plastic or rubber pad that can be applied to areas of muscle sprain, edema, or mild inflammation. The pad contains channels through which heated or cooled water flows.

Question 240

Electrolyte imbalances: Teaching with a client who is taking a diuretic

Answer 240

1. Check potassium levels a. Norms: 3.5-4.5 2. Check for dehydration s/s :Tachycardia, weak, thready pulse, Hypotension, orthostatic hypotension, decrease central venous pressure,Tachypneic (increased respirations), hypoxia, Hyperthermia, diminished capillary refill, cool clammy skin, diaphoresis, sunken eyeballs, flattened neck veins, poor skin turgor, tenting, dizziness, syncope confusion, weakness, fatigue,

Question 241

GI: Dietary teaching about celiac disease

Answer 241

1. For this disease, eliminate gluten from diet, give vitamin (ADEK - fat soluble) supplements. Can have rice & corn.

Question 242

Polycystic Kidney Disease, Acute Kidney Injury, and Chronic Kidney Disease: Interventions for CKD

Answer 242

1. Control protein intake based on the client's stage of chronic kidney disease and type of dialysis prescribed. 2. Restrict the client's dietary sodium, potassium, phosphorus, and magnesium. 3. Provide the client a diet that is high in carbohydrates and moderate in fat. 4. Restrict the client's intake of fluids (based on urinary output). 5. Monitor for weight gain trends. 6. Adhere to meticulous cleaning of areas on skin not intact and access sites to control infections. 7. Balance the client's activity and rest.

Question 243

Math: IV Infusion rate

Answer 243

- [Volume (mL)/ time (min)] X drop factor (gtt/mL)

Question 244

Priority action when mixing insulin

Answer 244

- Draw regular insulin first (Lispro, Aspart) before NPH insulin - Cannot mix glargine with anything

Question 245

DM Patients: Reinforce teaching about insulin lispro and insulin glargine self-administration

Answer 245

- HAND HYGIENE FIRST - Make sure the insulin is at room temperature before administration - Most common injection sites: abdomen (two inches away from the umbilicus) - Insulin pen: make sure to change cartridges before administration - Make sure to discard needles where it’s away from harming self and others

Question 246

Safe medication administration and error reduction: Identifying a client prior to medication administration

Answer 246

- Check patient name, order and medication THREE times prior to giving the medication

Question 247

Complications of postpartum period: Administration of medications for hemorrhage

Answer 247

- Uterine atony is the most common cause of hemorrhage - Medication: - Oxytocin (can be on continuous IV or 10 units IM) - Methylergonovine (avoid for people with HTN, preeclampsia or any cardiovascular disease) - Prostaglandin F2 Alpha (avoid for people with asthma; caution for people with HTN, Cardiac disease) - Misoprostol (taken PO or SL)

Question 248

Nonopioid analgesics: Contraindications for acetaminophen

Answer 248

- Liver failure, renal impairment, inflammation of liver due to Hep C

Question 249

Recommendations for Managing Iron-Deficiency Anemia

Answer 249

- Oral iron therapy - Do NOT administer parenteral iron therapy for those doing oral therapy (will cause anaphylaxis) - Blood transfusion

Question 250

Monitoring for Adverse Effects of Enoxaparin

Answer 250

1. Epistaxis

Question 251

Monitoring for Adverse effects of High-Ceiling Diuretics

Answer 251

- hypokalemia, hypomagnesemia, alkalosis, hyperglycemia (C/I in DM), hyperuricemia (C/I in gout) and dyslipidemia (seen with thiazides). Thiazides cause hypercalcemia while loop diuretics causes hypocalcemia

Question 252

Calculating an Enoxaparin Dosage

Answer 252

- Answer: 0.99 (ROUND IT OFF TO 1)

Question 253

Nursing care of newborns: Phytonadione Injection

Answer 253

- Use to treat or prevent low levels of blood clotting factors that the body normally produces - Help thicken blood - Normally given within 1 hour after birth - Dosage: 0.5-1 mg IM

Question 254

Priority findings to report for Penicillin G Potassium

Answer 254

- nausea - vomiting - pain, swelling, or redness in the area where the medication was injected - rash - hives - itching - difficulty breathing or swallowing - swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs - hoarseness - fever - muscle or joint pain - stomach pain - severe diarrhea (watery or bloody stools) with or without fever and stomach cramps that may occur up to 2 months or more after your treatment - unusual bleeding or bruising - blood in the urine - seizures - weakness - fast, slow, or irregular heartbeat - return of fever, sore throat, chills, or other signs of infection

Question 255

Client teaching about a loop diuretics

Answer 255

- Use to treat HTN and edema due to renal insufficiency and congestive heart failure - Makes the kidney pass more fluids - Side effects: hypokalemia, hyponatremia, headache, thirst, muscle cramps, hyperglycemia - Examples: furosemide (lasix), Bumetanide,

Question 256

Indications of Fluid Overload

Answer 256

- Overhydration: - Strenuous exercise with fluid replacement but not replacement of electrolytes. - Subjective and objective data for fluid excess - Subjective and Objective patient Data - Vital signs: Tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure - Neuromusculoskeletal: confusion, muscle weakness, headache - Gastrointestinal : weight gain and ascites - Respiratory: Dyspnea, orthopnea, crackles, diminished breath sounds - Other signs: edema, distended neck veins, pale and cool skin - Labs/tests: - Decreased osmolarity ( hemodilution) of less than 270 mOsm/L - Electrolytes, BUN and creatinine are decreased - Respiratory alkalosis ( When too much PaCO2 is being released, due to tachypnea) PACO2 is less than 35 mmHG, in which increases PH to greater than 7.45 (alkalosis) because the ratio of bicarbonate is too high (it's the carriers of CO2 out of the blood).

Question 257

Reinforcing teaching about nystatin suspension

Answer 257

- Use a dose-measuring cup, spoon, or dropper to measure the specified dose of thesuspension. - Swish the suspension around in your mouth, then either spit it out or swallow it, depending upon the instructions given by your doctor. - Take all of the nystatin that has been prescribed for you even if you begin to feel better

Question 258

DM: evaluating client use of an insulin pen

Answer 258

- Prefilled cartridges of 150 to 300 units of insulin in a programmable device with disposable needles. - Used if only one insulin is given at a time - Convenient for travel

Question 259

Immunizations: Administration of Herpes Zoster Vaccine

Answer 259

- Recommended for those 60 years old and older - Contraindications: - Allergy to gelatin - Weakened immune system: - HIV/AIDS - Cancer treatment such as chemo or radiation - Cancer affecting bone marrow or lymphatic system (leukemia and lymphoma) - Who MIGHT be pregnant

Question 260

Lupus Erythematous, Gout, and fibromyalgia: Patient teaching about skin care

Answer 260

- Use sunscreen - Use mild protein shampoo, and avoid harsh hair treatments - Use steroid creams for skin rash

Question 261

Patient teaching about an amniocentesis

Answer 261

a. It is performed to detect neural tube defect and fetal lung maturity. b. Report fever, chills, leakage of fluid or bleeding from insertion site, decreased fetal movement, vaginal bleeding or uterine contraction after the procedure. c. Drink plenty of liquids and rest for 24 hrs postprocedure. d. Empty the bladder before the procedure to reduce risk of inadvertent puncture.

Question 262

Creatinine clearance test

Answer 262

a. Normal creatinine clearance Men -: 97 -- 137 mL/min Women-: 88 -- 128 mL/min

Question 263

Evaluating treatment for Anorexia Nervosa

Answer 263

- Consider client’s preferences - Plan an inflexible eating schedule - Provide small, frequent meals - Provide a diet high in fiber - Provide a diet low in sodium - Himit high-fat and gassy foods - Administer a multivitamin - Avoid caffeine

Question 264

Increased ICP: Manifestations

Answer 264

a. Change in LOC (Headache, restlessness, irritability) b. Cranial nerve function (eye-blink response, gag reflex, tongue and shoulder movement) c. Pupillary response (PERRLA, pinpoint or dilated) d. Amnesia e. Decrease in motor response (decerebrate, decorticate and flaccidity) f. Change in Vital Signs (Increasing systolic pressure, Bradycardia, bounding pulse, Irregular respirations) g. Seizures

Question 265

Integumentary and Peripheral Vascular Systems: Locating the Dorsalis Pedis Pulse

Answer 265

- By the inner ankle

Question 266

V/S: Monitoring Respiration

Answer 266

- Regular rate: 12-20/min - Regular O2 sat: 90-100% - Administer O2 therapy if levels are low. - Raise the head of the bed.

Question 267

Specimen collection for glucose monitoring: Collecting a postprandial blood sample

Answer 267

- Normal level: 70 to 115 mg/dL - Taken after meals

Question 268

DM: Monitoring Laboratory Values

Answer 268

- Fasting blood glucose: - 126 mg/dL or above - NPO 8 hrs prior - No antidiabetic med until the level is drawn - Oral glucose tolerance test: - 200 mg/dL and above - Obtained every 30 minutes for 2 hours - Consume balanced diet for 3 days prior to the test - HbAd1c: - 4 - 6% is normal range - Best indicator of the average blood glucose level for the past 120 days - Casual blood glucose concentration - 200 mg/dL

Question 269

Respiratory Diagnostic and Therapeutic Procedures: Respiratory Acidosis

Answer 269

- Provide oxygen therapy - Maintain patent airway - Low pH; High PaCO2

Question 270

Inflammatory Bowel Disease: Postoperative Complications

Answer 270

- Bleeding - Fluid and electrolyte imbalance - Peritonitis - Life-threatening inflammation - Abscess formation - Rigid, boardlike abdomen - Nausea, vomiting - Rebound tenderness - Tachycardia - Fever

Question 271

Musculoskeletal trauma: Priority findings to report for a client who has a cast

Answer 271

- Monitor neurovascular status and collect data about pain - Apply ice for 24-48 hr - Handle a plaster cast with the palms, not fingertips - Avoid setting the cast on hard surfaces or sharp edges - Ensure the area is cleaned and dried - Tubular cotton web roll is placed over the affected area - Elevate the cast above the level of the heart during the first 24 to 48 hr - Drainage is seen: outlined, dated, and timed

Question 272

Respiratory diagnostic and therapeutic procedures: Postoperative care following a Bronchoscopy

Answer 272

- Monitor from PACU - Check LOC, gag reflex, ability to swallow - Offer ice chips one reflex returns - Monitor: productive cough, hemoptysis, hypoxemia - Provide oral hygiene - Encourage coughing and deep breathing every 2 hours

Question 273

Benign Prostatic Hyperplasia: Teaching following prostatectomy

Answer 273

a. Instruct the client to report symptoms of infection. b. Teach the client catheter care if he will be going home with one in place. c. Tell the client to avoid heavy lifting and strenuous activity for the prescribed period of time. d. Instruct the client to avoid tub baths for at least 2 to 3 weeks. e. Drink 12 or more 8oz. Of water each day f. Avoid bladder stimulant. (caffeine or coffee) g. If urine becomes bloody, stop the activity, rest and increase fluid intake.

Question 274

Hyperthyroidism: Client response following a total thyroidectomy

Answer 274

- Speak as soon as waking up from anesthesia - Cough and breathe deeply - Notify charge nurse of any tingling sensation of the mouth, distal extremities, or muscle twitching - Notify the surgeon of incision drainage, swelling, or redness - Monitor hypothermia, lethargy, and weight gain

Question 275

Middle and Inner Ear Disorders: Reinforcing teaching following a tympanoplasty

Answer 275

1. No Shampoo for one week

Question 276

Patient teaching about chest physiotherapy

Answer 276

- Coughing - Deep breathing - Use of incentive spirometer - Chest percussion - Chest vibration

Question 277

IV Therapy: Discontinuing an infusion following infiltration

Answer 277

- Stop the therapy - Notify the provider immediately - Warm compress the site - Put pressure on the site as you remove the IV

Question 278

Electrolyte imbalances: Identifying the location to Elicit a Chvostek Sign

Answer 278

- Sign of hypocalcemia - Contraction or twitching of the facial muscle produced by tapping on facial nerve on specific

Question 279

Pulmonary Embolism: Expected Findings

Answer 279

Expected Findings i) Dyspnea

Question 280

Respiratory management and mechanical ventilation: Care of a client receiving mechanical ventilation

Answer 280

ii) When the high pressure alarm goes off, suction the client

Question 281

Angina and myocardial infarction: Evaluating client understanding of chest pain

Answer 281

iii) Apply the nitroglycerin patch to a hairless area. iv) History: Chest pain

Question 282

Infections of the renal and urinary system: reinforcing client teaching about urinary tract infections

Answer 282

- Promote fluid intake - Pee as soon as possible - Urinate before and after sex - Promote good hygiene - Change tampons often - Change undergarments often - Wash and wipe - Wipe front to back

Question 283

Communicable diseases: expected findings with varicella

Answer 283

- Vesicles on the body - Fever - Malaise - anorexia

Question 284

Manifestations of Thyroid Storm

Answer 284

v) Increased Pulse and Blood Pressure

Question 285

GI Therapeutic Procedures: Colostomy Teaching

Answer 285

vi) Empty colostomy bag before procedure

Question 286

Skin Disorders: Teaching about psoriasis treatment

Answer 286

- Observe skin for thinning, striae, or hypopigmentation with high-potency corticosteroids - Avoid use on face or in skin folds, and take periodic medication vacations. - Use warm, moist, occlusive dressings of plastic wrap after applying the medication. - Can be left in place up to 8 hour each day. - Gloves - Plastic garments - Booties

Question 287

COPD: Expected findings of Emphysema

Answer 287

- Dyspnea - Productive cough (worst upon rising in the morning) - Hypoxemia - Crackles and wheezes - Rapid and shallow respirations - Use of accessory muscles - Barrel chest or increased chest diameter - Hyperresonance on percussion due to trapped air - Irregular breathing pattern - Thin extremities and enlarged neck muscles - Dependent edema (r/t RHF) - Clubbing of fingers and toes - Pallor and cyanosis - Low O2 Sat

Question 288

Clients with allergic reaction:

Answer 288

Administer epinephrine.

Question 289

Macular Degeneration effect/ manifestation:

Answer 289

Decreased Central Vision

Question 290

Furosemide adverse effect:

Answer 290

Hypokalemia

Question 291

Intravenous pump numbers are off:

Answer 291

Stop IV and reset pump

Question 292

Chadwick sign:

Answer 292

Purple vagina

Question 293

When there’s an increase flow rate of the client’s bladder:

Answer 293

Irrigate

Question 294

Levels:

Answer 294

Sodium: 135-145 Potassium: 3.5-5.0 Calcium: 9-11 Phosphate: 2.5-4.5 Magnesium: 1.5-2.5 Chloride: 97-107 Digoxin: 0.5-2 Lithium: 0.8-1.4 Hgb: m: 14-18; f: 12-16 RBC:M- 4.7-6.1millions, F:4.2-5.4millions WBC: 5,000-10,000 Platelets: 150,000-400,000

Question 295

How to draw up long and short insulin:

Answer 295

Inspect for cloudy contaminants Roll the vials Insert air (NPH insulin) Insert air (Regular) Withdraw Regular Withdraw and add NPH

Question 296

When a nurse is intoxicated while caring for the clients:

Answer 296

Remove the nurse from clients

Question 297

Use of inhalers:

Answer 297

Decreases bronchospasm

Question 298

*If you are giving 15 units of insulin, be sure to inject 15 units of air before pulling an insulin

Question 299

Client who has osteoarthritis:

Answer 299

Apply capsaicin cream QID

Question 300

Client who is receiving continuous bladder irrigation after TURP; intervention:

Answer 300

Maintain a drainage flow rate to keep the urine diluted

Question 301

Gastrostomy care:

Answer 301

Flush the tube with 60 mL of water

Question 302

Client accuses nurse stole her money; therapeutic response

Answer 302

Tell me how you decided who took your money

Question 303

Client has rubeola; what to implement?

Answer 303

Airbourne

Question 304

Client is prescribed with home O2 therapy; instructions

Answer 304

Apply water-based lubricant around the nostrils

Question 305

Prioritization of clients; who’s the priority?

Answer 305

Client who is at 36 weeks of gestation and reports painless vaginal bleeding

Question 306

Receiving morphine thru PCA pump:

Answer 306

Increase fluid intake

Question 307

Client has pneumonia; entries should the nurse include in the plan?

Answer 307

Bathing in the evening

Question 308

Client taking montelukast:

Answer 308

Daily at bedtime

Question 309

Metronidazole adverse effect:

Answer 309

Reddish-brown urine